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Early vs Standard Approach to Tracheostomy and Functional Outcome After Severe Stroke
To the Editor In the subgroup analysis of the recently published Stroke-Related Early Tracheostomy vs Prolonged Orotracheal Intubation in Neurocritical Care Trial 2 (SETPOINT2), the enrolled patients were divided into 3 subgroups according to their pathology diagnosis: acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. However, the type of stroke is not necessarily related to the need for tracheostomy. We believe it would be helpful to classify these patients based on the location of brain infarction, including distinct categories for brainstem or cerebellar stroke. The purpose of tracheostomy in...
Source: JAMA - September 13, 2022 Category: General Medicine Source Type: research

Remote Ischemic Conditioning —Feasible and Potentially Beneficial for Ischemic Stroke
Stroke is the second leading cause of death and disability in the world. In 1996, tissue plasminogen activator (tPA) was approved by the US Food and Drug Administration and remains the only approved pharmacologic agent for treatment of ischemic stroke in the US. In 2015, mechanical thrombectomy was shown to be beneficial for large vessel occlusion ischemic stroke, although 50% of patients treated with mechanical thrombectomy remain disabled at 3 months. Due to short time windows for thrombolytic therapy administration and the stroke system infrastructure needed for mechanical thrombectomy, these reperfusion therapies are a...
Source: JAMA - August 16, 2022 Category: General Medicine Source Type: research

Effect of Remote Ischemic Conditioning vs Usual Care on Neurologic Function in Patients With Acute Moderate Ischemic Stroke
This randomized clinical trial compares the efficacy of remote ischemic conditioning as an adjunct to guideline-based treatment vs usual care for patients with acute moderate ischemic stroke.
Source: JAMA - August 16, 2022 Category: General Medicine Source Type: research

Therapeutic Strategies for Intracranial Atherosclerosis
Intracranial atherosclerosis (ICAS) is a major cause of stroke worldwide. Although approximately 12% of White patients with a history of acute ischemic stroke or transient ischemic attack (TIA) have some form of ICAS detected on routine screening in predominantly older adults, ICAS accounts for an estimated up to one-third of ischemic strokes in Black, Asian, and Hispanic populations at comparatively younger ages. The reasons for these differences are not clear, because risk factor profiles are broadly similar across racial and ethnic groups. ICAS presents diagnostic challenges, not just in differentiating this condition f...
Source: JAMA - August 9, 2022 Category: General Medicine Source Type: research

Effect of Intravenous Tirofiban vs Placebo Before Endovascular Thrombectomy for Acute Ischemic Stroke
This clinical trial examines whether intravenous tirofiban could improve disability severity without increasing symptomatic intracranial hemorrhage or mortality in patients with acute ischemic stroke and proximal large vessel occlusions undergoing endovascular treatment.
Source: JAMA - August 9, 2022 Category: General Medicine Source Type: research

Changes in Incidence of Stroke and Other Vascular Events at Younger vs Older Ages, 2002-2018
This study assesses time trends in incidence of stroke, transient ischemic attack, and other major vascular events at younger vs older ages in a population living in Oxfordshire, England, in 2002-2018.
Source: JAMA - August 9, 2022 Category: General Medicine Source Type: research

Echocardiographic Measures of Left Atrial Function and Size and Incident Dementia
To the Editor A recent study described a significant association between left atrial function and an increased risk of subsequent dementia, independent of the presence of atrial fibrillation. These findings are similar to our 2009 study, which examined subclinical left atrial dysfunction and risk of stroke in patients with patent foramen ovale (PFO). We found that impairment of reservoir, conduit, and contractile strain and impairment of emptying, passive emptying, and active emptying fraction was present in patients with multiple ischemic events, PFO, and atrial septal aneurysm compared with healthy individuals. After PFO...
Source: JAMA - July 19, 2022 Category: General Medicine Source Type: research

Intra-arterial Alteplase vs Placebo After Successful Thrombectomy and Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke
To the Editor We have some concerns about the recent CHOICE study that compared intra-arterial alteplase with placebo among patients with large vessel occlusion acute ischemic stroke after successful thrombectomy.
Source: JAMA - June 28, 2022 Category: General Medicine Source Type: research

The Concept of Transient Ischemic Attack
To the Editor A recent Viewpoint suggested that the concept of transient ischemic attack (TIA) should be retired. The authors proposed the term acute ischemic cerebrovascular syndrome in its place, stating that all focal ischemia in the brain can cause tissue damage. Although I appreciate the contributions of both authors for raising awareness of TIA being a medical emergency that warrants emergency evaluation due to the high risk of stroke in the early period after a TIA, I do not agree that the concept of TIA should be retired.
Source: JAMA - June 28, 2022 Category: General Medicine Source Type: research

Intra-arterial Alteplase vs Placebo After Successful Thrombectomy and Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke —Reply
In Reply In response to the comments by Dr Mai and colleagues about the change in the primary outcome of the CHOICE trial, we would like to provide several clarifications. First, the definition of the primary outcome in the original protocol was submitted for publication on July 15, 2019. Second, the registered protocol (NCT03876119) was first posted on March 15, 2019, but the primary outcome definition was changed and posted on March 19, 2021. Third, the summary of the history of these protocol changes was included in Supplement 2 of the article. As required by Spanish law, these changes were also communicated to the Span...
Source: JAMA - June 28, 2022 Category: General Medicine Source Type: research

Use of Oral Anticoagulants and Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke
To the Editor A recent article suggested that the use of non –vitamin K antagonist oral anticoagulants (NOACs) within 7 days of intravenous alteplase was not associated with an increased risk of intracranial hemorrhage. However, we are concerned that some readers may interpret these results as an endorsement of the use of alteplase in patients with acute st roke who were taking NOACs, irrespective of the time frame of last use. Based on dose-finding studies, the drug half-life is 12 hours for apixaban, 11 to 13 hours for rivaroxaban, 10 to 14 hours for edoxaban, and 12 to 17 hours for dabigatran in patients with normal k...
Source: JAMA - June 21, 2022 Category: General Medicine Source Type: research

Use of Oral Anticoagulants and Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke —Reply
In Reply We agree that conclusions drawn from our observational cohort study should be interpreted within the context of the study design and its inherent limitations. One such limitation is the lack of granular data on the time of last NOAC dose. The GWTG-Stroke registry defines NOAC use as documentation that a patient was taking dabigatran, rivaroxaban, apixaban, or edoxaban within 7 days before hospital arrival. We attempted to overcome this limitation by including additional data from the ARAMIS registry.
Source: JAMA - June 21, 2022 Category: General Medicine Source Type: research

Ischemic Stroke in Patients With Asymptomatic Severe Carotid Stenosis
This retrospective cohort study estimated stroke outcomes among 3737 adult participants with asymptomatic severe carotid stenosis who did not undergo surgical intervention.
Source: JAMA - May 24, 2022 Category: General Medicine Source Type: research

Strategic Opportunities to Improve Stroke Systems of Care
Restoring reperfusion to the brain as quickly as possible during acute ischemic stroke is important to reduce long-term disability and optimize clinical outcomes for patients, although hospital and resource availability are frequently not well matched with patient location. Accordingly, many patients who may have large-vessel occlusion (LVO) lack rapid access to endovascular thrombectomy (EVT), a highly efficacious procedure with a number needed to treat of approximately 3 to 7 for regaining independence among carefully selected patients. Therefore, accurate out-of-hospital diagnosis and ensuring that the patient and the n...
Source: JAMA - May 10, 2022 Category: General Medicine Source Type: research

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