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    Collateral status predicts functional outcome in early-treated large-core anterior circulation stroke
    (Frontiers Media SA, 2026-04-14)
    Andrés Gallardo
    ;
    ;
    Pablo Albiña-Palmarola
    ;
    Gabriel Cavada
    ;
    Andrés Roldán
    <jats:sec> <jats:title>Background and purpose</jats:title> <jats:p>Endovascular therapy (EVT) is increasingly offered to patients with large-core acute ischemic stroke (AIS), yet outcomes remain highly heterogeneous. Collateral circulation may be a key determinant of infarct evolution and recovery, but its role in early-window large-core stroke is not fully defined.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>We retrospectively analyzed consecutive adults from a prospective stroke registry who presented within 6 h with anterior-circulation large-vessel occlusion, NIHSS ≥6, and a large ischemic core (MRI core &amp;gt;50 mL or CT perfusion core &amp;gt;70 mL, up to 150 mL). All patients received reperfusion therapy (intravenous thrombolysis, EVT, or both). Collateral status on baseline single-phase CTA was graded using the Tan scale (0–3); no patients had grade 3. The primary outcome was 90-day modified Rankin Scale (mRS); secondary outcome was NIHSS at discharge.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p> Fifty-four patients met inclusion criteria (Tan 0: <jats:italic>n</jats:italic> = 24; Tan 1: <jats:italic>n</jats:italic> = 14; Tan 2: <jats:italic>n</jats:italic> = 16). Baseline NIHSS, ASPECTS, and core volume were similar across groups. Patients without collaterals (Tan 0) had worse 90-day outcomes (median mRS 4 [IQR 3–6]) compared with those with Tan 1 (2 [IQR 1–3]) or Tan 2 (1 [IQR 1–2]) collaterals (both p &amp;lt; 0.001), whereas Tan 1 and Tan 2 did not differ significantly ( <jats:italic>p</jats:italic> = 0.27). NIHSS at discharge showed a similar gradient. In proportional-odds logistic regression, each one-grade increase in collateral status was associated with lower odds of worse 90-day mRS (adjusted per-grade OR 0.32; 95% CI 0.15–0.68; <jats:italic>p</jats:italic> = 0.003). </jats:p> </jats:sec> <jats:sec> <jats:title>Conclusion</jats:title> <jats:p>In early-treated large-core AIS, even simple CTA-based collateral assessment strongly predicts recovery. Patients with absent collaterals follow a distinctly poorer trajectory, while those with any collateral filling behave more favorably. Incorporating collateral status into routine evaluation may improve prognostic accuracy and support treatment decisions in this challenging subgroup.</jats:p> </jats:sec>
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    Emergency Department Workflow Times of Intravenous Thrombolysis with Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Prospective Cohort Study before and during the COVID-19 Pandemic
    (S. Karger AG, 2025-02-03)
    Matias Guzman
    ;
    ;
    Gabriel Cavada
    ;
    Alejandro M. Brunser
    ;
    Veronica V. Olavarria
    Introduction: Tenecteplase (TNK) has demonstrated to be non-inferior to alteplase (ALT) for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). There are potential workflow benefits associated with TNK use, aiming to reduce patient length of stay in the emergency department. Our aim was to investigate whether the routine use of TNK during the COVID-19 pandemic influenced workflow times compared to historical use of ALT, while maintaining non-inferior clinical outcomes in a non-drip and ship scenario of a comprehensive stroke center. Methods: We included patients with AIS admitted from September 2019 to September 2022 and compared those treated with TNK during the COVID-19 pandemic to those treated with ALT in the period immediately before. We compared emergency department length of stay (EDLOS), door-to-needle time (DTN), door-to-groin puncture time (DTG), clinical and safety outcomes with adjusted general linear regression models. Results: 110 patients treated with TNK and 111 with ALT were included in this study. Mean EDLOS was 251 (SD = 164) min for TNK users versus 240 (SD = 148) min for ALT (p = 0.62). Mean DTN was 43 (SD = 25) min for TNK versus 46 (SD = 27) min for ALT users (p = 0.39). Mean DTN under 60 min was achieved in 86 (78.2%) patients and in 85 (76.5%) patients of the TNK and ALT groups, respectively (p = 1.0). DTN under 45 min was achieved in 65.4% and 58.6% (p = 0.65) of the TNK and ALT groups, respectively. DTG time was 114 (SD = 43) min for TNK versus 111 (58 = SD) min in the ALT group (p = 0.88). DTG under 90 min was achieved in 32% of the TNK group and 35% of the ALT group (p = 0.69). There were no differences in any of the clinical or safety outcomes between groups at 90 days. Conclusions: The adoption of TNK during COVID-19 pandemic did not result in a change in EDLOS, DTN, or DTG times when compared to ALT in this cohort. Safety and clinical outcomes were similar between groups. Probably a greater benefit could have been seen in a drip and ship thrombolysis setting. Further research is needed to assess the potential advantages of TNK in drip and ship scenarios of IVT.
    Scopus© Citations 2  2
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    Patient centered outcomes in stroke: utility-weighted modified Rankin Scale results in a community-based study
    (Frontiers Media SA, 2025-03-21)
    Carlos Delfino
    ;
    Gabriel Cavada
    ;
    ; ;
    Background and aims</jats:title><jats:p>The transformation of modified Rankin Scale (mRS) scores based on the corresponding utilities of health-related quality of life questionnaires can facilitate the capture of Patient-Centered Outcomes (PCO) in stroke. We aimed to derive utility-weighted modified Rankin Scale (UW-mRS) values by mapping mRS functional status to EQ-5D-3L scores in a population-based cohort of stroke patients.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>The UW-mRS was obtained by analyzing the EQ5-D-3 L and mRS scores at 180 days after any stroke in the ÑANDU study, a large prospective community-based study in Chile. The mRS prediction was estimated using a linear regression adjusted by the EQ-5D-3L value. Generalized linear and binary logistic regression models were constructed to determine influencing factors of the UW-mRS, using STATA software (version 18.0).</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>We included 773 patients presenting with any stroke during 2015–2016: 48% were female, with a mean age of 71 years (SD 13.8), and 85% had an acute ischemic stroke (AIS). 82% of patients had a low socioeconomic status, 50% had less than 12 years of formal education, and only 32% lived in urban areas. UW-mRS values for mRS categories 0–6 at 180 days were 0.913, 0.694, 0.425, 0.249, −0.102, −0.347 and 0, respectively. Multivariable analysis identified age &amp;gt; 70 years (Coefficient <jats:italic>β</jats:italic> [β] -0.038 [Standard error SE 0.018], <jats:italic>p</jats:italic> = 0.032), prior mRS score 3–5 (<jats:italic>β</jats:italic> −0.556 [SE 0.197], <jats:italic>p</jats:italic> &amp;lt; 0.001), ischemic stroke (β −0.066 [SE 0.025], <jats:italic>p</jats:italic> = 0.010), and National Institutes of Health Stroke Scale (NIHSS) at admission&amp;gt;5 (<jats:italic>β</jats:italic> −0.015 [SE 0.002], <jats:italic>p</jats:italic> &amp;lt; 0.001) as significant predictors of worse UW-mRS scores (R<jats:sup>2</jats:sup> = 70%) in the overall group. Sex-disaggregated analysis showed that age &amp;gt; 70 years was a significant predictor in males (β −0.069 [SE 0.024], <jats:italic>p</jats:italic> = 0.006), while presenting an AIS had a greater impact on female’s worse UW-mRS score (β −0.087 [SE 0.033], <jats:italic>p</jats:italic> = 0.010).</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>These results present UW-mRS values derived from a population-based stroke study. Key determinants of health-related quality of life in post-stroke patients included age, prior disability, and stroke severity. Sex-disaggregated analysis revealed age being significant for males and AIS for females. Incorporating PCO as UW-mRS in stroke research can provide a more nuanced understanding of the impact of stroke on survivors, offering valuable insights for clinical decision-making and rehabilitation strategies across diverse healthcare contexts.<
    Scopus© Citations 1  6
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    Clinical and Radiological Differences between Patients Diagnosed with Acute Ischemic Stroke and Chameleons at the Emergency Room: Insights from a Single-Center Observational Study
    <jats:p>&lt;b&gt;&lt;i&gt;Introduction:&lt;/i&gt;&lt;/b&gt; Scarce data exist about clinical/radiological differences between acute ischemic strokes diagnosed in the emergency room (AISER) and stroke chameleons (SCs). We aimed at describing the differences observed in a comprehensive stroke center in Chile. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; Prospective observational study of patients with ischemic stroke syndromes admitted to the emergency room (ER) of Clínica Alemana between December 2014 and October 2023. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; 1,197 patients were included; of these 63 (5.2%, 95% CI: 4.1–6.6) were SC; these were younger (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001), less frequently hypertensive (&lt;i&gt;p&lt;/i&gt; = 0.03), and they also had lower systolic (SBP) (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001), diastolic blood pressures (DBP) (&lt;i&gt;p&lt;/i&gt; = 0.011), and NIHSS (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001). Clinically, they presented less frequently gaze (&lt;i&gt;p&lt;/i&gt; = 0.008) and campimetry alterations (&lt;i&gt;p&lt;/i&gt; = 0.03), facial (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001) and limb weakness (left arm [&lt;i&gt;p&lt;/i&gt; = 0.004], right arm (&lt;i&gt;p&lt;/i&gt; = 0.041), left leg (&lt;i&gt;p&lt;/i&gt; = 0.001), right leg &lt;i&gt;p&lt;/i&gt; = 0.0029), sensory abnormalities (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001), and dysarthria (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001). Neuroradiological evaluations included less frequently large vessel occlusions (&lt;i&gt;p&lt;/i&gt; = 0.01) and other stroke locations (&lt;i&gt;p&lt;/i&gt; = 0.005); they also differed in their etiologies (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001). Brainstem strokes (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001) and extinction/inattention symptoms (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001) were only seen in AISER. In multivariate analysis, younger age (OR: 0.945; 95% CI: 0.93–0.96), DBP (OR: 0.97; 95% CI, 0.95–0.99), facial weakness (OR: 0.39; 95% CI: 0.19–0.78), sensory abnormities (OR: 0.16.18; 95% CI, 0.05–0.4), infratentorial location (OR: 0.36; 95% CI, 0.15–0.78), posterior circulation involvement (OR: 3.02; 95% CI, 1.45–6.3), cardioembolic (OR: 3.5; 95% CI, 1.56–7.99), and undetermined (OR: 2.42; 95% CI, 1.22–4.7; 95%) etiologies, remained statistically significant. A stepwise analysis including only clinical elements present on the patient’s arrival to the ER, demonstrates that age (OR: 0.95; 95% CI: 0.94–0.97), DBP (OR: 0.97; 95% CI, 0.95–0.99), the presence of atrial fibrillation (OR: 2.22; 95% CI, 1.04–4.75, NIHSS (OR: 0.88; 95% CI, 0.71–0.89) and the presence in NIHSS of 1a level of consciousness (OR: 5.66; CI: 95% 1.8–16.9), 1b level of consciousness questions (OR: 3.023; 95% CI, 1.35–6.8), facial weakness (OR: 0.3; CI: 95% 0.17–0.8), and sensory abnormalities (OR: 0.27; 95% CI, 0.1–0.72) remained statistically significant. &lt;b&gt;&lt;i&gt;Conclusion:&lt;/i&gt;&lt;/b&gt; SC had clinical and radiological differences compared to AISER. An additional relevant finding is that neurological symptoms in a patient with atrial fibrillation, even with a negative diffusion-weighted imaging, should be carefully evaluated as a potential stroke until other causes are satisfactorily ruled out. </jats:p>
    Scopus© Citations 1  6
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    Scopus© Citations 7  4
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    Clinical Profile of Stroke Chameleons Receiving Intravenous Thrombolysis: Insights from a Single-Center Experience
    <jats:p>Introduction: In emergency rooms (ERs), 5% of patients experiencing an acute ischemic stroke (AIS) receive an alternative diagnosis; these cases are known as stroke chameleons (SC). The percentage of SC treated with intravenous thrombolysis (IVT) and the characteristics have not been well described. We aimed at investigating the variables associated with the probability receiving IVT. Methods: In this prospective study, we included consecutive patients with SC admitted at the ER of Clínica Alemana between September 2014 and October 2023. Results: Among 1,193 stroke patients; sixty-three (5.2%) corresponded to SC. Ten of these cases (15.8%, 95% CI: 8.8–26.8) were treated with IVT, mean door-to-needle (DTN) time of 85.7 (SD 35) min, median of 73.5 (IQR 62–113) min. SCs who underwent IVT were younger (p = 0.01), with higher NIHSS (p = 0.05). They presented more frequently with altered level of consciousness in the NIHSS (p = 0.01), language abnormities (p = 0.001), and dysarthria (p = 0.01). In multivariate analysis, none of the variables were significantly associated with IVT. A secondary analysis showed that only time to brain imaging was significantly associated with IVT (OR: 0.99; 95% CI: 0.98–0.99; p = 0.01). Conclusions: Almost 1 out of every 7 SC could be treated with IVT but with a prolonged DTN time; the chance of being treated is associated with time to brain imaging. &lt;p&gt;Introduction: In emergency rooms (ERs), 5% of patients experiencing an acute ischemic stroke (AIS) receive an alternative diagnosis; these cases are known as stroke chameleons (SC). The percentage of SC treated with intravenous thrombolysis (IVT) and the characteristics have not been well described. We aimed at investigating the variables associated with the probability receiving IVT. Methods: In this prospective study, we included consecutive patients with SC admitted at the ER of Clínica Alemana between September 2014 and October 2023. Results: Among 1,193 stroke patients; sixty-three (5.2%) corresponded to SC. Ten of these cases (15.8%, 95% CI: 8.8–26.8) were treated with IVT, mean door-to-needle (DTN) time of 85.7 (SD 35) min, median of 73.5 (IQR 62–113) min. SCs who underwent IVT were younger (p = 0.01), with higher NIHSS (p = 0.05). They presented more frequently with altered level of consciousness in the NIHSS (p = 0.01), language abnormities (p = 0.001), and dysarthria (p = 0.01). In multivariate analysis, none of the variables were significantly associated with IVT. A secondary analysis showed that only time to brain imaging was significantly associated with IVT (OR: 0.99; 95% CI: 0.98–0.99; p = 0.01). Conclusions: Almost 1 out of every 7 SC could be treated with IVT but with a prolonged DTN time; the chance of being treated is associated with time to brain imaging. &lt;/p&gt;</jats:p>
      1
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    Sex Differences in Profile and In‐Hospital Death for Acute Stroke in Chile: Data From a Nationwide Hospital Registry
    (2024)
    Marilaura Nuñez
    ;
    Ma.Ignacia Allende
    ;
    GONZALEZ MC CAWLEY, FRANCISCA
    ;
    Gabriel Cavada
    ;
    Craig S. Anderson
    <jats:sec xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en">Knowledge of local contextual sex differences in the profile and outcome for stroke can improve service delivery. We aimed to determine sex differences in the profile of patients with acute stroke and their associations with in‐hospital death in the national hospital database of Chile.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> We present a retrospective cohort based on the analysis of the 2019 Chilean database of Diagnosis‐Related Groups, which represents 70% of the operational expenditure of the public health system. Random‐effects multiple logistic regression models were used to determine independent associations of acute stroke (defined by main diagnosis <jats:italic>International Classification of Diseases, Tenth Revision</jats:italic> [ <jats:italic>ICD‐10</jats:italic> ] codes) and in‐hospital death, and reported with odds ratios (ORs) and 95% CIs. Of 1 048 575 hospital discharges, 15 535 were for patients with acute stroke (7074 [45.5%] in women), and 2438 (15.6%) of them died during hospitalization. Differences by sex in sociodemographic and clinical characteristics were identified for stroke and main subtypes. After fully adjusted model, women with ischemic stroke had lower in‐hospital death (OR, 0.79 [95% CI, 0.69–0.91]) compared with men; other independent predictors included age per year increase (OR, 1.03 [95% CI, 1.03–1.04]), chronic kidney disease (OR, 1.47 [95% CI, 1.20–1.80]), atrial fibrillation (OR, 1.50 [95% CI, 1.26–1.80]), and other risk factors. Conversely, for intracerebral hemorrhage, women had a higher in‐hospital mortality rate than men (OR, 1.19 [95% CI, 1.02–1.40]); other independent predictors included age per year increase (OR, 1.009 [95% CI, 1.003–1.01]), chronic kidney disease (OR, 1.55 [95% CI, 1.23–1.97]), oral anticoagulant use (OR, 1.88 [95% CI, 1.37–2.58]), and other risk factors. </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en">Sex differences in characteristics and in‐hospital death of hospitalized patients exist for acute stroke in Chile. In‐hospital death is higher for acute ischemic stroke in men and higher for intracerebral hemorrhage in women. Future research is needed to better identify contributing factors.</jats:p> </jats:sec>
      1Scopus© Citations 3
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    How the characteristics of pediatric neurologists in Latin America influence the communication of sudden unexpected death in epilepsy to patients and caregivers
    (2022)
    Viviana Venegas
    ;
    Carla Manterola
    ;
    Jose De Pablo
    ;
    Mariano Garcia
    ;
    Sonia Ponce de León
    <jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>This study aimed to describe the characteristics of pediatric neurologists (PNs) in Latin America (LA) who attend to children and adolescents with epilepsy and convey to them the risk of sudden unexpected death in epilepsy (SUDEP).</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Personal data and details of discussion of SUDEP with families, including relevance of SUDEP disclosure, frequency of such communication, perceived benefits and risks of disclosure, extent of training received on such disclosure, and professional experience with SUDEP, were collected through an online survey of PNs from LA. Their personal experience in carrying out this conversation was obtained through responses to an open question, further used to identify the main barriers.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Of the 442 surveys received, 367 (83%) were analyzed. Most participants (73.8%) responded that the communication of SUDEP risk was relevant or very relevant; however, only 17.9% reported communicating it always or very frequently. Factors that increased the frequency of SUDEP communication included patients with higher levels of complexity (OR = 2.18, <jats:italic>P</jats:italic> = .003) and the physician's personal experience with SUDEP (OR = 2.305, <jats:italic>P</jats:italic> &lt; .001). Direct questions from the family and avoiding scaring them about a rare outcome were the main motivations behind discussing and not discussing SUDEP, respectively. In the open question, respondents identified worries about the patient's ability to understand the information and cultural gaps as barriers. “Informing with the intention of improving adherence to treatment” and “establishing an empathic relationship” were significantly related. Further, the concept of “do not scare” was significantly related to “personal difficulties in discussing SUDEP.”</jats:p></jats:sec><jats:sec><jats:title>Significance</jats:title><jats:p>Although most PNs agree that communication about SUDEP is relevant, only a minority actually engages in it. Participants identified a lack of appropriate training in such communication as a barrier. A better understanding of communication expectations, education of health professionals, and communication techniques have a strong relevance in diminishing the gap between guidelines and practice.</jats:p></jats:sec>
      10Scopus© Citations 4
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      4