Acute ischemic stroke is the leading cause of permanent disability and second leading cause of death worldwide. Over the past 10 years, mechanical thrombectomy has become a powerful technique for improving outcomes after large-vessel occlusion in patients with a small baseline infarct. Reperfusion in patients with extensive infarction has historically been considered futile or harmful. However, a recent series of trials showed that endovascular therapy benefits patients who present with extensive baseline infarction. These new data represent a paradigm shift in the approach to stroke therapy, leading to an expansion of indications. Therefore, more patients will benefit from mechanical thrombectomy. Furthermore, these data challenge current definitions of infarct and ischemia as seen on imaging. The data suggest a new era of reperfusion therapy that focuses on optimizing patient-specific approaches and developing adjunctive neuroprotectants and neurorestorative therapies.

Stroke is a major cause of death and long-term disability worldwide. Diabetes is associated with an increased risk of cardiovascular complications, including stroke. People with diabetes have a 1.5–2 times higher risk of stroke compared with people without diabetes, with risk increasing with diabetes duration. These risks may also differ according to sex, with a greater risk observed among women versus men. Several mechanisms associated with diabetes lead to stroke, including large artery atherosclerosis, cerebral small vessel disease, and cardiac embolism. Hyperglycemia confers increased risk for worse outcomes in people presenting with acute ischemic stroke, compared with people with normal glycemia. Moreover, people with diabetes may have poorer post-stroke outcomes and higher risk of stroke recurrence than those without diabetes. Appropriate management of diabetes and other vascular risk factors may improve stroke outcomes and reduce the risk for recurrent stroke. Secondary stroke prevention guidelines recommend screening for diabetes following a stroke. The diabetes medications pioglitazone and glucagon-like peptide-1 receptor agonists have demonstrated protection against stroke in randomized controlled trials; this protective effect is believed to be independent of glycemic control. Neurologists are often involved in the management of modifiable risk factors for stroke (including hypertension, hyperlipidemia, and atrial fibrillation), but less often in the direct management of diabetes. This review provides an overview of the relationships between diabetes and stroke, including epidemiology, pathophysiology, post-stroke outcomes, and treatments for people with stroke and diabetes. This should aid neurologists in diabetes-related decision-making when treating people with acute or recurrent stroke.

BACKGROUND AND PURPOSE: The rate and outcomes of neurologic complications of patients receiving extracorporeal membrane oxygenation (ECMO) are poorly understood. The purpose of this study was to identify these parameters in ECMO patients. METHODS: All patients receiving ECMO were selected from the Nationwide Inpatient Sample between 2001-2011. The rate and outcomes of neurologic complications [acute ischemic stroke, intracranial hemorrhage (ICH), and seizures] among these patients was determined. Discharge status, mortality, length of stay, and hospitalization costs were compared between patients with and without neurologic complications using chi-squared tests for categorical variables and Student's t-test for continuous variables. RESULTS: In total, 23,951 patients were included in this study, of which 2,604 (10.9%) suffered neurologic complications of seizure (4.1%), stroke (4.1%), or ICH (3.6%). When compared to patients without neurologic complications, acute ischemic stroke patients had significantly higher rates of discharge to a long-term facility (12.2% vs. 6.8%, p<0.0001) and a significantly longer mean length of stay (41.6 days vs. 31.9 days, p<0.0001). ICH patients had significantly higher rates of discharge to a long-term facility (9.5% vs. 6.8%, p=0.007), significantly higher mortality rates (59.7% vs. 50.0%, p<0.0001), and a significantly longer mean length of stay (41.8 days vs. 31.9 days) compared to patients without neurologic complications. These outcomes did not differ significantly between seizure patients and patients without neurologic complications. CONCLUSIONS: Given the increasing utilization of ECMO and the high costs and poor outcomes associated with neurologic complications, more research is needed to help determine the best way to prevent these sequelae in this patient population.
Extracorporeal Membrane Oxygenation* ; Hospitalization ; Humans ; Inpatients ; Intracranial Hemorrhages ; Length of Stay ; Mortality ; Seizures ; Stroke

BACKGROUND AND PURPOSE: Aggressive treatment of posterior-circulation occlusions is important due to the high rates of morbidity and mortality associated with these infarctions. A large administrative database was evaluated to determine the outcomes of mechanical thrombectomy and intravenous tissue plasminogen activator (IV-tPA) for the treatment of posterior-circulation (vertebrobasilar) strokes. Outcomes were compared across age groups. METHODS: The United States Nationwide Inpatient Sample was used to evaluate the outcomes of patients treated for posterior-circulation acute ischemic stroke between 2006 and 2010. Patients who underwent endovascular mechanical thrombectomy and IV-tPA were selected. Primary outcomes were discharge status and mortality; secondary outcomes were length of stay, rate of intracranial hemorrhage, tracheostomy, and percutaneous endoscopic gastrostomy/jejunostomy tube placement. Outcomes were grouped according to age (i.e., <50, 50-64, and > or =65 years). Chi-squared test and Student's t-test were used for comparisons of categorical and continuous variables, respectively. RESULTS: During 2006-2010 there were 36,675 patients who had discharge International Classification of Diseases (9th edition) codes indicating posterior-circulation strokes. Of these, 631 (1.7%) underwent mechanical thrombectomy and 1554 (4.2%) underwent IV-tPA. The in-hospital mortality rate for mechanical thrombectomy patients was significantly lower for those aged <50 years than for those aged 50-64 years (30.4% versus 47.4%, p<0.01) and those aged > or =65 years (30.4% versus 43.0%, p< or =0.01). Age had no effect on the in-hospital mortality for IV-tPA patients, with an incidence of 22.7% for patients aged <50 years, compared to 25.4% for patients aged 50-64 years (p=0.46) and 23.0% for patients aged > or =65 years (p=0.92). CONCLUSIONS: Patients requiring IV-tPA and/or mechanical thrombectomy for the treatment of posterior-circulation strokes suffer from high mortality rates. Increased age is associated with significantly higher mortality rates among posterior-circulation stroke patients who require mechanical thrombectomy.
Brain Infarction ; Endovascular Procedures ; Hospital Mortality ; Humans ; Incidence ; Infarction ; Inpatients ; International Classification of Diseases ; Intracranial Hemorrhages ; Length of Stay ; Mortality ; Stroke* ; Thrombectomy* ; Tissue Plasminogen Activator* ; Tracheostomy ; United States