Literature Review

Women age 65 and older who endorse subjective memory complaints have an increased risk of cognitive impairment 18 years later, compared with women who do not endorse subjective memory complaints, according to research published online ahead of print October 28 in Neurology. The findings suggest that subjective memory complaints “may be a very early symptom of an insidious neurodegenerative disease process, such as Alzheimer’s disease,” said Allison R. Kaup, PhD, Assistant Professor of Psychiatry at University of California, San Francisco School of Medicine.

Most prior studies that evaluated the association between subjective memory complaints and later cognitive impairment followed participants for only a few years. To investigate the association over 18 years, Dr. Kaup and her research colleagues conducted a study of 1,107 community-dwelling women in the prospective Women, Cognitive Impairment Study of Exceptional Aging, an ancillary study of the Study of Osteoporotic Fractures. All of the women included in the analysis were Caucasian, age 65 or older, and cognitively normal at baseline.

The investigators assessed subjective memory complaints at baseline by having participants answer a “yes/no” question from the 15-item Geriatric Depression Scale: “Do you feel you have more problems with memory than most?” Participants answered the same question four, eight, and 14 years later. A final evaluation of cognitive status was conducted 18 years after the baseline assessment to diagnose mild cognitive impairment (MCI) and dementia.

The researchers used logistic regression to investigate the association between subjective memory complaints over time and risk of cognitive impairment. They adjusted for demographics, baseline cognition, and characteristics that differed between those with and without subjective memory complaints.

The percentage of participants who reported subjective memory complaints was 8.2% at baseline, 5.6% at four years, 7.3% at eight years, and 8.3% at 14 years. Those with subjective memory complaints at baseline had an increased risk of cognitive impairment 18 years later (adjusted odds ratio, 1.7). Excluding participants with baseline depression did not change the effect of subjective memory complaints. Those with subjective memory complaints at four, eight, and 14 years also had an increased risk of cognitive impairment at 18 years, with the strongest association closest to the diagnostic evaluation (adjusted odds ratios of 1.6, 1.9, and 3, respectively).

“This timing pattern suggests that subjective memory complaints may signal an insidious disease process as it first emerges and continues to unfold,” the researchers said. The risk of cognitive impairment at 18 years was higher in women who reported persistent patterns of subjective memory complaints as well as those who answered “yes” to the question at any single evaluation point during the study, compared with women who consistently answered “no.”

The associations, particularly in the earlier years, “are somewhat modest,” said the investigators. “There may be other reasons for an older adult to endorse subjective memory complaints that do not necessarily lead to the development of MCI or dementia.”

The study did not track the exact point at which participants converted to cognitive impairment, and the findings cannot be generalized to men or to other racial or ethnic groups. In addition, some survival bias is likely because the women in the study were generally in good health, the authors noted.

Future dementia prevention trials should target older women with subjective memory complaints as a high-risk group, Dr. Kaup and colleagues said. In addition, the results support the ideas that clinical providers should consider routine assessment of subjective memory complaints in older patients and that relatively brief assessments may be valuable screening tools, they concluded.

—Linda Peckel

Women age 65 and older who endorse subjective memory complaints have an increased risk of cognitive impairment 18 years later, compared with women who do not endorse subjective memory complaints, according to research published online ahead of print October 28 in Neurology. The findings suggest that subjective memory complaints “may be a very early symptom of an insidious neurodegenerative disease process, such as Alzheimer’s disease,” said Allison R. Kaup, PhD, Assistant Professor of Psychiatry at University of California, San Francisco School of Medicine.

Most prior studies that evaluated the association between subjective memory complaints and later cognitive impairment followed participants for only a few years. To investigate the association over 18 years, Dr. Kaup and her research colleagues conducted a study of 1,107 community-dwelling women in the prospective Women, Cognitive Impairment Study of Exceptional Aging, an ancillary study of the Study of Osteoporotic Fractures. All of the women included in the analysis were Caucasian, age 65 or older, and cognitively normal at baseline.

The investigators assessed subjective memory complaints at baseline by having participants answer a “yes/no” question from the 15-item Geriatric Depression Scale: “Do you feel you have more problems with memory than most?” Participants answered the same question four, eight, and 14 years later. A final evaluation of cognitive status was conducted 18 years after the baseline assessment to diagnose mild cognitive impairment (MCI) and dementia.

The researchers used logistic regression to investigate the association between subjective memory complaints over time and risk of cognitive impairment. They adjusted for demographics, baseline cognition, and characteristics that differed between those with and without subjective memory complaints.

The percentage of participants who reported subjective memory complaints was 8.2% at baseline, 5.6% at four years, 7.3% at eight years, and 8.3% at 14 years. Those with subjective memory complaints at baseline had an increased risk of cognitive impairment 18 years later (adjusted odds ratio, 1.7). Excluding participants with baseline depression did not change the effect of subjective memory complaints. Those with subjective memory complaints at four, eight, and 14 years also had an increased risk of cognitive impairment at 18 years, with the strongest association closest to the diagnostic evaluation (adjusted odds ratios of 1.6, 1.9, and 3, respectively).

“This timing pattern suggests that subjective memory complaints may signal an insidious disease process as it first emerges and continues to unfold,” the researchers said. The risk of cognitive impairment at 18 years was higher in women who reported persistent patterns of subjective memory complaints as well as those who answered “yes” to the question at any single evaluation point during the study, compared with women who consistently answered “no.”

The associations, particularly in the earlier years, “are somewhat modest,” said the investigators. “There may be other reasons for an older adult to endorse subjective memory complaints that do not necessarily lead to the development of MCI or dementia.”

The study did not track the exact point at which participants converted to cognitive impairment, and the findings cannot be generalized to men or to other racial or ethnic groups. In addition, some survival bias is likely because the women in the study were generally in good health, the authors noted.

Future dementia prevention trials should target older women with subjective memory complaints as a high-risk group, Dr. Kaup and colleagues said. In addition, the results support the ideas that clinical providers should consider routine assessment of subjective memory complaints in older patients and that relatively brief assessments may be valuable screening tools, they concluded.

—Linda Peckel

Women age 65 and older who endorse subjective memory complaints have an increased risk of cognitive impairment 18 years later, compared with women who do not endorse subjective memory complaints, according to research published online ahead of print October 28 in Neurology. The findings suggest that subjective memory complaints “may be a very early symptom of an insidious neurodegenerative disease process, such as Alzheimer’s disease,” said Allison R. Kaup, PhD, Assistant Professor of Psychiatry at University of California, San Francisco School of Medicine.

Most prior studies that evaluated the association between subjective memory complaints and later cognitive impairment followed participants for only a few years. To investigate the association over 18 years, Dr. Kaup and her research colleagues conducted a study of 1,107 community-dwelling women in the prospective Women, Cognitive Impairment Study of Exceptional Aging, an ancillary study of the Study of Osteoporotic Fractures. All of the women included in the analysis were Caucasian, age 65 or older, and cognitively normal at baseline.

The investigators assessed subjective memory complaints at baseline by having participants answer a “yes/no” question from the 15-item Geriatric Depression Scale: “Do you feel you have more problems with memory than most?” Participants answered the same question four, eight, and 14 years later. A final evaluation of cognitive status was conducted 18 years after the baseline assessment to diagnose mild cognitive impairment (MCI) and dementia.

The researchers used logistic regression to investigate the association between subjective memory complaints over time and risk of cognitive impairment. They adjusted for demographics, baseline cognition, and characteristics that differed between those with and without subjective memory complaints.

The percentage of participants who reported subjective memory complaints was 8.2% at baseline, 5.6% at four years, 7.3% at eight years, and 8.3% at 14 years. Those with subjective memory complaints at baseline had an increased risk of cognitive impairment 18 years later (adjusted odds ratio, 1.7). Excluding participants with baseline depression did not change the effect of subjective memory complaints. Those with subjective memory complaints at four, eight, and 14 years also had an increased risk of cognitive impairment at 18 years, with the strongest association closest to the diagnostic evaluation (adjusted odds ratios of 1.6, 1.9, and 3, respectively).

“This timing pattern suggests that subjective memory complaints may signal an insidious disease process as it first emerges and continues to unfold,” the researchers said. The risk of cognitive impairment at 18 years was higher in women who reported persistent patterns of subjective memory complaints as well as those who answered “yes” to the question at any single evaluation point during the study, compared with women who consistently answered “no.”

The associations, particularly in the earlier years, “are somewhat modest,” said the investigators. “There may be other reasons for an older adult to endorse subjective memory complaints that do not necessarily lead to the development of MCI or dementia.”

The study did not track the exact point at which participants converted to cognitive impairment, and the findings cannot be generalized to men or to other racial or ethnic groups. In addition, some survival bias is likely because the women in the study were generally in good health, the authors noted.

Future dementia prevention trials should target older women with subjective memory complaints as a high-risk group, Dr. Kaup and colleagues said. In addition, the results support the ideas that clinical providers should consider routine assessment of subjective memory complaints in older patients and that relatively brief assessments may be valuable screening tools, they concluded.

—Linda Peckel

The prevalence of marijuana use more than doubled between 2001–2002 and 2012–2013, according to an article published online ahead of print October 21 in JAMA Psychiatry. According to the report, there was a simultaneous increase in marijuana use disorders. “While not all marijuana users experience problems, nearly three of 10 marijuana users manifested a marijuana use disorder in 2012–2013,” reported lead author Deborah S. Hasin, PhD, and colleagues. Dr. Hasin is Professor of Clinical Epidemiology in the Department of Psychiatry at Columbia University’s College of Physicians and Surgeons in New York.

Social attitudes and legal perspectives about marijuana are becoming more permissive, but little is known about whether the prevalence rates of marijuana use and marijuana use disorders have changed in the 21st century. Dr. Hasin and colleagues sought to create a nationally representative profile of the past-year prevalence of marijuana use and marijuana use disorders among the US general population to determine whether prevalence rates have changed over the past decade.

Using the data collected by the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) from 2001–2002 and from the NESARC-III from 2012–2013, the researchers were able to draw conclusions about the changing prevalence of marijuana use in the US. According to the researchers’ report, the estimated prevalence of marijuana use in 2001–2002 was 4.1%, and in 2012–2013 it had risen to 9.5%. The prevalence of DSM-IV marijuana use disorders (ie, abuse or dependence) was 1.5% in 2001–2002 and 2.9% in 2012–2013.

Subgroups that experienced a more exaggerated increase in marijuana use included women and individuals who were black, Hispanic, living in the South, and those who were middle-age or older. Subgroups with sharper increases in the prevalence of marijuana use disorders included individuals between ages 45 and 64, blacks, Hispanics, and those with the lowest incomes or living in the South.

Regarding the near doubling of marijuana use disorder prevalence, the authors speculated that the phenomenon may be due to the doubling of number of total users. The researchers found that the number of marijuana use disorders actually decreased among past-year users from 35.6% to 30.6% from 2001 to 2013. The authors noted, “If the prevalence of marijuana users in the adult general population continues to increase, then the numbers of those with marijuana use disorders may increase as well” to explain the increase in use disorder among all users studied.

“While many in the United States think prohibition of recreational marijuana should be ended, this study and others suggest caution and the need for public education about the potential harms in marijuana use, including the risk for addiction,” the researchers wrote. “As is the case with alcohol, many individuals can use marijuana without becoming addicted. However, the clear risk for marijuana use disorders among users (approximately 30%) suggests that as the number of US users grows, so will the number of those experiencing problems related to such use. This information is important to convey in a balanced manner to health care professionals, policy makers, and the public.”

—Ashley Payton

The prevalence of marijuana use more than doubled between 2001–2002 and 2012–2013, according to an article published online ahead of print October 21 in JAMA Psychiatry. According to the report, there was a simultaneous increase in marijuana use disorders. “While not all marijuana users experience problems, nearly three of 10 marijuana users manifested a marijuana use disorder in 2012–2013,” reported lead author Deborah S. Hasin, PhD, and colleagues. Dr. Hasin is Professor of Clinical Epidemiology in the Department of Psychiatry at Columbia University’s College of Physicians and Surgeons in New York.

Social attitudes and legal perspectives about marijuana are becoming more permissive, but little is known about whether the prevalence rates of marijuana use and marijuana use disorders have changed in the 21st century. Dr. Hasin and colleagues sought to create a nationally representative profile of the past-year prevalence of marijuana use and marijuana use disorders among the US general population to determine whether prevalence rates have changed over the past decade.

Using the data collected by the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) from 2001–2002 and from the NESARC-III from 2012–2013, the researchers were able to draw conclusions about the changing prevalence of marijuana use in the US. According to the researchers’ report, the estimated prevalence of marijuana use in 2001–2002 was 4.1%, and in 2012–2013 it had risen to 9.5%. The prevalence of DSM-IV marijuana use disorders (ie, abuse or dependence) was 1.5% in 2001–2002 and 2.9% in 2012–2013.

Subgroups that experienced a more exaggerated increase in marijuana use included women and individuals who were black, Hispanic, living in the South, and those who were middle-age or older. Subgroups with sharper increases in the prevalence of marijuana use disorders included individuals between ages 45 and 64, blacks, Hispanics, and those with the lowest incomes or living in the South.

Regarding the near doubling of marijuana use disorder prevalence, the authors speculated that the phenomenon may be due to the doubling of number of total users. The researchers found that the number of marijuana use disorders actually decreased among past-year users from 35.6% to 30.6% from 2001 to 2013. The authors noted, “If the prevalence of marijuana users in the adult general population continues to increase, then the numbers of those with marijuana use disorders may increase as well” to explain the increase in use disorder among all users studied.

“While many in the United States think prohibition of recreational marijuana should be ended, this study and others suggest caution and the need for public education about the potential harms in marijuana use, including the risk for addiction,” the researchers wrote. “As is the case with alcohol, many individuals can use marijuana without becoming addicted. However, the clear risk for marijuana use disorders among users (approximately 30%) suggests that as the number of US users grows, so will the number of those experiencing problems related to such use. This information is important to convey in a balanced manner to health care professionals, policy makers, and the public.”

—Ashley Payton

The prevalence of marijuana use more than doubled between 2001–2002 and 2012–2013, according to an article published online ahead of print October 21 in JAMA Psychiatry. According to the report, there was a simultaneous increase in marijuana use disorders. “While not all marijuana users experience problems, nearly three of 10 marijuana users manifested a marijuana use disorder in 2012–2013,” reported lead author Deborah S. Hasin, PhD, and colleagues. Dr. Hasin is Professor of Clinical Epidemiology in the Department of Psychiatry at Columbia University’s College of Physicians and Surgeons in New York.

Social attitudes and legal perspectives about marijuana are becoming more permissive, but little is known about whether the prevalence rates of marijuana use and marijuana use disorders have changed in the 21st century. Dr. Hasin and colleagues sought to create a nationally representative profile of the past-year prevalence of marijuana use and marijuana use disorders among the US general population to determine whether prevalence rates have changed over the past decade.

Using the data collected by the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) from 2001–2002 and from the NESARC-III from 2012–2013, the researchers were able to draw conclusions about the changing prevalence of marijuana use in the US. According to the researchers’ report, the estimated prevalence of marijuana use in 2001–2002 was 4.1%, and in 2012–2013 it had risen to 9.5%. The prevalence of DSM-IV marijuana use disorders (ie, abuse or dependence) was 1.5% in 2001–2002 and 2.9% in 2012–2013.

Subgroups that experienced a more exaggerated increase in marijuana use included women and individuals who were black, Hispanic, living in the South, and those who were middle-age or older. Subgroups with sharper increases in the prevalence of marijuana use disorders included individuals between ages 45 and 64, blacks, Hispanics, and those with the lowest incomes or living in the South.

Regarding the near doubling of marijuana use disorder prevalence, the authors speculated that the phenomenon may be due to the doubling of number of total users. The researchers found that the number of marijuana use disorders actually decreased among past-year users from 35.6% to 30.6% from 2001 to 2013. The authors noted, “If the prevalence of marijuana users in the adult general population continues to increase, then the numbers of those with marijuana use disorders may increase as well” to explain the increase in use disorder among all users studied.

“While many in the United States think prohibition of recreational marijuana should be ended, this study and others suggest caution and the need for public education about the potential harms in marijuana use, including the risk for addiction,” the researchers wrote. “As is the case with alcohol, many individuals can use marijuana without becoming addicted. However, the clear risk for marijuana use disorders among users (approximately 30%) suggests that as the number of US users grows, so will the number of those experiencing problems related to such use. This information is important to convey in a balanced manner to health care professionals, policy makers, and the public.”

—Ashley Payton

Among patients with subarachnoid hemorrhage, loss of consciousness at symptom onset is independently associated with death and poor functional outcomes at one year, according to data published online ahead of print November 9 in JAMA Neurology. The findings indicate that loss of consciousness, one of the most common presenting symptoms of subarachnoid hemorrhage, “is a simple and robust indicator of a severe bleeding event,” said Sureerat Suwatcharangkoon, MD, of the Neurological Intensive Care Unit at Columbia University Medical Center in New York and Mahidol University’s Ramathibodi Hospital in Bangkok.

Patients who lost consciousness had significantly larger subarachnoid, intraventricular, and parenchymal intracerebral hemorrhages on admission CT scan findings, compared with patients who did not lose consciousness. “Loss of consciousness has important prognostic value, implying a more than 2.8-fold increase in the risk of death or severe disability at one year, even after controlling for age, admission clinical grade, aneurysm size, and admission physiological derangements,” Dr. Suwatcharangkoon and colleagues said.

A Retrospective Analysis

To clarify the association between loss of consciousness at subarachnoid hemorrhage onset and patient outcomes, the researchers conducted a retrospective analysis of 1,460 consecutively treated patients with spontaneous subarachnoid hemorrhage who were part of the Columbia University Subarachnoid Hemorrhage Outcomes Project (SHOP). Patients were enrolled in the prospective observational cohort study between August 6, 1996, and July 23, 2012. Researchers conducted the analysis from December 1, 2013, to February 28, 2015. The mean patient age was 55. One-third of the patients were men.

Subarachnoid hemorrhage was diagnosed using CT scan or xanthochromia in the CSF. The researchers excluded patients with traumatic subarachnoid hemorrhage and arteriovenous malformation, those younger than 18, and those who were hospitalized more than 14 days after the onset of subarachnoid hemorrhage. Loss of consciousness was broadly defined as any sudden, abnormal alteration of alertness, awareness, or responsiveness to sensory stimuli at symptom onset during the prehospital phase of the illness. The researchers conducted structured interviews with the patients and first responders to identify loss of consciousness. The investigators followed patients for as long as one year to assess functional recovery and assigned modified Rankin Scale (mRS) scores based on telephone or in-person interviews with the patients, family members, or caregivers. One-year outcomes were imputed using discharge or three-month data for approximately 20% of patients who were lost to follow-up.

Risk of Poor Outcome

In this cohort, 590 patients (40.4%) reported loss of consciousness at onset of subarachnoid hemorrhage. The investigators found that 51.2% of patients with loss of consciousness were dead or severely disabled at 12 months (ie, mRS score of 4–6), compared with 17.7% of patients who did not lose consciousness. After excluding patients with prehospital cardiac arrest, witnessed tonic-clonic activity at onset, or poor grade on admission (ie, Hunt and Hess score of 4 or 5), loss of consciousness remained significantly related to functional outcome at 12 months (odds ratio, 2.0).

Loss of consciousness was associated with a higher frequency of global cerebral edema as well as more prehospital tonic-clonic activity (22.7% vs 4.2%) and cardiopulmonary arrest (9.7% vs 0.5%) at admission, compared with no loss of consciousness. There were no differences in age, gender, race/ethnicity, or systolic blood pressure between patients with and without loss of consciousness.

Patients with loss of consciousness were more likely to have their aneurysms coiled than clipped. They were treated on average one-half day earlier than patients who did not lose consciousness, the researchers said.

Duration of Loss of Consciousness

Starting in 2002, the researchers recorded duration of loss of consciousness. Among the 443 patients whose duration of loss of consciousness was recorded, 169 (38.1%) lost consciousness for less than 10 minutes, 93 (21%) for 10 to 60 minutes, and 181 (40.9%) for longer than 60 minutes. If loss of consciousness lasted less than 10 minutes, the risk of presenting with a Hunt and Hess scale score of 4 or 5 was 16.0% and 6.5%, respectively. If it lasted more than an hour, the risk was 21.5% and 67.4%, respectively.

Unlike in prior studies, loss of consciousness was not independently associated with subsequent delayed cerebral ischemia or aneurysm rebleeding. The researchers speculated that lower rates of those events in their study due to modernized care may be one reason why the associations seen in prior studies were not replicated. One limitation of the study was that researchers depended on patient histories to identify loss of consciousness.

“Given its strong association with global cerebral edema and poor admission clinical grade, loss of consciousness should be considered a straightforward and clinically important marker of early brain injury after subarachnoid hemorrhage, with ominous implications,” the researchers concluded. “In the future, the presence or absence of loss of consciousness may be useful for risk stratification and targeting therapy designed to minimize the effects of early brain injury after subarachnoid hemorrhage.”

—Jake Remaly

Among patients with subarachnoid hemorrhage, loss of consciousness at symptom onset is independently associated with death and poor functional outcomes at one year, according to data published online ahead of print November 9 in JAMA Neurology. The findings indicate that loss of consciousness, one of the most common presenting symptoms of subarachnoid hemorrhage, “is a simple and robust indicator of a severe bleeding event,” said Sureerat Suwatcharangkoon, MD, of the Neurological Intensive Care Unit at Columbia University Medical Center in New York and Mahidol University’s Ramathibodi Hospital in Bangkok.

Patients who lost consciousness had significantly larger subarachnoid, intraventricular, and parenchymal intracerebral hemorrhages on admission CT scan findings, compared with patients who did not lose consciousness. “Loss of consciousness has important prognostic value, implying a more than 2.8-fold increase in the risk of death or severe disability at one year, even after controlling for age, admission clinical grade, aneurysm size, and admission physiological derangements,” Dr. Suwatcharangkoon and colleagues said.

A Retrospective Analysis

To clarify the association between loss of consciousness at subarachnoid hemorrhage onset and patient outcomes, the researchers conducted a retrospective analysis of 1,460 consecutively treated patients with spontaneous subarachnoid hemorrhage who were part of the Columbia University Subarachnoid Hemorrhage Outcomes Project (SHOP). Patients were enrolled in the prospective observational cohort study between August 6, 1996, and July 23, 2012. Researchers conducted the analysis from December 1, 2013, to February 28, 2015. The mean patient age was 55. One-third of the patients were men.

Subarachnoid hemorrhage was diagnosed using CT scan or xanthochromia in the CSF. The researchers excluded patients with traumatic subarachnoid hemorrhage and arteriovenous malformation, those younger than 18, and those who were hospitalized more than 14 days after the onset of subarachnoid hemorrhage. Loss of consciousness was broadly defined as any sudden, abnormal alteration of alertness, awareness, or responsiveness to sensory stimuli at symptom onset during the prehospital phase of the illness. The researchers conducted structured interviews with the patients and first responders to identify loss of consciousness. The investigators followed patients for as long as one year to assess functional recovery and assigned modified Rankin Scale (mRS) scores based on telephone or in-person interviews with the patients, family members, or caregivers. One-year outcomes were imputed using discharge or three-month data for approximately 20% of patients who were lost to follow-up.

Risk of Poor Outcome

In this cohort, 590 patients (40.4%) reported loss of consciousness at onset of subarachnoid hemorrhage. The investigators found that 51.2% of patients with loss of consciousness were dead or severely disabled at 12 months (ie, mRS score of 4–6), compared with 17.7% of patients who did not lose consciousness. After excluding patients with prehospital cardiac arrest, witnessed tonic-clonic activity at onset, or poor grade on admission (ie, Hunt and Hess score of 4 or 5), loss of consciousness remained significantly related to functional outcome at 12 months (odds ratio, 2.0).

Loss of consciousness was associated with a higher frequency of global cerebral edema as well as more prehospital tonic-clonic activity (22.7% vs 4.2%) and cardiopulmonary arrest (9.7% vs 0.5%) at admission, compared with no loss of consciousness. There were no differences in age, gender, race/ethnicity, or systolic blood pressure between patients with and without loss of consciousness.

Patients with loss of consciousness were more likely to have their aneurysms coiled than clipped. They were treated on average one-half day earlier than patients who did not lose consciousness, the researchers said.

Duration of Loss of Consciousness

Starting in 2002, the researchers recorded duration of loss of consciousness. Among the 443 patients whose duration of loss of consciousness was recorded, 169 (38.1%) lost consciousness for less than 10 minutes, 93 (21%) for 10 to 60 minutes, and 181 (40.9%) for longer than 60 minutes. If loss of consciousness lasted less than 10 minutes, the risk of presenting with a Hunt and Hess scale score of 4 or 5 was 16.0% and 6.5%, respectively. If it lasted more than an hour, the risk was 21.5% and 67.4%, respectively.

Unlike in prior studies, loss of consciousness was not independently associated with subsequent delayed cerebral ischemia or aneurysm rebleeding. The researchers speculated that lower rates of those events in their study due to modernized care may be one reason why the associations seen in prior studies were not replicated. One limitation of the study was that researchers depended on patient histories to identify loss of consciousness.

“Given its strong association with global cerebral edema and poor admission clinical grade, loss of consciousness should be considered a straightforward and clinically important marker of early brain injury after subarachnoid hemorrhage, with ominous implications,” the researchers concluded. “In the future, the presence or absence of loss of consciousness may be useful for risk stratification and targeting therapy designed to minimize the effects of early brain injury after subarachnoid hemorrhage.”

—Jake Remaly

Among patients with subarachnoid hemorrhage, loss of consciousness at symptom onset is independently associated with death and poor functional outcomes at one year, according to data published online ahead of print November 9 in JAMA Neurology. The findings indicate that loss of consciousness, one of the most common presenting symptoms of subarachnoid hemorrhage, “is a simple and robust indicator of a severe bleeding event,” said Sureerat Suwatcharangkoon, MD, of the Neurological Intensive Care Unit at Columbia University Medical Center in New York and Mahidol University’s Ramathibodi Hospital in Bangkok.

Patients who lost consciousness had significantly larger subarachnoid, intraventricular, and parenchymal intracerebral hemorrhages on admission CT scan findings, compared with patients who did not lose consciousness. “Loss of consciousness has important prognostic value, implying a more than 2.8-fold increase in the risk of death or severe disability at one year, even after controlling for age, admission clinical grade, aneurysm size, and admission physiological derangements,” Dr. Suwatcharangkoon and colleagues said.

A Retrospective Analysis

To clarify the association between loss of consciousness at subarachnoid hemorrhage onset and patient outcomes, the researchers conducted a retrospective analysis of 1,460 consecutively treated patients with spontaneous subarachnoid hemorrhage who were part of the Columbia University Subarachnoid Hemorrhage Outcomes Project (SHOP). Patients were enrolled in the prospective observational cohort study between August 6, 1996, and July 23, 2012. Researchers conducted the analysis from December 1, 2013, to February 28, 2015. The mean patient age was 55. One-third of the patients were men.

Subarachnoid hemorrhage was diagnosed using CT scan or xanthochromia in the CSF. The researchers excluded patients with traumatic subarachnoid hemorrhage and arteriovenous malformation, those younger than 18, and those who were hospitalized more than 14 days after the onset of subarachnoid hemorrhage. Loss of consciousness was broadly defined as any sudden, abnormal alteration of alertness, awareness, or responsiveness to sensory stimuli at symptom onset during the prehospital phase of the illness. The researchers conducted structured interviews with the patients and first responders to identify loss of consciousness. The investigators followed patients for as long as one year to assess functional recovery and assigned modified Rankin Scale (mRS) scores based on telephone or in-person interviews with the patients, family members, or caregivers. One-year outcomes were imputed using discharge or three-month data for approximately 20% of patients who were lost to follow-up.

Risk of Poor Outcome

In this cohort, 590 patients (40.4%) reported loss of consciousness at onset of subarachnoid hemorrhage. The investigators found that 51.2% of patients with loss of consciousness were dead or severely disabled at 12 months (ie, mRS score of 4–6), compared with 17.7% of patients who did not lose consciousness. After excluding patients with prehospital cardiac arrest, witnessed tonic-clonic activity at onset, or poor grade on admission (ie, Hunt and Hess score of 4 or 5), loss of consciousness remained significantly related to functional outcome at 12 months (odds ratio, 2.0).

Loss of consciousness was associated with a higher frequency of global cerebral edema as well as more prehospital tonic-clonic activity (22.7% vs 4.2%) and cardiopulmonary arrest (9.7% vs 0.5%) at admission, compared with no loss of consciousness. There were no differences in age, gender, race/ethnicity, or systolic blood pressure between patients with and without loss of consciousness.

Patients with loss of consciousness were more likely to have their aneurysms coiled than clipped. They were treated on average one-half day earlier than patients who did not lose consciousness, the researchers said.

Duration of Loss of Consciousness

Starting in 2002, the researchers recorded duration of loss of consciousness. Among the 443 patients whose duration of loss of consciousness was recorded, 169 (38.1%) lost consciousness for less than 10 minutes, 93 (21%) for 10 to 60 minutes, and 181 (40.9%) for longer than 60 minutes. If loss of consciousness lasted less than 10 minutes, the risk of presenting with a Hunt and Hess scale score of 4 or 5 was 16.0% and 6.5%, respectively. If it lasted more than an hour, the risk was 21.5% and 67.4%, respectively.

Unlike in prior studies, loss of consciousness was not independently associated with subsequent delayed cerebral ischemia or aneurysm rebleeding. The researchers speculated that lower rates of those events in their study due to modernized care may be one reason why the associations seen in prior studies were not replicated. One limitation of the study was that researchers depended on patient histories to identify loss of consciousness.

“Given its strong association with global cerebral edema and poor admission clinical grade, loss of consciousness should be considered a straightforward and clinically important marker of early brain injury after subarachnoid hemorrhage, with ominous implications,” the researchers concluded. “In the future, the presence or absence of loss of consciousness may be useful for risk stratification and targeting therapy designed to minimize the effects of early brain injury after subarachnoid hemorrhage.”

—Jake Remaly

Among adult patients with medically refractory partial-onset seizures, treatment with responsive neurostimulation is not associated with cognitive decline over two years, according to data published in the November issue of Epilepsia. The therapy may in fact induce small but significant improvements in naming among patients with neocortical seizure onset and modest improvements in verbal learning among patients with seizure onset in the mesial temporal lobe.

“These findings require replication but suggest potential cognitive therapeutic benefit associated with responsive neurostimulation,” said David W. Loring, PhD, Professor of Neurology and Pediatrics and Director of Neuropsychology in the Neurology Department at Emory University in Atlanta. “It is unclear if these effects are due to a direct positive effect on the stimulated structures or to modulatory reductions in the adverse effects of seizures or interictal discharges.”

Blinded and Open-Label Stimulation

Neurostimulation has been associated with declines in verbal fluency among patients with Parkinson’s disease, and with a decreased rate of cognitive decline among patients with Alzheimer’s disease. Patients with intractable partial seizures who received deep brain stimulation (DBS) complained of poorer memory and mood, although they had no evidence of neuropsychologic declines.

Dr. Loring and colleagues sought to determine the effect of long-term responsive neurostimulation on neuropsychologic performance among patients with epilepsy. The researchers examined data from a double-blind, randomized, sham-stimulation controlled study of the RNS System, which is manufactured by NeuroPace. Participants were between ages 18 and 66 and had an average of three or more simple partial motor, complex partial, or secondarily generalized tonic–clonic seizures per month. All participants had inadequate seizure control with at least two antiepileptic drugs (AEDs).

After a three-month baseline period, patients received implantation of the neurostimulator and leads. The device was programmed immediately to detect specific patterns of brain activity. One month after implantation, patients were randomized in groups of equal size to receive active or sham stimulation in response to detections. Participants were followed for four months before they received open-label responsive neurostimulation for 18 months.

The researchers collected neuropsychologic data at baseline and during the open-label period at one and two years after implantation. Primary neuropsychologic tests included the Boston Naming Test (BNT) and the Rey Auditory Verbal Learning Test (AVLT). Additional neuropsychologic domains were analyzed as secondary outcomes.

Seizure-Onset Zone Affected Outcomes

Data for 175 patients were analyzed. The study population’s average age was approximately 35, and 18% of participants were female. In all, 86 patients had seizure onset in the mesial temporal lobe, and 76 had seizure onset in the neocortex. Thirteen patients had seizure onset in both regions. They were included in analyses of all participants, but not in analyses according to seizure-onset zone.

Dr. Loring and colleagues observed no significant group performance decline on any neuropsychologic outcome measure. They did, however, find significant improvements on the BNT in 23.5% of participants. Approximately 7% of participants had declines on the BNT. The investigators also noted statistically significant improvements on the AVLT in 6.9% of patients. Approximately 1% of patients had declines on the AVLT. Dr. Loring and colleagues found a trend toward significant improvement on delayed AVLT recall, but no performance change for delayed AVLT recognition.

When the researchers analyzed the data according to seizure-onset zone, they found a significant improvement on the BNT among patients with neocortical seizure onsets. This improvement was not observed in participants with seizure onset in the mesial temporal lobe. In contrast, Dr. Loring’s group noted a significant overall improvement in AVLT learning in patients with seizure onset in the mesial temporal lobe, but not in patients with neocortical seizure onset. Adjusting the data for prior epilepsy surgery and for change in seizure frequency did not alter the results.

Improvements in naming and verbal memory are “an important observation, given the cognitive side effects of some AEDs and the presence of cognitive decline with DBS stimulation of the subthalamic nuclei or of the globus pallidus for Parkinson’s disease,” said Dr. Loring. “The double dissociation observed serves primarily to provide empirical evidence that neurostimulation techniques may ultimately provide therapeutic benefit, and to conceptually support future studies directed explicitly at establishing and optimizing neurostimulation parameters to enhance cognition.”

The fact that naming and verbal memory performance varied according to the seizure-onset region indicates that performance improvements were unlikely to be practice effects. “Practice effects are expected to occur at equal magnitudes in all clinical groups with comparable overall status,” said Dr. Loring. Nor did cognitive outcomes at two years appear to be associated with changes in AEDs.

“This series provides evidence that adults with frequent, intractable, partial onset seizures treated with responsive neurostimulation are not at increased risk for developing cognitive dysfunction, and that some aspects of cognition may be improved,” Dr. Loring concluded.

—Erik Greb

Among adult patients with medically refractory partial-onset seizures, treatment with responsive neurostimulation is not associated with cognitive decline over two years, according to data published in the November issue of Epilepsia. The therapy may in fact induce small but significant improvements in naming among patients with neocortical seizure onset and modest improvements in verbal learning among patients with seizure onset in the mesial temporal lobe.

“These findings require replication but suggest potential cognitive therapeutic benefit associated with responsive neurostimulation,” said David W. Loring, PhD, Professor of Neurology and Pediatrics and Director of Neuropsychology in the Neurology Department at Emory University in Atlanta. “It is unclear if these effects are due to a direct positive effect on the stimulated structures or to modulatory reductions in the adverse effects of seizures or interictal discharges.”

Blinded and Open-Label Stimulation

Neurostimulation has been associated with declines in verbal fluency among patients with Parkinson’s disease, and with a decreased rate of cognitive decline among patients with Alzheimer’s disease. Patients with intractable partial seizures who received deep brain stimulation (DBS) complained of poorer memory and mood, although they had no evidence of neuropsychologic declines.

Dr. Loring and colleagues sought to determine the effect of long-term responsive neurostimulation on neuropsychologic performance among patients with epilepsy. The researchers examined data from a double-blind, randomized, sham-stimulation controlled study of the RNS System, which is manufactured by NeuroPace. Participants were between ages 18 and 66 and had an average of three or more simple partial motor, complex partial, or secondarily generalized tonic–clonic seizures per month. All participants had inadequate seizure control with at least two antiepileptic drugs (AEDs).

After a three-month baseline period, patients received implantation of the neurostimulator and leads. The device was programmed immediately to detect specific patterns of brain activity. One month after implantation, patients were randomized in groups of equal size to receive active or sham stimulation in response to detections. Participants were followed for four months before they received open-label responsive neurostimulation for 18 months.

The researchers collected neuropsychologic data at baseline and during the open-label period at one and two years after implantation. Primary neuropsychologic tests included the Boston Naming Test (BNT) and the Rey Auditory Verbal Learning Test (AVLT). Additional neuropsychologic domains were analyzed as secondary outcomes.

Seizure-Onset Zone Affected Outcomes

Data for 175 patients were analyzed. The study population’s average age was approximately 35, and 18% of participants were female. In all, 86 patients had seizure onset in the mesial temporal lobe, and 76 had seizure onset in the neocortex. Thirteen patients had seizure onset in both regions. They were included in analyses of all participants, but not in analyses according to seizure-onset zone.

Dr. Loring and colleagues observed no significant group performance decline on any neuropsychologic outcome measure. They did, however, find significant improvements on the BNT in 23.5% of participants. Approximately 7% of participants had declines on the BNT. The investigators also noted statistically significant improvements on the AVLT in 6.9% of patients. Approximately 1% of patients had declines on the AVLT. Dr. Loring and colleagues found a trend toward significant improvement on delayed AVLT recall, but no performance change for delayed AVLT recognition.

When the researchers analyzed the data according to seizure-onset zone, they found a significant improvement on the BNT among patients with neocortical seizure onsets. This improvement was not observed in participants with seizure onset in the mesial temporal lobe. In contrast, Dr. Loring’s group noted a significant overall improvement in AVLT learning in patients with seizure onset in the mesial temporal lobe, but not in patients with neocortical seizure onset. Adjusting the data for prior epilepsy surgery and for change in seizure frequency did not alter the results.

Improvements in naming and verbal memory are “an important observation, given the cognitive side effects of some AEDs and the presence of cognitive decline with DBS stimulation of the subthalamic nuclei or of the globus pallidus for Parkinson’s disease,” said Dr. Loring. “The double dissociation observed serves primarily to provide empirical evidence that neurostimulation techniques may ultimately provide therapeutic benefit, and to conceptually support future studies directed explicitly at establishing and optimizing neurostimulation parameters to enhance cognition.”

The fact that naming and verbal memory performance varied according to the seizure-onset region indicates that performance improvements were unlikely to be practice effects. “Practice effects are expected to occur at equal magnitudes in all clinical groups with comparable overall status,” said Dr. Loring. Nor did cognitive outcomes at two years appear to be associated with changes in AEDs.

“This series provides evidence that adults with frequent, intractable, partial onset seizures treated with responsive neurostimulation are not at increased risk for developing cognitive dysfunction, and that some aspects of cognition may be improved,” Dr. Loring concluded.

—Erik Greb

Among adult patients with medically refractory partial-onset seizures, treatment with responsive neurostimulation is not associated with cognitive decline over two years, according to data published in the November issue of Epilepsia. The therapy may in fact induce small but significant improvements in naming among patients with neocortical seizure onset and modest improvements in verbal learning among patients with seizure onset in the mesial temporal lobe.

“These findings require replication but suggest potential cognitive therapeutic benefit associated with responsive neurostimulation,” said David W. Loring, PhD, Professor of Neurology and Pediatrics and Director of Neuropsychology in the Neurology Department at Emory University in Atlanta. “It is unclear if these effects are due to a direct positive effect on the stimulated structures or to modulatory reductions in the adverse effects of seizures or interictal discharges.”

Blinded and Open-Label Stimulation

Neurostimulation has been associated with declines in verbal fluency among patients with Parkinson’s disease, and with a decreased rate of cognitive decline among patients with Alzheimer’s disease. Patients with intractable partial seizures who received deep brain stimulation (DBS) complained of poorer memory and mood, although they had no evidence of neuropsychologic declines.

Dr. Loring and colleagues sought to determine the effect of long-term responsive neurostimulation on neuropsychologic performance among patients with epilepsy. The researchers examined data from a double-blind, randomized, sham-stimulation controlled study of the RNS System, which is manufactured by NeuroPace. Participants were between ages 18 and 66 and had an average of three or more simple partial motor, complex partial, or secondarily generalized tonic–clonic seizures per month. All participants had inadequate seizure control with at least two antiepileptic drugs (AEDs).

After a three-month baseline period, patients received implantation of the neurostimulator and leads. The device was programmed immediately to detect specific patterns of brain activity. One month after implantation, patients were randomized in groups of equal size to receive active or sham stimulation in response to detections. Participants were followed for four months before they received open-label responsive neurostimulation for 18 months.

The researchers collected neuropsychologic data at baseline and during the open-label period at one and two years after implantation. Primary neuropsychologic tests included the Boston Naming Test (BNT) and the Rey Auditory Verbal Learning Test (AVLT). Additional neuropsychologic domains were analyzed as secondary outcomes.

Seizure-Onset Zone Affected Outcomes

Data for 175 patients were analyzed. The study population’s average age was approximately 35, and 18% of participants were female. In all, 86 patients had seizure onset in the mesial temporal lobe, and 76 had seizure onset in the neocortex. Thirteen patients had seizure onset in both regions. They were included in analyses of all participants, but not in analyses according to seizure-onset zone.

Dr. Loring and colleagues observed no significant group performance decline on any neuropsychologic outcome measure. They did, however, find significant improvements on the BNT in 23.5% of participants. Approximately 7% of participants had declines on the BNT. The investigators also noted statistically significant improvements on the AVLT in 6.9% of patients. Approximately 1% of patients had declines on the AVLT. Dr. Loring and colleagues found a trend toward significant improvement on delayed AVLT recall, but no performance change for delayed AVLT recognition.

When the researchers analyzed the data according to seizure-onset zone, they found a significant improvement on the BNT among patients with neocortical seizure onsets. This improvement was not observed in participants with seizure onset in the mesial temporal lobe. In contrast, Dr. Loring’s group noted a significant overall improvement in AVLT learning in patients with seizure onset in the mesial temporal lobe, but not in patients with neocortical seizure onset. Adjusting the data for prior epilepsy surgery and for change in seizure frequency did not alter the results.

Improvements in naming and verbal memory are “an important observation, given the cognitive side effects of some AEDs and the presence of cognitive decline with DBS stimulation of the subthalamic nuclei or of the globus pallidus for Parkinson’s disease,” said Dr. Loring. “The double dissociation observed serves primarily to provide empirical evidence that neurostimulation techniques may ultimately provide therapeutic benefit, and to conceptually support future studies directed explicitly at establishing and optimizing neurostimulation parameters to enhance cognition.”

The fact that naming and verbal memory performance varied according to the seizure-onset region indicates that performance improvements were unlikely to be practice effects. “Practice effects are expected to occur at equal magnitudes in all clinical groups with comparable overall status,” said Dr. Loring. Nor did cognitive outcomes at two years appear to be associated with changes in AEDs.

“This series provides evidence that adults with frequent, intractable, partial onset seizures treated with responsive neurostimulation are not at increased risk for developing cognitive dysfunction, and that some aspects of cognition may be improved,” Dr. Loring concluded.

—Erik Greb

Endovascular mechanical thrombectomy yields better function and revascularization rates, and similar mortality and intracranial hemorrhage rates, compared with standard medical therapy using t-PA, according to a meta-analysis published November 3 in JAMA. The meta-analysis included eight high-quality randomized clinical trials that compared the two approaches for acute ischemic stroke.

This meta-analysis included only large multicenter trials published between 2013 and the present. Previous trials and meta-analyses “had several well-recognized limitations,” including inconsistent use of vascular imaging to confirm vessel occlusion before randomization, variable use of t-PA in patients who eventually were assigned to endovascular therapy, and reliance on less effective and now outdated mechanical devices, said Jetan H. Badhiwala, MD, of the Division of Neurosurgery at the University of Toronto, and his associates.

The eight trials included 2,423 patients (mean age, 67.4); 46.7% of participants were women. A total of 1,313 patients underwent endovascular therapy, defined as the intra-arterial use of a microcatheter or other device for mechanical thrombectomy, with or without the local use of a chemical thrombolytic agent. The remaining 1,110 participants received standard medical therapy (ie, t-PA). The upper limit of time between stroke onset and endovascular treatment varied from five to 12 hours across these studies, and the mean time was 3.8 hours.

Patients who received endovascular thrombectomy had significantly higher rates of functional independence at 90 days (44.6%) than did those who received t-PA (31.8%, odds ratio [OR], 1.71). The rate of angiographic revascularization at 24 hours also was markedly higher for endovascular thrombectomy (75.8% vs 34.1%, OR, 6.49), the investigators said.

However, there were no significant differences between the two study groups in rates of symptomatic intracranial hemorrhage at 90 days (5.7% vs 5.1%) or all-cause mortality at 90 days (15.8% vs 17.8%). Overall morbidity, including in-hospital rates of deep venous thrombosis, myocardial infarction, and pneumonia, also was similar between the groups.

“It is important to note some limitations with this well-conducted meta-analysis,” said Joanna M. Wardlaw, MD, Chair of Applied Neuroimaging and Head of Neuroimaging Sciences, and Martin S. Dennis, MD, Head of the Brain Vascular Disease Section, both at the Centre for Clinical Brain Sciences at the University of Edinburgh, in an accompanying editorial. “First, functional outcomes showed significant heterogeneity, which the authors attributed to variations in patient-, treatment-, and study-related factors. Second, the confidence intervals for mortality and intracranial hemorrhage were wide, indicating that more data are necessary to fully inform these outcomes. Third, five of the eight trials were halted early because of the evident superiority of endovascular thrombectomy, which means they fell substantially short (by up to 74%) of their planned sample sizes. This [situation] tends to cause overestimation of treatment effects. Fourth, nearly all these strokes involved carotid territory, nearly all the patients were on the young end of the age spectrum, and very few participants had comorbidities such as [atrial fibrillation] or diabetes. Such favorable characteristics do not reflect real-world experience with ischemic stroke.”

—Mary Ann Moon

Endovascular mechanical thrombectomy yields better function and revascularization rates, and similar mortality and intracranial hemorrhage rates, compared with standard medical therapy using t-PA, according to a meta-analysis published November 3 in JAMA. The meta-analysis included eight high-quality randomized clinical trials that compared the two approaches for acute ischemic stroke.

This meta-analysis included only large multicenter trials published between 2013 and the present. Previous trials and meta-analyses “had several well-recognized limitations,” including inconsistent use of vascular imaging to confirm vessel occlusion before randomization, variable use of t-PA in patients who eventually were assigned to endovascular therapy, and reliance on less effective and now outdated mechanical devices, said Jetan H. Badhiwala, MD, of the Division of Neurosurgery at the University of Toronto, and his associates.

The eight trials included 2,423 patients (mean age, 67.4); 46.7% of participants were women. A total of 1,313 patients underwent endovascular therapy, defined as the intra-arterial use of a microcatheter or other device for mechanical thrombectomy, with or without the local use of a chemical thrombolytic agent. The remaining 1,110 participants received standard medical therapy (ie, t-PA). The upper limit of time between stroke onset and endovascular treatment varied from five to 12 hours across these studies, and the mean time was 3.8 hours.

Patients who received endovascular thrombectomy had significantly higher rates of functional independence at 90 days (44.6%) than did those who received t-PA (31.8%, odds ratio [OR], 1.71). The rate of angiographic revascularization at 24 hours also was markedly higher for endovascular thrombectomy (75.8% vs 34.1%, OR, 6.49), the investigators said.

However, there were no significant differences between the two study groups in rates of symptomatic intracranial hemorrhage at 90 days (5.7% vs 5.1%) or all-cause mortality at 90 days (15.8% vs 17.8%). Overall morbidity, including in-hospital rates of deep venous thrombosis, myocardial infarction, and pneumonia, also was similar between the groups.

“It is important to note some limitations with this well-conducted meta-analysis,” said Joanna M. Wardlaw, MD, Chair of Applied Neuroimaging and Head of Neuroimaging Sciences, and Martin S. Dennis, MD, Head of the Brain Vascular Disease Section, both at the Centre for Clinical Brain Sciences at the University of Edinburgh, in an accompanying editorial. “First, functional outcomes showed significant heterogeneity, which the authors attributed to variations in patient-, treatment-, and study-related factors. Second, the confidence intervals for mortality and intracranial hemorrhage were wide, indicating that more data are necessary to fully inform these outcomes. Third, five of the eight trials were halted early because of the evident superiority of endovascular thrombectomy, which means they fell substantially short (by up to 74%) of their planned sample sizes. This [situation] tends to cause overestimation of treatment effects. Fourth, nearly all these strokes involved carotid territory, nearly all the patients were on the young end of the age spectrum, and very few participants had comorbidities such as [atrial fibrillation] or diabetes. Such favorable characteristics do not reflect real-world experience with ischemic stroke.”

—Mary Ann Moon

Endovascular mechanical thrombectomy yields better function and revascularization rates, and similar mortality and intracranial hemorrhage rates, compared with standard medical therapy using t-PA, according to a meta-analysis published November 3 in JAMA. The meta-analysis included eight high-quality randomized clinical trials that compared the two approaches for acute ischemic stroke.

This meta-analysis included only large multicenter trials published between 2013 and the present. Previous trials and meta-analyses “had several well-recognized limitations,” including inconsistent use of vascular imaging to confirm vessel occlusion before randomization, variable use of t-PA in patients who eventually were assigned to endovascular therapy, and reliance on less effective and now outdated mechanical devices, said Jetan H. Badhiwala, MD, of the Division of Neurosurgery at the University of Toronto, and his associates.

The eight trials included 2,423 patients (mean age, 67.4); 46.7% of participants were women. A total of 1,313 patients underwent endovascular therapy, defined as the intra-arterial use of a microcatheter or other device for mechanical thrombectomy, with or without the local use of a chemical thrombolytic agent. The remaining 1,110 participants received standard medical therapy (ie, t-PA). The upper limit of time between stroke onset and endovascular treatment varied from five to 12 hours across these studies, and the mean time was 3.8 hours.

Patients who received endovascular thrombectomy had significantly higher rates of functional independence at 90 days (44.6%) than did those who received t-PA (31.8%, odds ratio [OR], 1.71). The rate of angiographic revascularization at 24 hours also was markedly higher for endovascular thrombectomy (75.8% vs 34.1%, OR, 6.49), the investigators said.

However, there were no significant differences between the two study groups in rates of symptomatic intracranial hemorrhage at 90 days (5.7% vs 5.1%) or all-cause mortality at 90 days (15.8% vs 17.8%). Overall morbidity, including in-hospital rates of deep venous thrombosis, myocardial infarction, and pneumonia, also was similar between the groups.

“It is important to note some limitations with this well-conducted meta-analysis,” said Joanna M. Wardlaw, MD, Chair of Applied Neuroimaging and Head of Neuroimaging Sciences, and Martin S. Dennis, MD, Head of the Brain Vascular Disease Section, both at the Centre for Clinical Brain Sciences at the University of Edinburgh, in an accompanying editorial. “First, functional outcomes showed significant heterogeneity, which the authors attributed to variations in patient-, treatment-, and study-related factors. Second, the confidence intervals for mortality and intracranial hemorrhage were wide, indicating that more data are necessary to fully inform these outcomes. Third, five of the eight trials were halted early because of the evident superiority of endovascular thrombectomy, which means they fell substantially short (by up to 74%) of their planned sample sizes. This [situation] tends to cause overestimation of treatment effects. Fourth, nearly all these strokes involved carotid territory, nearly all the patients were on the young end of the age spectrum, and very few participants had comorbidities such as [atrial fibrillation] or diabetes. Such favorable characteristics do not reflect real-world experience with ischemic stroke.”

—Mary Ann Moon

The cost of care for patients with dementia in their last five years of life is significantly higher than for patients who die from heart disease, cancer, or other causes, according to a study published online ahead of print October 27 in Annals of Internal Medicine. In addition, out-of-pocket spending was 81% higher for patients with dementia than for patients who died of other causes. Dementia patients’ out-of-pocket spending totaled 32% of their wealth in the last five years of life, compared with 11% for those in the nondementia group. In subgroups who were black, unmarried or widowed women, or those with less than a high school education, spending made up even larger proportions of patients’ wealth.

“The families of patients with dementia have more expenses than other families, and the financial burden is greatest among families that may be least able to manage it,” stated Amy Kelley, MD, Associate Professor of Geriatrics and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York.

Dr. Kelley and colleagues analyzed data from 1,702 Medicare beneficiaries, age 70 or older, who died between 2005 and 2010. The group was then sorted into the following four categories: individuals with high probability of dementia and individuals who died of heart disease, cancer, or other causes. Findings indicated that the average total cost for deceased patients with dementia was $287,038 in the last five years of life, compared with $175,136 for patients who died of heart disease, $173,383 for patients with cancer, and $197,286 for other causes of death.

Average cost of informal care of decedents with dementia was more than double the costs of those without dementia. These implicit costs differed between various sociodemographic subgroups. Black households were given more informal care ($117,496) than nonblack households ($80,038) in both high- and low-risk dementia groups, but out-of-pocket costs of black decedents were much lower ($23,425) than costs in nonblack decedents ($64,819). The lower out-of-pocket cost most likely results from decreased financial resources, but out-of-pocket cost and cost of informal care balanced out to similar levels for both racial groups. A similar pattern was found between groups with and without high school diplomas.

“The discussion of health care reform must include the significant uninsured care needs of older adults with dementia and examine ways to mitigate the financial risk currently faced by Medicare beneficiaries,” Dr. Kelley said.

—Evelyn Tran

The cost of care for patients with dementia in their last five years of life is significantly higher than for patients who die from heart disease, cancer, or other causes, according to a study published online ahead of print October 27 in Annals of Internal Medicine. In addition, out-of-pocket spending was 81% higher for patients with dementia than for patients who died of other causes. Dementia patients’ out-of-pocket spending totaled 32% of their wealth in the last five years of life, compared with 11% for those in the nondementia group. In subgroups who were black, unmarried or widowed women, or those with less than a high school education, spending made up even larger proportions of patients’ wealth.

“The families of patients with dementia have more expenses than other families, and the financial burden is greatest among families that may be least able to manage it,” stated Amy Kelley, MD, Associate Professor of Geriatrics and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York.

Dr. Kelley and colleagues analyzed data from 1,702 Medicare beneficiaries, age 70 or older, who died between 2005 and 2010. The group was then sorted into the following four categories: individuals with high probability of dementia and individuals who died of heart disease, cancer, or other causes. Findings indicated that the average total cost for deceased patients with dementia was $287,038 in the last five years of life, compared with $175,136 for patients who died of heart disease, $173,383 for patients with cancer, and $197,286 for other causes of death.

Average cost of informal care of decedents with dementia was more than double the costs of those without dementia. These implicit costs differed between various sociodemographic subgroups. Black households were given more informal care ($117,496) than nonblack households ($80,038) in both high- and low-risk dementia groups, but out-of-pocket costs of black decedents were much lower ($23,425) than costs in nonblack decedents ($64,819). The lower out-of-pocket cost most likely results from decreased financial resources, but out-of-pocket cost and cost of informal care balanced out to similar levels for both racial groups. A similar pattern was found between groups with and without high school diplomas.

“The discussion of health care reform must include the significant uninsured care needs of older adults with dementia and examine ways to mitigate the financial risk currently faced by Medicare beneficiaries,” Dr. Kelley said.

—Evelyn Tran

The cost of care for patients with dementia in their last five years of life is significantly higher than for patients who die from heart disease, cancer, or other causes, according to a study published online ahead of print October 27 in Annals of Internal Medicine. In addition, out-of-pocket spending was 81% higher for patients with dementia than for patients who died of other causes. Dementia patients’ out-of-pocket spending totaled 32% of their wealth in the last five years of life, compared with 11% for those in the nondementia group. In subgroups who were black, unmarried or widowed women, or those with less than a high school education, spending made up even larger proportions of patients’ wealth.

“The families of patients with dementia have more expenses than other families, and the financial burden is greatest among families that may be least able to manage it,” stated Amy Kelley, MD, Associate Professor of Geriatrics and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York.

Dr. Kelley and colleagues analyzed data from 1,702 Medicare beneficiaries, age 70 or older, who died between 2005 and 2010. The group was then sorted into the following four categories: individuals with high probability of dementia and individuals who died of heart disease, cancer, or other causes. Findings indicated that the average total cost for deceased patients with dementia was $287,038 in the last five years of life, compared with $175,136 for patients who died of heart disease, $173,383 for patients with cancer, and $197,286 for other causes of death.

Average cost of informal care of decedents with dementia was more than double the costs of those without dementia. These implicit costs differed between various sociodemographic subgroups. Black households were given more informal care ($117,496) than nonblack households ($80,038) in both high- and low-risk dementia groups, but out-of-pocket costs of black decedents were much lower ($23,425) than costs in nonblack decedents ($64,819). The lower out-of-pocket cost most likely results from decreased financial resources, but out-of-pocket cost and cost of informal care balanced out to similar levels for both racial groups. A similar pattern was found between groups with and without high school diplomas.

“The discussion of health care reform must include the significant uninsured care needs of older adults with dementia and examine ways to mitigate the financial risk currently faced by Medicare beneficiaries,” Dr. Kelley said.

—Evelyn Tran