American Heart Association

Higher Intensity, Higher Dose Aerobic Exercise Training After Stroke

Kate Hayward, PhD, PT
@kate_hayward_

Klassen TD, Dukelow SP, Bayley MT, Benavente O, Hill MD, Krassioukov A, Liu-Ambrose T, Pooyania S, Poulin MJ, Schneeberg A, et al. Higher Doses Improve Walking Recovery During Stroke Inpatient Rehabilitation. Stroke. 2020;51:2639-2648.

Stroke recovery and rehabilitation trials have received much criticism for underdosing the tested intervention,1 which remains an important consideration when interpreting past trials in the field.2

In this trial of aerobic exercise during inpatient rehabilitation by Klassen et al.,3 the intensity (heart rate reserve during training and walking steps) and amount (minutes of training) of aerobic exercise were increased from usual care. The control group (usual care) typically received 1 hour, 5 days/week, while the Determining Optimal Post-Stroke Exercise 1 (DOSE1) group received 1 hour, 5 days/week (with a target of double the intensity of the control group), and the DOSE2 group received 2 hours, 5 days/week (with a target of quadruple the intensity of the control group), each for a 4-week duration (20 sessions).

Article Commentary: “Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients”

Burton J. Tabaac, MD
@burtontabaac

Escalard S, Chalumeau, Escalard C, Redjem H, Delvoye F, Hébert S, Smajda S, Ciccio G, Desilles J-P, Mazighi M, et al. Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients. Stroke. 2020.

In May of this year, amidst the sweeping COVID-19 global pandemic, the New England Journal of Medicine published a paper detailing how large vessel occlusive disease might be a presenting feature in patients with strokes secondary to the infection.1 The authors of this particular paper, cited above, build upon the NEJM observation with imaging evidence to posit that strokes secondary to COVID-19 are also more severe in nature.

Patients were selected and included to be a part of the comparative cohort if COVID-19 was diagnosed (via real-time PCR) and had documented acute large vessel occlusion between the observation and recruitment timeframe between March 15 and April 30, 2020. Two of the authors of the study were blinded to the COVID-19 status of the patient and were asked to quantify the infarct core volume for all patients with large vessel occlusion during the time period. During the study, fifteen patients with large vessel occlusion and confirmed COVID-19 infection were treated.

Article Commentary: “Smoking Causes Fatal Subarachnoid Hemorrhage”

Deepak Gulati, MD

Rautalin I, Korja M, Kaprio J. Smoking Causes Fatal Subarachnoid Hemorrhage: A Case-Control Study of Finnish Twins. Stroke. 2020.

Smoking has been identified as the most important lifestyle risk factor for subarachnoid hemorrhage (SAH) and accounts for at least one third of all cases.

Familial risk is defined as the probability of a healthy family member being affected by the same disease that has already affected at least one other family member. Familial risk of SAH depends on a number of factors, including genetic and environmental factors. It has been a challenge to estimate the genetic risk of SAH in relatives given the relatively low incidence of SAH. The accurate estimation of genetic risk could have significant implications on prophylactic screening protocols of intracranial aneurysms. Large twin cohorts provide a “shortcut” to carry out the estimation of heritability. Twin studies usually provide the natural way to separate familial resemblance from genetic influence. The Nordic Twin Study in 2010 indicated that most twin pairs were discordant for SAH, i.e., only one twin died from SAH. However, the role of risk factors in explaining this discordance was not studied.

The Relationship Between Infection and Stroke

Parneet Grewal, MD
@parneetgrewal6

Elkind MSV, Boehme AK, Smith CJ, Meisel A, Buckwalter MS. Infection as a Stroke Risk Factor and Determinant of Outcome After Stroke. Stroke. 2020.

In this article, Dr. Elkind and colleagues aimed to elucidate the putative relationship between infection and stroke, which has gained increased recognition in the era of coronavirus disease 2019 (COVID-19).1 Multiple studies in the past, such as the Cardiovascular Health Study and the Atherosclerosis Risk in Communities study, have provided evidence that systemic infection can trigger or precipitate acute ischemic stroke since bacteremia is a strong stimulus to inflammation and thrombosis. The proposed mechanisms by which infections can trigger stroke include infection-related platelet activation and aggregation, inflammation-related thrombosis, impaired endothelial function, infection-provoked cardiac arrhythmias, and dehydration-induced thrombosis (Figure). On further characterization, it is now known that a variety of infections are associated with an increased risk of ischemic stroke, with the strongest association found for urinary tract infection (UTI) (OR 5.32, 95% CI, 3.69-7.68) within 7 days.2

Proposed model for short- and long-term associations of infection, stroke, cognitive decline, and dementia.
Figure. Proposed model for short- and long-term associations of infection, stroke, cognitive decline, and dementia.

The authors focus particularly on the role of viral infections as a trigger for stroke. Influenza has been previously studied as a stroke trigger, especially in high-risk elderly population. Data from California provide evidence that the odds of ischemic stroke are higher in the first 15 days after influenza-like illness (OR 2.88, 95%CI 1.86-4.47).3 Many herpes viruses also have a neurotropic tendency, with strong evidence linking Cytomegalovirus (CMV) to atherogenesis and Varicella zoster virus (VZV) to cerebral arteriopathy. Infectious burden (IB) is described as a cumulative effect of exposure to an increasing number of pathogens and lately has gained popularity due to its role in carotid and cerebral atherosclerosis. For example, higher mean IB index in Hispanics, non-Hispanic Blacks, and women in the Northern Manhattan Study provides indirect evidence to explain disparities in stroke risk. Recently, multiple studies have reported an increased risk for stroke in patients who are infected with COVID -19, with incidence ranging from 0.5 to 3%. The incidence is higher in critically ill patients with COVID-19 approaching 6%. Moreover, unexplained large vessel occlusions have been identified as a frequent presentation.

By |September 25th, 2020|clinical|0 Comments

Looking Beyond the Primary Infarction: Remote Regional Brain Atrophy After Stroke

Lin Kooi Ong, PhD
@DrLinOng

Brodtmann A, Khlif MS, Egorova N, Veldsman M, Bird LJ, Werden E. Dynamic Regional Brain Atrophy Rates in the First Year After Ischemic Stroke. Stroke. 2020;51:e183–e192.

Brain atrophy refers to a loss of brain cells or a loss in the networks between brain cells, and is a common feature for many neurodegenerative diseases. Ischemic stroke is usually viewed as an acute cerebrovascular injury, and not as a neurodegenerative condition. Nevertheless, there is now emerging evidence demonstrating that stroke can cause persistent regional brain atrophy for months and even years after the initial event. Further, this regional brain atrophy after stroke has been linked to several late phase functional disturbances, including cognitive impairment. Notably, stroke increases the risk of developing vascular dementia.

The CANVAS study (Cognition and Neocortical Volume After Stroke) is a longitudinal study in people recruited from Melbourne hospitals, Australia, following ischemic stroke, comparing brain volume and cognitive function over 3 years with a group of healthy age- and sex-matched control participants.(1) In this article, Brodtmann and colleagues examined the trajectories of total and regional brain volume changes in the first year following stroke. Specifically, brain magnetic resonance imaging (MRI) was performed on stroke and healthy control participants, with 86 stroke participants completing testing at baseline, 125 at 3 months, and 113 participants at 12 months, as well as 40 healthy control participants. Five brain measures — hippocampal volume, thalamic volume, total brain and hemispheric brain volume, and cortical thickness — were examined to evaluate whether brain atrophy rates differed between time points and groups.

Achieving the Goal of Reducing Delayed Ischemia in Aneurysmal SAH?

Kevin O’Connor, MD

Anetsberger A, Gempt J, Blobner M, Ringel F, Bogdanski R, Heim M, Schneider G, Meyer B, Schmid S, Ryang YM, et al. Impact of Goal-Directed Therapy on Delayed Ischemia After Aneurysmal Subarachnoid Hemorrhage: Randomized Controlled Trial. Stroke. 2020;51:2287-2296.

Delayed cerebral ischemia (DCI) is one of the complications of aneurysmal subarachnoid hemorrhage (SAH) that can lead to increased morbidity and mortality. The risk of DCI is associated with the initial volume of hemorrhage and the extent of the neurologic injury. Anetsberger et al. conducted a randomized controlled trial to compare goal-directed hemodynamic therapy (GDHT) to standard clinical care in reducing the frequency of DCI in patients with aneurysmal SAH.

Treatment for both groups included enteral nimodipine, normothermia, euglycemia, electrolyte stability, and appropriate ventilation with similar systolic blood pressure (BP) and mean arterial pressure (MAP) goals before and after identified vasospasm. A transpulmonary thermodilution monitor was used in all patients to monitor hemodynamic variables such as cardiac output, ejection fraction, and extravascular lung water.

Regardless of the presence of vasospasm, the GDHT group received volume therapy according to a standardized algorithm (Supplemental Figure I). The study did not explicitly define standard clinical care, but it was noted that avoidance of hypovolemia and hyponatremia are recommended and that there is an absence of consensus guidance for achieving those goals.

By |September 22nd, 2020|clinical|0 Comments

Fire and Forget, or Treat to Target?

Vera Sharashidze, MD
@SharashidzeVera

Endres M, Kernan WN. LDL (Low-Density Lipoprotein) Cholesterol Below 70: Good to Go! Stroke. 2020;51:2276–2278.

The current guidelines of the American Heart Association/American Stroke Association (AHA/ASA) recommend high-intensity statin therapy initiation or continuation with the aim of achieving a 50% or greater reduction in low-density lipoprotein cholesterol (LDL-C) levels in patients with stroke who are 75 years of age or younger. In patients who are unable to tolerate high-intensity therapy, moderate intensity statins should be started with the goal of achieving a 30% to 49% reduction in LDL-C levels.

The first evidence that stroke patients could benefit from statins came out from the Heart Protection Study that was a double-blind, randomized, placebo-controlled study in which patients received either placebo or simvastatin 40 mg daily. This study showed that in patients with high risk for cardiovascular disease, cholesterol lowering with simvastatin was associated with reduction in all-cause mortality and major vascular event risk.

Malaysia Stroke Virtual Conference 2020: “Stroke Strikes Fast, ResQ Faster!”

Malaysia Stroke Virtual Conference 2020
August 14 – 16, 2020
Contents available online from August 14 to September 14, 2020 at: https://msconference2020.com/index.php

Lin Kooi Ong, PhD
@DrLinOng

Wan Asyraf Wan Zaidi, MMed*
@DrAsyraf

As a consequence of the COVID-19 pandemic, the Malaysia Stroke Council, in collaboration with Angels Initiative, organized the first-ever Malaysia Stroke Virtual Conference 2020. This virtual conference had an excellent scientific program which covered hyperacute stroke, stroke emergency, stroke rehab, basic/translational stroke research, and many more topics (https://msconference2020.com/programme.php). The program included live plenary lectures, symposia, e-posters, a virtual expo, and a Game of Stroke tournament. In addition to talks by leading Malaysian clinicians and researchers, this virtual conference also featured experts around the world, including Professor Sheila Martins (Brazilian Stroke Network), Professor Valery Feigin (University of Auckland), and Dr Ramesh Sahathevan (Ballarat Health Service).

The Deputy Director General of Health Malaysia Datuk Dr Hj. Rohaizat Hj. Yon officiated the opening ceremony of the conference. He also presented the World Stroke Organisation Angels Awards to five Malaysian hospitals: Hospital Tuanku Jaafar in Seremban (Gold), Hospital Seberang Jaya (Gold), Sarawak General Hospital (Gold and Diamond), Regency Specialist Hospital (Gold), and Pantai Hospital Penang (Diamond), as recognition for outstanding stroke care.

The Malaysia Stroke Virtual Conference 2020 was declared open. (Left to right) Assoc. Prof. Dr. Hoo Fan Kee (Malaysia Stroke Council President), Datuk Dr Hj. Rohaizat Hj. Yon (Deputy Director General Ministry of Health Malaysia), Dr. Santhi Datuk Puvanarajah (Head of Neurology Service Ministry of Health Malaysia), Mrs. Sylvia Chong (National Stroke Association of Malaysia CEO), Prof. Dr. Hamidon Basri (Malaysia Stroke Council advisor), and Prof. Dr. Khairul Azmi Abdul Kadir (President of Malaysia Neurointerventional Society). Photo provided by Dr. Wan Asyraf Wan Zaidi, co-scientific chairperson of the Malaysia Stroke Conference 2020, with permission. 

The first live plenary session was by Dr. Law Wan Chung (Sarawak General Hospital), who spoke about “Data Monitoring: Why I Need This For My Stroke Centre?”. Dr. Law presented some exciting data related to thrombolysis outcome and stroke outcome from the Sarawak General Hospital. He highlighted that 1442 ischemic stroke patients were admitted to the hospital between June 2013 and August 2018, and the mean age was 60. The incidence of stroke in individuals under age 60 has risen at an alarming rate; in this case, approximately 13% were under 45 years.

Article Commentary: “Predicting Longitudinal Progression in Functional Mobility After Stroke”

Tamaya Van Criekinge, PT, PhD
@tamayavc

Buvarp D, Rafsten L, Sunnerhagen KS. Predicting Longitudinal Progression in Functional Mobility After Stroke: A Prospective Cohort Study. Stroke. 2020;51:2179–2187.

Regaining the ability to walk is the primary therapy goal for the majority of stroke survivors. However, gait rehabilitation does not end when a patient is able to walk up and down the corridor for six meters. People living with stroke need to be able to walk independently, with or without aids, on stable and unstable surfaces, in crowded environments full of distractions, under time pressure of moving traffic, while performing dual tasks, and all this in an energy-efficient manner. To optimize the walking pattern of stroke survivors, we need to fully understand the underlying impairments and recovery process. The aim of this study was to investigate the longitudinal progression in functional mobility during the first year after stroke and determine the rate of change between different levels of stroke severity.

In total, 140 participants who are over 18 years of age, diagnosed with stroke according to the World Health Organization (WHO) criteria, living near the rehabilitation center (Sahlgrenska University Hospital, Sweden), The National Institutes of Health Stroke Scale (NIHSS) ≤16, Barthel Index (BI) ≥50, life expectance ≥1 year, were included in this study. The Timed up-and-Go test (TUG) was used to assess functional mobility after 5 days of onset, within 24 hours of discharge, 1 after discharge, 3 months and 1-year post-stroke. In addition, clinical and activity limitations were assessed with the NIHSS, Fugl-Meyer Assessment, Montreal Cognitive Assessment, modified Rankin Scale (mRS) and BI.

By |September 2nd, 2020|clinical|0 Comments

Navigating Major Bleeding and Embolic Strokes of Undetermined Source

Kevin O’Connor, MD

Mikulík R, Eckstein J, Pearce LA, Mundl H, Rudilosso S, Olavarría VV, Shoamanesh A, Chamorro Á, Martí-Fàbregas J, Veltkamp R, et al. Frequency and Predictors of Major Bleeding in Patients With Embolic Strokes of Undetermined Source: NAVIGATE-ESUS Trial. Stroke. 2020;51:2139-2147.

About a third of ischemic strokes are categorized as being cryptogenic. Embolic strokes of unknown source (ESUS) represent a subset of these cryptogenic strokes. Clinicians are often faced with choosing between an anticoagulant and a platelet antiaggregant as one component of secondary prevention in patients having an ESUS. The NAVIGATE-ESUS trial provides data on the frequency and predictors of major bleeding in ESUS patients based on antithrombotic therapy choice, which can help inform treatment decisions.

NAVIGATE-ESUS was an international, double-blind, phase III trial that included 7213 participants from 31 countries who were randomized to receive rivaroxaban 15 mg once daily or aspirin 100 mg once daily. Sites were in Europe, East Asia, North America, and Latin America. The primary outcome of this analysis was major bleeding. Clinically-relevant nonmajor bleeding (CRNMB) was excluded for several reasons: CRNMB determinations were not determined centrally, whereas there was centralized adjudication of major bleeding events; intracranial bleeding was not considered to be a CRNMB; and analysis of independent predictors of major bleeding and CRNMBs such as epistaxis requiring medical attention would have been potentially spurious. NAVIGATE-ESUS was terminated before targeted enrollment was completed after an interim analysis found increased bleeding among rivaroxaban-treated participants, but no reduction in recurrent stroke.

By |August 31st, 2020|clinical|0 Comments