Stroke incidence has been
decreasing over time. It is acknowledged that a reduction is occurring in older
adults (age >65 years), but trends in younger adults remain less clear.
Long-term cohort studies, such as the Framingham Study, provide the opportunity
to characterize trends in rates of ischemic stroke. Such work can inform
prevention efforts, both nationally and internationally.
In this paper, Aparicio
and colleagues report on the trends in 10-year incidence of ischaemic stroke
among participants of the Framingham Heart Study. They divided participants into
35 to 54 years of age (younger adults) and ≥55 years of age (older adults).
Individuals that attended exams at the Study clinic during four epochs from
1962 through 2005 were included.
Reperfusion with mechanical thrombectomy and recombinant tissue
plasminogen activator is a standard of care for patients with ischemic stroke.
However, there is evidence from animal and clinical studies that the process of
reperfusion contributes to vascular inflammation, secondary thrombosis and oxidative
stress. The molecular mechanisms of this thrombo-inflammatory injury are not
well understood.
The recent study by Dhanesha et al. published in Stroke examined the role of cellular
fibronectin containing extra domain A (Fn-EDA) in thrombo-inflammatory injury. Fn-EDA
is a glycoprotein that is present in a cellular form on the endothelial cells of
the arteries and in a non-cellular form in the blood plasma. Previous studies
have shown a significant elevation in the levels of plasma Fn-EDA in patients
with cardiovascular disease. Additionally, severe vascular dysfunction in
stroke is associated with increased expression of cellular Fn-EDA in activated endothelial
cells. The aim of this study was to investigate contribution of plasma versus
cellular Fn-EDA on stroke injury.
Animal
models and clinical studies show that partial or complete reversal of diffusion-weighted
imaging (DWI) lesions occurs following reperfusion, including with intravenous
thrombolysis. Endovascular thrombectomy (EVT) can also reduce infarct expansion
and potentially reverse DWI lesions; however, further clinical studies are
needed. Yoo et al. performed a retrospective analysis of patients with acute
ischemic anterior circulation stroke receiving EVT who were prospectively
enrolled in a multicenter registry. They determined the odds of DWI reversal
after EVT, clinical outcomes, and independent predictors of DWI reversal.
Baseline
(pre-EVT) and follow-up (post-EVT) DWI volumes were measured. If the follow-up
DWI volume decreased from baseline, the DWI lesion was considered reversible. Onset-to-baseline
DWI time for patients with and without DWI reversal was 277±214 versus 257±209 minutes (P=0.487). Mean onset-to-puncture time was 338±222 minutes. Time from baseline to
follow-up DWI was 4.7±2.4 days. Of 404 patients, 63 (15.5%) had DWI
reversal. Initial stroke severity based on the National Institutes of Health
Stroke Scale (NIHSS) score was similar,
but the score was lower in the DWI reversal group at 7 days. Patients with DWI reversal
had better functional outcomes at 3 months.
Three years ago, I started a large community hospital’s
stroke program, which recently received primary stroke center certification. The
first piece was the inpatient side by necessity to be in compliance with Get With
The Guidelines, which is based on the national Stroke Guidelines. The “Recommendations
for the Establishment of Stroke Systems of Care: A 2019 Update” by Adeoye et
al. focuses on the pre- and post-hospital care of stroke patients.
After establishing compliant inpatient metrics, we have now
started to focus on the follow-up in the clinic and have found that we have
around 20% follow-up from discharge to clinic, problems making room for
follow-up among scheduled general neurology patients, difficulty with
coordination of care among rehab modalities, difficulty with standardization
among providers, and difficulty with widespread education of the community .
Mechanical thrombectomy has emerged as the standard of care for
patients with large vessel occlusion; however, the optimal method of
re-canalizing a large vessel occlusion is up for debate. A recent JNIS article illustrated the wide
practice heterogeneity between neurointerventionalists, with no less than
twelve different techniques for endovascular treatment of stroke mentioned [1]. Use vs. nonuse of a balloon
guide catheter is an example of one such practice variation between different
centers and neurointerventionalists.
A balloon guide catheter is a supportive catheter typically
placed into the internal carotid artery (or sometimes the common carotid if
there is extensive stenosis of the internal carotid) and then inflated to cause
flow arrest during mechanical thrombectomy, or in some cases, contact
aspiration thrombectomy [2]. The theory behind placing a
balloon guide catheter to cause flow arrest, which may aid in the procedure by
two mechanisms: to reduce the risk of distal clot embolization [3, 4], and to decrease the systemic
arterial pressure impacting the clot to enhance the effect of stent retriever
thrombectomy [5].
In this recently published study in Stroke, Zaidat et al. reported on the use of balloon guide catheter
in the STRATIS registry, a multicenter prospective registry of patients who underwent
mechanical thrombectomy with the Solitaire device. For purposes of the study,
patients with posterior circulation large vessel occlusion were excluded as
balloon guide catheter is used less frequently in these occlusions;
additionally, patients who underwent a proximal carotid intervention such as
angioplasty or stenting were excluded. Patients meeting inclusion criteria were
grouped into three categories based on procedural technique (Figure 1): conventional guide catheter
(CGC), distal access catheter (DAC), and balloon guide catheter (BGC). There
were between-group differences such as a lower baseline ASPECTs in the DAC
group compared to the BGC group (8.2 vs 8.3, p = 0.023), more carotid occlusions
in the DAC group compared to the BGC group (p = 0.018), and less general
anesthesia in the DAC group compared to the BGC group (p = 0.001).
Figure 1. Adjunctive techniques in the STRATIS Registry. A, Illustration of middle cerebral artery clot treated with Solitaire stent retriever. The different adjunctive techniques are shown. B, Study flowchart. Some subjects met multiple exclusion criteria, and hence individual category N do not sum to total of exclusions. BGC indicates balloon guide catheter; CGC, conventional guide catheter; DAC, distal access catheter; and STRATIS, Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke.
Intracerebral hemorrhage (ICH) survivors are at high risk of stroke
recurrence. Most of the available
studies focused on the risk of future cerebrovascular events whether the
occurrence of extracranial vascular diseases remains poorly characterized. In
this single center prospective cohort study, Dr. Casolla and colleagues
described the incidence and predictors of cerebral (ischemic and hemorrhagic)
and extracranial (ischemic and hemorrhagic) vascular events in patients alive
at 30 days after acute ICH.
A total of 310 patients met the inclusion criteria and were followed
for a median of 6 years. The overall cumulative incidence of major vascular
events was 20%. The long-term natural history of ICH in terms of vascular
events was remarkably different in deep versus lobar ICH survivors, with deep
ICH being associated with greater ischemic risk (subhazard ratio, 1.85; 95% CI,
1.01–3.40) and lobar ICH having a higher risk of future hemorrhagic events (subhazard
ratio, 2.38; 95% CI, 1.17–4.86).
Sepsis is
associated with increased risk for stroke; however, the mechanisms remain unknown.
Shao et al performed a retrospective review of a California inpatient database
to identify patients at greatest risk of stroke within 1 year of hospitalization
for sepsis. Stroke occurred rarely in this patient population, with 0.5% having
either an ischemic or hemorrhagic stroke within the first year. Risk factors
more prevalent in patients with stroke post-sepsis were valvular heart disease,
renal failure, congestive heart failure, coagulopathy, peripheral vascular
diseases, pulmonary circulation disorders, and lymphoma.
Based on
an adjusted multivariable logistic model including these risk factors as
covariates, a composite risk score was developed by assigning an integer to
each risk factor based on the odds ratios. Absolute risk of stroke increased as
the composite risk score increased. For each point increase in the score, odds
of stroke were slightly higher for patients 18-45 years of age when compared to
patients older than 45 years. For all groups, risk of stroke was highest in
those with coagulopathy (coagulopathy included antithrombotic coagulation
defects, qualitative platelet defects, and thrombocytopenia).
In this entry, I discuss a recent publication by Rachel
Hawe and colleagues (1) regarding the potential biases
of the mathematical properties of the proportional recovery rule and how this
may impact application in the field of stroke recovery. Proportional recovery
is the idea that most individuals post-stroke (“fitters” to the rule) will
recover 70% of their potential on a given outcome (see paper for rule equation).
The authors cite multiple studies that have demonstrated proportional recovery
for upper limb motor impairment using a single outcome (Fugl Meyer Upper Limb
assessment, out of 66 points), and recent work extending this rule to lower
limb, aphasia and hemispatial neglect recovery outcomes.
The principal mathematical concept discussed as a
limitation of the proportional recovery rule is mathematical coupling. This concept
refers to when one variable directly or indirectly contains all or a part of
another. For example, in the case of proportional recovery of the upper limb
post-stroke, the initial score on Fugl Meyer Upper Limb assessment is part of
both the independent and dependent variables of the proportional recovery rule.
European Stroke Organisation Conference May 22–24, 2019
Andrea Morotti, MD
This interesting session dedicated to intracerebral
hemorrhage (ICH) started with a pragmatic talk on rare causes of intracranial
bleeding, discussing the diagnostic accuracy of neuroimaging in the acute phase,
by Floris Schreuder.
Christian Weimar presented the main strengths and
limitations of currently available tools to stratify ICH prognosis.
The pathophysiology and management of perihematomal
edema was illustrated by Kevin Sheth, with a focus on edema measurement with
advanced neuroimaging.
The annual European Stroke Organisation Conference was held May 22 to 24 in Milan. There were countless sessions with a high scientific quality. In particular, the scientific communications session “Endovascular Treatment – Clinical Practice,” held on May 22, revealed interesting findings. Among all the refreshing results, I would like to highlight the following:
Dr. Georgios Tsivgoulis, from the National & Kapodistrian University of Athens, showed interesting data about a systematic review and meta-analysis of bridging therapy (BT) versus direct mechanical thrombectomy(MT) in stroke patients with large vessel occlusion (LVO). The mentioned systematic review included 38 studies with a sample of 11.798 patients. The main conclusions of the study exposed that pretreatment with IVT does not increase complication nor results in measurably delayed reperfusion in LVO patients treated with MT. In addition, their results, also showed a potential benefit on functional outcome and mortality in patients receiving BT compared to direct MT.
1 hour ago The July issue of Stroke is now available online. Check out the issue for the latest Original Contributions, as well as Topical Reviews, Controversies in #Stroke, #Cochrane Corner, #InterSECT, and more. https://t.co/NIvJpo9Oe5
7 hours ago Creating a #Stroke System is More Difficult Than Creating Stroke Care #BloggingStroke's Richard Jackson discusses the "Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update: A Policy Statement From the American Stroke Association" https://t.co/u6iAXfsasU
Sami Al Kasab, MD*
Mohammad Anadani, MD
Rohan Arora, MD
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Bahar M. Beaver, MD
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Philip Chang, MD*
Kat Dakay, DO
Danielle de Sa Boasquevisque, MD
Victor J. Del Brutto, MD
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Qing Hao, MD, PhD
Kathryn S. Hayward, PhD, PT
Richard Jackson, MD
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Gurmeen Kaur, MBBS*
Abbas Kharal, MD, MPH
Houman Khosravani, MD, PhD
Tapan Mehta, MBBS, MPH*
Muhammad Zeeshan Memon, MD
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Lin Kooi Ong, PhD
Raffaele Ornello, MD
Lina Palaiodimou, MD
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Richa Sharma, MD, MPH
Shashank Shekhar, MD, MS*
Kristina Shkirkova, BSc
Alexis N. Simpkins, MD, PhD
Ravinder-Jeet Singh, MBBS, DM
Kara Jo Swafford, MD
Burton J. Tabaac, MD
Elena Zapata-Arriaza, MD
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