Rachel Forman, MD

Rinaldo L, Rabinstein AA, Cloft H, Knudsen JM, Rangel Castilla L, Brinjikji W. Racial and Ethnic Disparities in the Utilization of Thrombectomy for Acute Stroke: Analysis of Data From 2016 to 2018. Stroke. 2019

I was excited for the chance to review this article, as this topic is near and dear to my heart as someone who does community stroke education to help improve healthcare disparities in this area. From my experience in providing stroke education to more diverse communities, there is much less knowledge in terms of recognizing stroke symptoms and the importance of prompt care to be eligible for tPA and mechanical thrombectomy (MT).  Unfortunately, I was not surprised when I read the results of this paper. 

It has already been established that minority patients receive less MT; however, this study looked at updated data (2016-2018) to see if this still held true following the publication of multiple positive MT trials in 2015. MT has become increasingly utilized after a series of positive trials published in 2015 and is now the standard of care for treatment of stroke due to large vessel occlusion. For more information on these trials, the HERMES collaboration is a meta-analysis of five major trials in The Lancet, published in 2016. 

Elizabeth M. Aradine, DO

Boisseau W, Fahed R, Lapergue B, Desilles J-P, Zuber K, Khoury N, et al. Predictors of Parenchymal Hematoma After Mechanical Thrombectomy: A Multicenter Study. Stroke. 2019

Parenchymal hematoma (PH) is a potential complication of IV thrombolytics or mechanical thrombectomy; however, risk factors for hematoma after thrombectomy are still uncertain. PH after acute stroke intervention can increase morbidity and mortality. In this study, the authors retrospectively reviewed data from a registry of thrombectomy patients to identify variables to predict post thrombectomy PH. Patients presenting with an anterior circulation large vessel or intracranial carotid occlusion who had a thrombectomy from 2011-2016 were included. MRI or CT based brain and vessel imaging were used to select patients for thrombectomy and to calculate the ASPECT score. Post thrombectomy, a 24-hour brain image was routinely performed on all patients to evaluate for PH. PH was classified using the European Cooperative Acute Stroke Study (ECASS) criteria. 90-day post stroke outcome was assessed using the mRS. This data was compared to baseline patient characteristics including age, smoking status, hypertension, diabetes, admission NIHSS, and antiplatelet or anticoagulation use. Data on the presence of collateralization on angiogram and general anesthesia use was also recorded.

Charlotte Zerna, MD, MSc
@CharlotteZerna

Young-Saver DF, Gornbein J, Starkman S, Savel JL. Magnitude of Benefit of Combined Endovascular Thrombectomy and Intravenous Fibrinolysis in Large Vessel Occlusion Ischemic Stroke. Stroke. 2019

Little is known about the effect size of the combination of intravenous alteplase therapy (IVT) and endovascular therapy (EVT) compared to supportive treatment alone for patients with anterior circulation large vessel occlusion (LVO). At the time EVT was proven effective with the randomized controlled trials, IVT had already been the standard of care for almost 20 years and thus chosen as a comparator group. Since no randomized controlled trial data are available to compare IVT+EVT to supportive therapy alone, Young-Saver et al. chose to undertake a post-hoc analysis matching patients from the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT-PRIME) trial with patients from the 2 National Institute for Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator (NINDS rt-PA) trials.

In the main analysis, a total of 240 patients (80 from the SWIFT-PRIME IVT+EVT group, 80 from the NINDS rt-PA Study IVT alone group, and 80 from the NINDS rt-PA Study placebo group) were 1:1 inverse variance matched for presenting National Institutes of Health Stroke Scale (NIHSS) score to identify NINDS rt-PA Study patients likely harboring LVOs and age since it is a strong determinant of outcome. The 90-day modified Rankin Scale (mRS) score was used as the outcome, analyzed both as an ordinal scale (shift across all 7 mRS levels) with ordinal logistic regression analysis and as a dichotomized outcome ( 0-1 vs. 2-6 and 0-2 vs. 3-6) using Fisher exact test.

Piyush Ojha, MBBS, MD, DM

Petersen NH, Ortega-Gutierrez S, Wang A, Lopez GV, Strander S, Kodali S, et al. Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcome. Stroke. 2019;50:1797–1804

Recent studies have shown that acute ischemic stroke patients with large vessel occlusion (LVO) have good clinical outcome following endovascular thrombectomy (EVT), which is now a new standard of care. However, only 46% of patients undergoing EVT were functionally independent (mRS 0-2) at 90 days, and only 10% were neurologically normal in the meta-analysis of EVT trials [Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials (HERMES)].¹ Several factors could potentially contribute to this observation. Both clinical and imaging variables have been shown to correlate with poor outcome, especially age, stroke severity, lack of effective reperfusion and infarct volume.  

Management of blood pressure is hotly debated in the stroke literature. There are theoretical concerns and benefits of acute blood pressure lowering in acute ischemic stroke. Blood pressure fluctuations during EVT could lead to inadequate cerebral perfusion causing poor final radiological (infarct progression) and clinical outcomes (functional status) in patients with LVO. Hypotension prior to reperfusion may compromise collateral flow, which may be further worsened by the exhaustion of compensatory vasodilatory capacity distal to the occluded vessel and the loss of intrinsic autoregulatory function in the ischemic tissue leading to a poor clinical and radiological outcome.