American Heart Association

Intracerebral Hemorrhage Shape Predicts the Risk of Intracerebral Hematoma Expansion

Andrea Morotti, MD

Li Q, Liu Q-J, Yang W-S, Wang X-C, Zhao L-B, Xiong X, et al. Island Sign: An Imaging Predictor for Early Hematoma Expansion and Poor Outcome in Patients With Intracerebral Hemorrhage. Stroke. 2017

Intracerebral Hemorrhage (ICH) is a dynamic disease, with up to half of the patients experiencing active bleeding in the acute phase. Hematoma growth represents a potential therapeutic target to improve patients’ outcome. Rapid identification of subjects at high risk of hematoma growth is, therefore, crucial in clinical practice and in the setting of clinical trials testing anti-expansion treatments. The CT angiography (CTA) spot sign is a robust marker of ICH expansion. However, CTA is not available in many institutions, and a large proportion of ICH patients do not receive a CTA as part of their diagnostic workup 1. This highlights the need for novel markers of hematoma growth that do not require a CTA.

Using a well-characterized cohort including 252 ICH patients, Qi Li and colleagues described the island sign, a novel marker of hematoma growth that can be evaluated on baseline non-contrast CT (NCCT). The island sign was defined as presence of at least 3 scattered small hematomas all separate from the main hemorrhage or at least 4 small hematomas, some or all of which may be connected with the main hemorrhage. An illustrative example of the island sign is provided in Figure 1. ICH expansion was defined as hematoma growth > 6mL or > 33% from baseline hematoma volume.

Figure 1. Illustration of island sign. Axial noncontrast computed tomography (CT) images of 4 patients with CT island sign.

Figure 1. Illustration of island sign. Axial noncontrast computed tomography (CT) images of 4 patients with CT island sign.

Administration of Statin on Acute Ischemic Stroke Patient (ASSORT) Trial

Aristeidis H. Katsanos, MD, PhD

Yoshimura S, Uchida K, Daimon T, Takashima R, Kimura K, Morimoto T, on behalf of ASSORT Trial Investigator. Randomized Controlled Trial of Early Versus Delayed Statin Therapy in Patients With Acute Ischemic Stroke ASSORT Trial (Administration of Statin on Acute Ischemic Stroke Patient). Stroke. 2017

Even though the role of statins in both primary and secondary stroke prevention has been well established, with a considerable number of acute ischemic stroke (AIS) patients receiving statin treatment during the first days of ictus, the usefulness of statin therapy in the acute phase of cerebral ischemia still remains debatable.

The Administration of Statin on Acute Ischemic Stroke Patient (ASSORT) Trial is a multicenter, Japanese, open-label, randomized clinical trial (RCT) with the aim to determine the efficacy of early (≤24 hours) versus delayed (7th day) statin initiation in AIS. After randomizing a total of 257 patients (early: 131, delayed: 126), authors concluded that there is no superiority of early statin administration for AIS, as no significant differences were found on the 3-month functional outcome, stroke recurrence or mortality between patients receiving early or delayed statin therapy. As highlighted by the authors, the low dose of statins that were administered in the current trial (atorvastatin 20mg/d, pitavastatin 4mg/d or rosuvastatin 5mg/d) could partially account for the aforementioned lack of efficacy, concluding that higher doses should be attested in future studies.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization

Pouya Tahsili-Fahadan, MD

Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, et al. Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis. Stroke. 2017

This article tackles a very important and popular question since the introduction of Mechanical Thrombectomy (MT) for treatment of acute ischemic stroke: Sedation. Endotracheal intubation and anesthesia may be indicated regardless of MT for airway protection and in those with acute respiratory failure after stroke. In other patients, however, risks versus benefits of general anesthesia (GA) versus conscious sedation are less clear. Multiple earlier reports had pointed towards the choice of sedation as a potential factor in patients’ outcomes after MT with a majority of them favoring GA. Accordingly, the American Heart Association recommended “it might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke” (Powers et al., Stroke 2015).

Twenty-two previous reports, including 3 randomized control trials, with a total of 4716 patients, were included in this meta-analysis. 1819 patients (38.5%) underwent GA. The primary end-point of the study was good functional outcome defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days after MT. GA group was associated with lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48–0.64) along with higher odds of mortality (OR 2.02; 95% CI, 1.66–2.45), vascular complications (OR, 1.43; 95% CI, 1.01–2.03), and respiratory complications (OR, 1.70; 95% CI, 1.22–2.37) in comparison to patients in the non-GA group. Although symptomatic hemorrhagic conversion was more common among patients in the GA group, it did not reach statistical significance (OR, 1.43; 95% CI, 0.85–2.39).

By |December 6th, 2017|clinical|0 Comments

The PLUMBER Study Yields an Important Piece of the Stroke Systems of Care Puzzle

Neal S. Parikh, MD 
@NealSParikhMD

Dozois A, Hampton L, Kingston CW, Lambert G, Porcelli TJ, Sorenson D, et al. PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response). Stroke. 2017

Optimizing access to endovascular therapy has become a public health priority. While various national guidelines seek to shape acute stroke EMS triage practices broadly, regulatory bodies have also acknowledged the need to tailor protocols to local and regional environments.

In deciding whether to triage an individual patient with suspected stroke to an endovascular center instead of a primary stroke center, EMS may consider factors such as relative travel distances, stroke severity, and the likelihood of a large vessel occlusion (LVO).

LVO screening tools have inherent imprecision, and the positive predictive value, of course, depends on the prevalence of LVO. For this reason, knowing the prevalence of LVO among acute ischemic stroke 9-1-1 dispatches is of importance. Further, at an organizational level, the accuracy and precision of LVO detection in the field has upstream implications for case load at endovascular and non-endovascular centers. The importance of these considerations varies by locale.

Adherence and Intensity of Statin Therapy

Kevin S. Attenhofer, MD

Kim J, Lee HS, Nam CM, Heo JH. Effects of Statin Intensity and Adherence on the Long-Term Prognosis After Acute Ischemic Stroke. Stroke. 2017

Statin medications and cholesterol management remain topics of debate over ten years after the publishing of the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial. With many questions remaining, the authors investigated the effects of statin intensity and adherence on the long-term prognoses after acute ischemic strokes in Korea.

In this paper, Kim et al. present a retrospective cohort study based on nationwide Korean population-based health insurance data. They used diagnosis codes to identify patients with ischemic stroke and then collected prescription records (type, dosage, duration, and date) of statins. In order to determine adherence, they calculated the proportion of days covered (PDC) by any statin prescription for a period of 1 year after acute ischemic stroke. Poor adherence was PDC < 40%, intermediate adherence was PDC 40-80%, and good adherence was PDC > 80%. Their primary outcome was composite of recurrent stroke, myocardial infarction (MI) and all-cause death. Again, diagnosis codes were used to obtain this information. Recurrent stroke was defined as re-hospitalization with a primary diagnosis of I60-63. MI was defined as primary diagnosis code of I21.

By |December 1st, 2017|clinical|0 Comments

Peri-Procedural Silent and Clinical Infarctions in Cardiovascular Procedures

Gurmeen Kaur, MBBS
@kaurgurmeen

Cho S-M, Deshpande A, Pasupuleti V, Hernandez AV, Uchino K. Radiographic and Clinical Brain Infarcts in Cardiac and Diagnostic Procedures: A Systematic Review and Meta-Analysis. Stroke. 2017

Cardiovascular procedures including Aortic Valve Replacement (AVR), coronary artery bypass grafting (CABG), and cardiac and cerebral catheterization have been associated with increased prevalence of peri-procedural acute ischemic brain lesions on magnetic resonance imaging (MRI).

In this systematic review, Cho et al compared the ratio of radiographic brain infarcts (RBI) to strokes and transient ischemic attacks across cardiac and vascular procedures. RBIs are common after invasive vascular procedures and are encountered a lot more frequently than clinical strokes or TIAs. Literature suggests that peri-procedural ischemic events might serve as a potential surrogate marker for optimizing invasive procedures, which is why an effort was made to compare the rates of RBIs to clinical events.

Physical Activity and Stroke Risk: A Role for Moderate Physical Activity

Mark R. Etherton, MD, PhD

Willey JZ, Voutsina J, Sherzai A, Ma H, Bernstein L, Elkind MSV, et al. Trajectories in Leisure-Time Physical Activity and Risk of Stroke in Women in the California Teachers Study. Stroke. 2017

In this entry, I discuss a recent publication by Joshua Willey and colleagues regarding the protective effects of physical activity on stroke risk.

A beneficial role of physical activity in the prevention of cardiovascular disease and ischemic stroke has been consistently demonstrated. An outstanding question, however, is how changes in physical activity impact incident stroke risk. The authors of this manuscript, therefore, set out to investigate the association between changes in self-reported physical activity at two time points and incident stroke risk.

The authors used the California Teachers Study cohort, which is a large prospective cohort of female teachers in the state of California, and examined self-reported physical activity at two time points (1995 and 2005-6). In total, 61,256 participants were included in the analysis with notable exclusion criteria, including history of stroke or age less than 26 years old. Exercise was reported as moderate (e.g. brisk walking) or strenuous (e.g. swimming, running) and quantified as hours per week and months per year in the past 3 years. The authors used this data to then establish average minutes/week and dichotomized the measures by the AHA recommendations for moderate (150 minutes/week) or strenuous (75 minutes/week) activity. Using these metrics of physical activity, the authors assessed incident stroke risk.

Is Circuit Training Useful After Stroke?

Stephen Makin, PhD
@StephenMakin

English C, Hillier S, Lynch E. Circuit Class Therapy for Improving Mobility After Stroke. Stroke. 2017

There are few things in life I find more boring than going to the gym. Running on a treadmill or lifting weights for what seems like hours just doesn’t interest me.

Circuit class can be fun though. You get to try lots of different exercises and move onto the next one before they get boring.

But could they also work in the stroke unit gym? After all, that’s nothing like a usual gym.

This is something people have been asking for a while. The first study of circuit training in stroke rehabilitation was carried out in 2000. English and colleagues have updated the Cochrane review on circuit training after stroke.

Remote Ischemic Conditioning May Improve Outcomes of Patients With Cerebral Small-Vessel Disease

Alexis N. Simpkins, MD, PhD

Wang Y, Meng R, Song H, Liu G, Hua Y, Cui D, et al. Remote Ischemic Conditioning May Improve Outcomes of Patients With Cerebral Small-Vessel Disease. Stroke. 2017

Cerebral small vessel disease (sCVD) is an important cause of both vascular dementia and lacunar infarction. Accumulation of white matter lesions and lacunar infarcts from sCVD is associated with cognitive dysfunction, increased risk of stroke, and worsened neurologic outcome after stroke. Here the authors test the hypothesis that remote ischemic conditioning (RIC) can improve cognitive outcomes in patients with mild cognitive impairment and cSVD as a follow up to the pilot study in which they showed that cSVD can reduce white matter disease and increase mean velocity of the middle cerebral arteries.

This study was a 1-year, single-center, prospective, double-blinded, randomized, placebo controlled study of consented patients of Han Chinese decent between 45 and 80 years of age with mild cognitive impairment defined by a pre-treatment MMSE and MOCA score, sCVD as defined by the Standards for Reporting Vascular Changes on Neuroimaging criteria on pre-treatment brain MRI and automated measurements of white matter disease of MRI-fluid-attenuated inversion recovery sequences. Patients were excluded if they did not complete > 80 % of the therapy, had significant cardiac disease, medical illness, medical contraindication to having RIC performed, intracerebral hemorrhage, stroke within the past 6 months, or an alternate etiology of small vessel disease such as vasculitis, genetic disorder, > 50% stenosis of intracranial vessel, or atrial fibrillation. The difference between the RIC and placebo group was the pressure of the cuff inflation from the automated device (200 mmHg in RIC cycling for 5 cycles of inflation and deflating for 5 minutes vs. 50mmHg in control).

Cost Effectiveness and Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke

Sami Al Kasab, MD

Sevick LK, Ghali S, Hill MD, Danthurebandara V, Lorenzetti DL, Noseworthy T, et al. Systematic Review of the Cost and Cost-Effectiveness of Rapid Endovascular Therapy for Acute Ischemic Stroke. Stroke. 2017

Stroke remains one of the most devastating neurological illnesses and the leading cause of long-term disability in the U.S. It’s projected that the total cost of stroke from 2005 to 2050 will be $1.52 trillion for non-Hispanic whites, $313 billion for Hispanics, and $379 billion for African Americans. Until 2015, intravenous alteplase (rtPA) was the only proven treatment for acute ischemic stroke. In 2015, a series of five randomized controlled trials demonstrated the effectiveness of mechanical thrombectomy for patients presenting with acute ischemic stroke due to anterior circulation large vessel occlusion within 6 hours of symptom onset.

In this study, Sevick et al perform a systematic review to evaluate cost effectiveness of endovascular therapy (EVT) for acute ischemic stroke. The authors also aim to synthesize all the publicly available economic literature regarding EVT.