American Heart Association

Mobile Stroke Units in the Management of Intracerebral Hemorrhage

Andrew Micieli, MD

Cooley SR, Zhao H, Campbell BCV, Churilov L, Coote S, Easton D, Langenberg F, Stephenson M, Yan B, Desmond PM, et al. Mobile Stroke Units Facilitate Prehospital Management of Intracerebral Hemorrhage. Stroke. 2021.

The phrase “time is brain” refers to the rapid identification and potential administration of reperfusion therapy (thrombolysis and/or endovascular therapy) in the setting of ischemic stroke. However, this phrase is also applicable to intracerebral hemorrhage (ICH). At the present time, treatment of ICH is targeted at early diagnosis with neuroimaging followed by therapy targeted at preventing hematoma expansion. This includes early lowering of blood pressure, reversal of coagulopathy or anticoagulation, critical care management and potential surgical options. Time is critical, as hematoma expansion is a strong determinant of neurological deterioration and worse clinical outcomes. This treatment paradigm lends itself well to the mobile stroke unit (MSU).

By |October 13th, 2021|clinical|0 Comments
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Stroke in the COVID-19 Era

Kevin O’Connor, MD

Katsanos AH, Palaiodimou L, Zand R, Yaghi S, Kamel H, Navi BB, Turc G, Benetou V, Sharma VK, Mavridis D, et al. Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Stroke. 2021.

COVID-19 complicates many aspects of clinical care, including care of stroke patients. Katsanos et al. conducted a meta-analysis on the impact of COVID-19 on the provision of stroke care, independent of SARS-CoV-2 infection status. They collected 46 studies capturing data from 129,491 patients across Africa, Asia, Europe, and the Americas comparing common stroke care variables pre- and post-pandemic onset. These included demographic information, vascular risk factors, intravenous thrombolysis (IVT) administration, endovascular thrombectomy (EVT) performance, relevant time metrics, and hospitalization outcomes.

By |October 12th, 2021|clinical, health care, policy|0 Comments
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Article Commentary: “Endovascular Thrombectomy for Treatment of Acute Ischemic Stroke During Pregnancy and the Early Postpartum Period”

Ericka Teleg, MD

Dicpinigaitis AJ, Sursal T, Morse CA, Briskin C, Dakay K, Kurian C, Kaur G, Sahni R, Bowers C, Gandhi CD, et al. Endovascular Thrombectomy for Treatment of Acute Ischemic Stroke During Pregnancy and the Early Postpartum Period. Stroke. 2021.

This study begins with emphasizing the lack of evidence in the management of pregnant patients or those in the early postpartum period confronted with acute ischemic stroke within the time window for endovascular therapy. In the advent of the landmark clinical trials on the benefit of endovascular therapy for acute ischemic stroke, it is the authors’ hypothesis that this particular group will also show a favorable clinical course and short-term outcomes likened to those found in the general population. Pregnant and postpartum women were systematically excluded from the clinical trials in acute reperfusion therapies for acute ischemic stroke. Acute reperfusion therapy with endovascular thrombectomy in the setting of pregnancy and the postpartum period is an important area to navigate. Pathophysiology of stroke among this population includes a hypercoagulable physiological state. It is important that this study answers this need in terms of benefit, complications, and outcomes, as stroke physicians are bound to encounter these complex cases in their lifetime. 

By |October 11th, 2021|clinical, treatment|0 Comments
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Article Commentary: “Peanut Consumption and Risk of Stroke and Ischemic Heart Disease in Japanese Men and Women”

Hannah Roeder, MD, MPH

Ikehara S, Iso H, Kokubo Y, Yamagishi K, Saito I, Yatsuya H, Kimura T, Sawada N, Iwasaki M, Tsugane S, and the JPHC Study Group. Peanut Consumption and Risk of Stroke and Ischemic Heart Disease in Japanese Men and Women: The JPHC Study. Stroke. 2021.

In the health care community, we continuously search for the best diet to prevent vascular disease. The authors investigated whether greater peanut consumption, as recorded in a food frequency questionnaire in the Japan Public Health Center-based Prospective Study, was correlated with lower rates of stroke and heart disease among middle-aged Japanese men and women. More than 70,000 participants aged 45 to 74 years completed food frequency questionnaires, and the participants were monitored for a median follow-up of 14.8 years. The authors calculated multivariable hazard ratios for the highest versus lowest quartiles of peanut consumption (after adjusting for some demographic features, medical co-morbidities, and dietary factors). Hazard ratios were 0.84 (95% CI: 0.77-0.93) for total stroke, 0.80 (0.71-0.90) for ischemic stroke, 0.93 (0.79-1.08) for hemorrhagic stroke, 0.97 (0.80-1.17) for ischemic heart disease, and 0.87 (0.80-0.94) for cardiovascular disease (defined as stroke and heart disease). The authors concluded that higher peanut consumption was associated with reduced risk of stroke, particularly ischemic stroke, but not ischemic heart disease. The authors proposed that the high level of unsaturated fatty acids improving lipid profiles and lowering blood pressure contributes to the beneficial effects.

By |October 8th, 2021|clinical|0 Comments
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DOACs Can Safely Be Administered in Dependent Patients With Recent Stroke

Ayush Agarwal, DM
@drayushagarwal

Meya L, Polymeris AA, Schaedelin S, Schaub F, Altersberger VL, Traenka C, Thilemann S, Wagner B, Fladt J, Hert L, et al. Oral Anticoagulants in Atrial Fibrillation Patients With Recent Stroke Who Are Dependent on the Daily Help of Others. Stroke. 2021.

Cardio-embolic strokes comprise one third of all acute ischemic strokes.1 Trials have proven direct oral anticoagulants (DOACs) to be as effective as vitamin K antagonists (VKAs) with lesser intracranial bleeding risk.2 The added absence of dietary interactions and routine blood level monitoring makes DOACs the preferred alternative over VKAs.3

However, all major DOAC trials recruited patients with only minor strokes and transient ischemic attacks, and patients with disabling strokes were excluded.4-7 This excluded population forms a significant proportion of stroke burden as approximately 40% of strokes attributable to atrial fibrillation (AF) are dependent on caregivers for their daily living.8

By |October 7th, 2021|clinical|0 Comments
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Choosing Amongst Different Revascularization Techniques for Recurrent Carotid Stenosis After Carotid Endarterectomy

Muhammad Rizwan Husain, MD
@RIZWANHUSAINMD

Elsayed N, Ramakrishnan G, Naazie I, Sheth S, Malas MB. Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy. Stroke. 2021;52:3199–3208.

The incidence of restenosis after carotid endarterectomy (CEA) varies from 6 to 16%, and these patients were historically treated with redo-CEA. However, redo-CEA is associated with a risk of increased mortality and cranial nerve injury while transfemoral carotid stenting (TFCAS) has a higher 30-day rate of perioperative strokes. TCAR (transcarotid artery revascularization) is a newer technique that helps with reducing risk of distal embolization and is reported to be associated with a 65% reduction in stroke or death compared with TFCAS. In treatment of primary carotid disease, TCAR has been seen to perform as well as CEA and better than TFCAS. The authors here evaluate the outcomes of TCAR, TFCAS and redo-CEA in patients who develop restenosis after CEA.

A retrospective analysis was conducted of the VQI (Vascular quality initiative) database for patients who after ipsilateral CEA underwent TCAR, TFCAS or redo-CEA. Patients with prior carotid stenting, trauma or dissections were excluded. In this cohort, 21.8% underwent redo-CEA, 37.8% underwent TCAR and 40.4% underwent TFCAS.

By |October 6th, 2021|clinical|0 Comments
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Assessing MR Perfusion-Diffusion Mismatch in Pediatric Acute Ischemic Stroke

Kevin O’Connor, MD

Visser MJ, Yang JYM, Calamante F, Kean M, Adamson CL, Sharma G, Anderson V, Campbell BCV, Mackay MT. Automated Perfusion-Diffusion Magnetic Resonance Imaging in Childhood Arterial Ischemic Stroke. Stroke. 2021.

Visser et al. explore the feasibility of automated software to evaluate MRI perfusion-diffusion mismatch in children with acute ischemic stroke. Their retrospective study examined 29 children with acute ischemic stroke and MR perfusion imaging obtained within 72 hours of symptom onset at a single center. They excluded 158 children, predominantly for lack of perfusion imaging, among other reasons.

Perfusion-diffusion mismatch assessment was automated with RAPID software. The software detected an ischemic core in 19 children (66%). The remaining children (n=10, 34%) tended to present later (undetected onset-to-imaging time median 21.8 hours, IQR, 14.3–27 versus detected onset-to-imaging time median 11 hours, IQR, 7.2–23.5) and have smaller ischemic lesions (undetected core volume median 2.7 mL, IQR, 1.1–6.2 versus detected core volume median 17.3 mL, IQR, 12.4–49.6) that limited the software’s effectiveness. Eighteen of the 29 children required sedation, and they tended to be younger (median age 4.4, IQR, 2.8–7.3 versus median age 14.8, IQR, 10.7–15.7).

By |October 5th, 2021|clinical|0 Comments
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Obstructive Sleep Apnea: Further Evidence on its Impact in Cardiovascular Disease

Wern Yew Ding, MBChB

Dalmar A, Singh M, Heis Z, Cumpian TL, Ceretto C, Mortada ME, Bhatia A, Niazi I, Chua TY, Sra J, Jahangir A. Risk of Atrial Fibrillation and Stroke After Bariatric Surgery in Patients With Morbid Obesity With or Without Obstructive Sleep Apnea. Stroke. 2021;52:2266-2274.

Obstructive sleep apnea (OSA) is common in morbidly obese patients and has been linked to the initiation and maintenance of atrial fibrillation (AF), which in turn predisposes patients to an increased risk of ischemic stroke. The benefits of gastric banding in patients with and without AF have previously been demonstrated. However, there is a lack of studies examining the effects of OSA in such patients.

In this study by Dalmar and colleagues, the authors sought to determine whether incident AF and stroke rates after gastric banding are influenced by OSA using a single-centre retrospective analysis of 853 morbidly obese patients (defined as body mass index ≥35 kg/m2 with obesity-associated comorbidity or body mass index ≥40 kg/m2) who failed conservative treatment for weight loss and were selected for laparoscopic adjustable gastric banding by a multidisciplinary team approach. Most patients were females (84%) with a mean age of 44 years old, body weight of 136kg and body mass index of 48.6 kg/m2. OSA was present in 27% of this cohort. Over a follow-up period of 6 years, it was reported that new-onset AF and incident stroke were significantly higher in the OSA group than in the non-OSA group (new-onset AF: 1.7% vs 0.5%, incident stroke: 2.1% vs. 0.5%). The findings persisted after propensity score matched analysis to account for differences in baseline characteristics between the groups. Furthermore, OSA was found to be an independent risk factor for new-onset AF and incident stroke after adjustment for other risk factors.

By |October 4th, 2021|clinical|0 Comments
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Early Infarct Recurrence in Patients With Symptomatic Intracranial Atherosclerotic Disease: Importance of Diagnostic Biomarkers

Meghana Srinivas, MD
@SrinivasMeghana

Prabhakaran S, Liebeskind DS, Cotsonis G, Nizam A, Feldmann E, Sangha RS, Campo-Bustillo I, Romano JG, and on behalf of the MYRIAD Investigators. Predictors of Early Infarct Recurrence in Patients With Symptomatic Intracranial Atherosclerotic Disease. Stroke. 2021;52:1961–1966.

Intracranial atherosclerotic disease (ICAD) is a progressive pathological process of the cerebral vasculature which can lead to symptomatic stenosis of the blood vessels, causing occurrence and/or recurrence of strokes. Intracranial stenosis accounts for 10% of ischemic strokes in the United States with 12 to 20% experiencing recurrent strokes within one year of index stroke.

Shyam Prabhakaran et al. performed a post hoc analysis of the MYRIAD study (Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease) of ICAD patients with recent (less than 21 days) stroke/transient ischemic attack, 50-99% stenosis and those who had 6–8 weeks MRI Brain per protocol.  The study reported the risk of clinical stroke recurrence in the territory of the symptomatic artery at 1 year was 8.8%, with nearly 25% of patients having recurrent infarcts on 6- to 8-week brain magnetic resonance imaging (MRI). 

By |October 1st, 2021|clinical|0 Comments
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FLAIR Imaging Serves as a Tissue Clock

Fransisca Indraswari, MD

Aoki J, Sakamoto Y, Suzuki K, Nishi Y, Kutsuna A, Takei Y, et al. Fluid-Attenuated Inversion Recovery May Serve As a Tissue Clock in Patients Treated With Endovascular Thrombectomy. Stroke. 2021;52:2232–2240.

This retrospective study by Aoki et al. investigated the role of fluid-attenuated inversion recovery (FLAIR) sequence in the magnetic resonance imaging (MRI) of the brain as a tool to predict outcome after an endovascular thrombectomy (EVT), regardless of the time of symptom onset. The notion of imaging-based prognostication of clinical outcome has been elucidated in previous trials, e.g., THAWS1 and WAKE UP.2 Similarly, the concept of extending therapeutic window of thrombectomy up to 24 hours based on imaging selection criteria in DAWN3 and DEFUSE3.4 They hypothesized that if the signal change on FLAIR was associated with the clinical outcome after EVT, FLAIR may be able to serve not only as a time clock, but also as a tissue clock.

Patients with acute ischemic stroke treated with EVT were recruited between September 2014 and December 2018. They were divided between FLAIR-positive and FLAIR-negative groups based on the parenchymal change on FLAIR sequence in their MRI brain. The clinical characteristics, imaging findings, EVT parameters, and the intracranial hemorrhage defined as Heidelberg Bleeding Classification ≥1c hemorrhage (parenchymal hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, and/or subdural hemorrhage) were compared between the 2 groups. Clinical outcome at 3 months was defined as modified Rankin Scale Score (mRS) with 0-1 being good outcome.

By |September 28th, 2021|clinical|0 Comments
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