American Heart Association

Neuronal Loss in Ischemic Stroke: Time is Relative

Alejandro Fuerte, MD
@DrFuerte1

Desai SM, Rocha M, Jovin TG, Jadhav AP. High Variability in Neuronal Loss: Time Is Brain, Requantified. Stroke. 2018;50:34–37

Acute ischemic stroke caused because of large-vessel occlusion (LVO) is a neurological emergency characterized by abrupt interruption in blood flow that causes rapid neuronal death. It has been shown that time in this situation is directly proportional to the infarcted brain tissue. In this context, there is an approximate loss of 1.9 million neurons every minute, which means “run!”. However, as we have observed in the DAWN and DEFUSE 3 trials, there is inter-individual variability, and the therapeutic window can be widened in those cases of patients whose ischemic core grows slowly.

The main goal of Desai et al. was to calculate the rate of loss of brain tissue within a cross-section of LVO patients with different infarct growth rate (IGR). For this purpose, they performed a retrospective review of a prospectively acquired database of acute ischemic strokes with occlusion of the internal carotid artery or middle cerebral artery. Ischemic core volume was measured with automated software and time from last known well to imaging was recorded. For the final calculations, they used what is already known about the volume of forebrain (total number of neurons, synapses, and myelinated fiber length) and, with the results, a statistical analysis was performed.

By |March 19th, 2019|clinical|0 Comments

Differences in Outcomes of Interhospital Transfer Patients Versus Direct Presentations

Gurmeen Kaur, MBBS
@kaurgurmeen

Shah S, Xian Y, Sheng S, Zachrison KS, Saver JL, Sheth KN, et al. Use, Temporal Trends, and Outcomes of Endovascular Therapy after Interhospital Transfer in the United States. Circulation. 2019

The current decade has seen a revolution in stroke care with the advent of endovascular therapy (EVT) and extended timelines for stroke intervention. With the expansion of stroke care, there is a tremendous increase in the need for angiographic suites and providers. Most smaller, non thrombectomy capable centers have set up contracts with academic or bigger centers nearby to transfer their stroke patients for emergent large vessel occlusions.

However, given that the number of treatable strokes far exceeds the number of thrombectomy capable centers, it is the right time to review our nationwide policies on transfers for improved patient care and quality improvement. In this paper, authors Shah et al. have done a great job elucidating the temporal trends in transfer of patients for EVT and how those transfer trends are influencing the final outcome, using the Get with the Guidelines database.

By |March 18th, 2019|clinical|0 Comments

Tandem Lesions: To Stent or Not To Stent?

Robert W. Regenhardt, MD, PhD
@rwregen

Jadhav AP, Zaidat OO, Liebeskind DS, Yavagal DR, Haussen DC, Hellinger FR, et al. Emergent Management of Tandem Lesions in Acute Ischemic Stroke: Analysis of the STRATIS Registry. Stroke. 2018;50:428–433.

With the 2015 trials irrefutably showing the superiority of endovascular thrombectomy (ET) over intravenous tPA alone for the treatment of stroke secondary to large vessel occlusion (LVO), and the 2018 trials showing it may be effective for up to 24 hours from symptom onset, current research efforts focus on expanding the number of patients who may be eligible for this highly effective treatment (e.g., larger core, more distal occlusions) and optimizing protocols for more complex cases. The latter is exemplified by questions that remain about the best approach to treating tandem lesions, which involve both the cervical internal carotid artery (ICA) and an intracranial artery. The most common etiology is cervical ICA atherosclerosis, but tandem lesions can also result from cervical ICA dissection.

Perhaps the biggest conundrum in the management of tandem lesions is whether or not to stent the cervical ICA in the acute setting. Given the risk of dual antiplatelet therapy, especially in patients who received tPA and have larger cores, some interventionalists choose to defer in the acute setting and offer stenting versus endarterectomy later. If stenting is offered in the acute setting, it is unclear whether cervical ICA stenting should be done before or after intracranial ET. Furthermore, the role of angioplasty and the optimum antithrombotic regimen have yet to be determined. There is limited data available to help guide these decisions. While many of the ET trials included patients with tandem lesions, the management was highly variable. Tandem lesions were present in 32% of MR CLEAN, 18% of REVASCAT, and 17% of ESCAPE, while they were excluded from SWIFT PRIME and EXTEND IA. An analysis of the 30 patients with tandem lesions that were treated with ET in ESCAPE showed 17 underwent cervical ICA stenting, 10 before and 7 after intracranial ET. Of the 13 for which stenting was deferred in the acute setting, only 4 underwent ICA revascularization later.

Using COMPASS for Primary and Secondary Ischemic Stroke Prevention?

Aristeidis H. Katsanos, MD, PhD

Sharma M, Hart RG, Connolly SJ, Bosch J, Shestakovska O, Ng KKH, et al. Stroke Outcomes in the COMPASS Trial. Circulation. 2019;139:1134–1145.

The Cardiovascular OutcoMes for People using Anticoagulation StrategieS (COMPASS) is a double-blind randomized clinical trial, which assigned a total of 27,395 participants with stable coronary artery or peripheral artery disease to receive either aspirin 100 mg once daily or rivaroxaban 5 mg twice daily or rivaroxaban 2.5 mg twice daily plus aspirin. Stroke occurrence during a mean follow-up of 23 months was reduced to 0.5% in the rivaroxaban 2.5 mg BID plus aspirin group (HR=0.58, 95%CI: 0.44-0.76, p<0.0001), while no significant difference was noted in the occurrence of stroke in the rivaroxaban 5 mg BID group (HR=0.82, 95%CI: 0.65-1.05) compared to aspirin monotherapy. Interestingly, the incidence of hemorrhagic stroke was significantly increased in the rivaroxaban 5mg BID group compared to the aspirin alone group (HR=2.70, 95%CI: 1.31-5.58, p=0.005), but no increase in the risk of hemorrhagic stroke was found for the combination of rivaroxaban 2.5 mg BID with aspirin group (HR=1.49, 95%CI: 0.67-3.31, p=0.33). The annualized rate of disabling or fatal stroke (modified Rankin Scale scores 3-6) was also found to be reduced in the rivaroxaban 2.5 mg BID plus aspirin group (HR=0.58, 95%CI: 0.37-0.89, p=0.01).

By |March 12th, 2019|clinical|0 Comments

Stent Retriever: Does the Size Really Matter?

Elena Zapata-Arriaza, MD
@ElenaZaps

Zaidat OO, Haussen DC, Hassan AE, Jadhav AP, Mehta BP, Mokin M, et al. Impact of Stent Retriever Size on Clinical and Angiographic Outcomes in the STRATIS Stroke Thrombectomy Registry. Stroke. 2019;50:441–447.

The introduction of stent retriever has involved a great advance in the reperfusion treatment of acute ischemic stroke with large vessel occlusion. Stent retriever has increased procedural success, leading the American Heart Association/American Stroke Association guidelines to recommend the use of stent retrievers for mechanical thrombectomy within 8 hours of symptom onset. However, some concerns related to the safety and efficacy of the stent retriever are maintained regarding its diameter and size.

To answer the question, Zaidat et al. performed a retrospective ad hoc analysis of data from the STRATIS registry (a prospective, multicenter study of patients with large vessel occlusion treated with the Solitaire stent retriever). Main angiographic end points were first-pass effect (FPE), defined as modified thrombolysis in cerebral infarction (mTICI) ≥2c recanalization grade after the first pass without the use of rescue therapy, and rates of modified FPE (mFPE), defined as meeting all criteria for FPE but achieving mTICI ≥2b after first pass. The primary clinical endpoint was functional independence (modified Rankin scale, 0–2) at 3 months as determined on-site. Rates of distal embolization, embolization into new territory, and final mTICI among others were evaluated as well.

By |March 11th, 2019|clinical|0 Comments

The Heart of All Matters: Atrial Cardiopathy

Hatim Attar, MD

The etiologies of cerebral infarcts have always been under scrutiny. As it stands today, about a third of strokes are still cryptogenic. The impact of stroke does not need to be emphasized to the audience of this blog. Despite staggering data with modern technological advances, a significant percentage of stroke patients remain a mystery. The solace is that we have made some advances, wherein I can introduce this hot topic of discussion: atrial cardiopathy.

The term atrial cardiomyopathy was first published in 1972, to describe a familial syndrome affecting the atria and atrioventricular system with resultant rhythm abnormalities. The term has percolated through the years, evolving in its definition. The current definition for atrial cardiopathy, created by the European Heart Rhythm Association, is the most accepted one: any complex structural, architectural, contractile or electrophysiological changes affecting atria with potential to produce clinically relevant manifestations. This suggests that the various markers of atrial cardiopathy include Left Atrium (LA) size, Left Atrial Appendage (LAA) function and morphology, P wave terminal force on EKG, atrial ectopy and serum BNP.

By |March 8th, 2019|clinical|1 Comment

Statins for Chronic Subdural Hematoma

Kat Dakay, DO

Jiang R, Zhao S, Wang R, Feng H, Zhang J, Li X, et al. Safety and efficacy of atorvastatin for chronic subdural hematoma in Chinese patients: A randomized clinical trial. JAMA Neurol. 2018;75:1338-1346. [1]

Statins are a commonly used treatment in patients with hyperlipidemia, coronary artery disease, and ischemic stroke; however, the role of statins in intracranial hemorrhage is less clear. More recently, the role of statins in chronic subdural hematoma has been investigated.

Chronic subdural hematoma increases with aging and represents a clinical challenge; while surgical management with burrhole drainage can be successful, patients can also experience recurrence in approximately 1/3 of cases [2]. Additionally, the risk of surgery may be a concern, particularly in elderly patients or those with medical comorbidities. At this time, there is no clear established medical treatment for chronic subdural hematoma, but statins have been posited as a possible nonsurgical option for treatment of chronic SDH. In this study published in JAMA Neurology, Jiang and colleagues present the results of a randomized controlled trial of low-dose atorvastatin in patients with chronic subdural hematoma [1].

Author Interview: Prof. Turgut Tatlisumak, MD, PhD, on “Nontraumatic intracerebral haemorrhage in young adults”

Prof. Turgut Tatlisumak

Prof. Turgut Tatlisumak

A conversation with Turgut Tatlisumak, MD, PhD, from the Department of Clinical Neuroscience and Neurology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.

Interviewed by Shashank Shekhar (@ArtofStroke), MD, MS, Assistant Professor, Division of Vascular Neurology, University of Mississippi Medical Center.

They will be discussing the article “Nontraumatic intracerebral haemorrhage in young adults,” published in Nature Reviews Neurology.

Dr. Shekhar: First, I would like to thank Prof. Tatlisumak for agreeing to do this interview. This is an interesting review paper in which you have discussed in detail nontraumatic intracerebral hemorrhage (ICH) in young adults. Could you tell the readers why you decided to write about hemorrhage in young adults?

Prof. Tatlisumak: We have long been investigating stroke in young adults, but most of our attention went to ischemic strokes. I wished to extend our research to ICH in young adults and found only few original patient series. Sometime later, I noticed that there is not a single review on this topic, and there is an unmet need. Then we set up a small group of experts sharing the tasks. That is how we started.

Rising Incidence of Stroke in Pregnancy: What’s to Blame?

Kara Jo Swafford, MD

Liu S, Chan W-S, Ray JG, Kramer MS, Joseph KS, and for the Canadian Perinatal Surveillance System (Public Health Agency of Canada). Stroke and Cerebrovascular Disease in Pregnancy: Incidence, Temporal Trends, and Risk Factors. Stroke. 2018;50:13–20.

Stroke is the most common cause of long-term disability in women after pregnancy. In Canada, the incidence of stroke at delivery was 4.8 per 100,000 deliveries between 2003-2007, with an associated case fatality of 9.4%. In the United States, the rate of stroke during the antepartum period increased from 15 to 22 per 100,000 deliveries between 1994-1995 and 2006-2007, with the rate during the postpartum period increasing from 12 to 22 per 100,000 deliveries over the same time period.

Liu et al. investigated the incidence, trends and risk factors associated with stroke in pregnancy in Canada by performing a retrospective population-based cohort study including antenatal, delivery and postpartum admissions within 42 days between 2003-2016. Stroke incidence was 13.4 cases per 100,000 deliveries between 2003-2016; 60% hemorrhagic and 30% ischemic stroke, with a 7.4% case fatality rate. Over half (51.7%) of cases occurred during the postpartum period. The rate of stroke increased from 10.8 to 16.6 cases per 100,000 deliveries between 2003-2004 and 2015-2016. Risk increased with increasing gestational duration, advanced maternal age, gestational hypertension, preeclampsia, eclampsia, connective tissue disorders, sepsis, postpartum hemorrhage requiring blood transfusion, congenital heart disease, HIV infection and thrombophilia. Several potential confounders, such as smoking, body mass index, ethnicity and socio-economic status, were not available.

A New Way to Think About Moyamoya

Richard Jackson, MD

Yin H, Liu X, Zhang D, Zhang Y, Wang R, Zhao M, et al. A Novel Staging System to Evaluate Cerebral Hypoperfusion in Patients With Moyamoya Disease. Stroke. 2018

Moyamoya disease is one of those rare diseases that we come across infrequently and are uncertain what to do about when we do.  The syndromic disease is easily recognizable, and the work-up largely revolves around ruling out secondary moyamoya syndrome from an identifiable cause that can be modified.  Primary moyamoya vasculopathy has remained a surgical disease due to lack of understanding of its etiology.

I was excited to see Hu Yin et al. had collected a large cohort of 506 patients with primary moyamoya disease and attempted to stratify them radiographically into who would respond best to treatment.  The group used Gao et al.’s CT-Perfusion scale system of stages of pre-infarction in moyamoya disease (MMD) to explore perfusion differences in pre-surgical intervention with direct or combined bypass techniques and to explore the perfusion difference between hemorrhagic and ischemic patients.