American Heart Association

Monthly Archives: September 2013

NIHSS scores across a population: Sampling our collective stroke “health”

Peter Hannon, MD

Reeves M. Khoury J, Alwell K, Moomaw C, Flaherty M, Woo D, et al. Distribution of National Institutes of Health Stroke Scale in the Cincinnati/Northern Kentucky Stroke Study. Stroke. 2013


We all perform an NIHSS to quickly assess an acute stroke patient’s status, but what if we could utilize this score as a means to assess the stroke health of a community? Reeves and colleagues have investigated doing just this by collecting retrospective NIHSS scores from ischemic stroke patients within the Cincinnati/Northern Kentucky Stroke Study for one calendar year.



In 2005, ischemic strokes were screened at 17 hospitals, as well as at hospital-based ERs and outpatient clinics, public health clinics, and via a sampling scheme, at 51 of 832 physician offices and 25 of 126 nursing homes. A total of 2233 ischemic strokes were identified, and a retrospective NIHSS (rNIHSS) was performed based on physical findings at the initial examination. rNIHSS distribution was stratified by age, sex, race and location of ascertainment. The median scores were found to be higher for in-hospital strokes (7), lowest for out-of-hospital strokes (1), and right at the overall median for cases admitted to the hospital (3). Patients over 80 had higher scores than those younger (4 vs. 3), but there were no significant differences by sex or race. Surprisingly, >50% had mild symptoms severity at presentation (rNIHSS <3), which the authors note is in general agreement with other reports that have presented NIHSS data from population or community-based studies.
While this study has some limitations, such as having to retrospectively assess NIH Stroke Scales, it does raise the interesting concept of being able to utilize a collective NIHSS to track trends in a community’s stroke “health” as efforts continue in outreach, education and stroke prevention. If this information was continuously collected and readily accessible, what could it tell us about a community’s health over time?
By |September 30th, 2013|Uncategorized|1 Comment

Population Health and Stroke Care-a wave of the future?

Waimei Tai, MD

Today at the Population Health colloquium(see agenda here) held at Stanford University, speakers from around the world engaged on a serious question that many traditional clinicians haven’t really thought about: taking care of the health of a population.



This event was sponsored by the Stanford Population Health Initiatives with the aim to draw collaborators from different disciplines to help design and implement learning health care systems for the future of whole populations of patients. The aim is to continually improve the quality and efficiency of care by rapidly translating evidence from scientific research and patient outcomes into clinical practice.

As an audience member I couldn’t help but reflect upon my own clinical work as a stroke neurologist. Sure, I see patients in my clinic and counsel them individually on how to best manage their cholesterol and hypertension. Yes, I see patients when they present with acute stroke symptoms. But ask me how my panel of 500 patients is doing with their hemoglobin A1c or weight loss program and I would freeze. I have no idea how my population of patients are doing, and in fact, even asking that question seems preposterous. I can’t imagine how I would go about querying my panels’ data. I imagine the electronic health record programmers are not particularly interested in writing scripts for that query unless this was an initiative led by quality and performance improvement.

Of course, we all know this is where the future of healthcare is going:
Meaningful Use 3 is not too far away and we as clinicians must think long and hard about how to best care for not only the patient sitting across from you in the exam room, but also the whole population of patients. 

One way we’re expanding our work for stroke care is to focus on not only individually managing the patients who present with stroke symptoms in the hospital, but how to best care for a population of such patients who has already suffered from a stroke and need optimization of their secondary stroke prevention risk factors, as well as targeting patients with a bevy of different vascular comorbidities predispose them to an even higher risk of stroke. We’re working on proactively engaging patients to manage their own health.  Learn more about our program at the Clinical Excellence Research Center.
By |September 26th, 2013|Uncategorized|2 Comments

Stroke Care in the Republic of Armenia: Impressions from the Recent Stroke Treatment 2013 Conference

Last week I attended a stroke symposium in the Republic of Armenia entitled: Stroke Treatment 2013. This was a joint conference put on by the Yerevan State Medical University (YSMU), the Ministry of Health, the Fund for Armenian Relief (FAR) and the Armenian Medical International Committee (AMIC). It was a collaborative project headed up by Professor Viken Babikian of Boston University and the head of Neurosurgery at YSMU, Professor Rouben Fanardjian. We lectured on a host of topics related to stroke treatment and stroke prevention.


The Republic of Armenia is a developing nation that lacks the presence of a stroke system of care. This is highlighted by the fact that in its history, there has been one known case of acute stroke treatment with thrombolytic. There is one center, at the YSMU, with the capabilities to perform neuroendovascular procedures. In general neurologists are not involved with the care of acute stroke patients, which are attended to by emergency physicians and critical care anesthesiologists.

There are a lot of challenges in developing stroke care in Armenia, as in many developing nations. According to official statistics, the incidence of stroke was 176/100.000 in Armenia in 2012, with 5417 cases, and in-hospital mortality was 20.6%.

We proposed establishing a stroke center at the University Hospital of the YSMU to serve as an acute stroke center for the city of Yerevan and its region, as well as a referral center for all of Armenia. This request was made in writing to the Ministry of Health and we are awaiting their response. We put forth a plan to build the center in stages, over a period of 3 to 5 years.

Our greatest challenge may be in preparing a group of physicians and nurses specially trained in the diagnosis and treatment of stroke. Other challenges include re-organizing the Emergency Medical Services of City of Yerevan, and providing further educational programs to the EMS personnel. These efforts will not yield results without education of the general public about stroke prevention and treatment.

My experiences in Armenia have led me to have a greater appreciation for the work of the World Stroke Organization. I have also come to realize that treating and preventing stroke in the developing world is something we should all support.

By |September 26th, 2013|Uncategorized|1 Comment

Population Health and Stroke Care-a wave of the future?

Population Health Sciences Colloquium
September 26, 2013

At the Population Health colloquium (see agenda here) held at Stanford University, speakers from around the world engaged on a serious question that many traditional clinicians haven’t really thought about: taking care of the health of a population.



This event was sponsored by the Stanford Population Health Initiatives with the aim to draw collaborators from different disciplines to help design and implement learning health care systems for the future of whole populations of patients. The aim is to continually improve the quality and efficiency of care by rapidly translating evidence from scientific research and patient outcomes into clinical practice.

As an audience member I couldn’t help but reflect upon my own clinical work as a stroke neurologist. Sure, I see patients in my clinic and counsel them individually on how to best manage their cholesterol and hypertension. Yes, I see patients when they present with acute stroke symptoms. But ask me how my panel of 500 patients is doing with their hemoglobin A1c or weight loss program and I would freeze. I have no idea how my population of patients are doing, and in fact, even asking that question seems preposterous. I can’t imagine how I would go about querying my panels’ data. I imagine the electronic health record programmers are not particularly interested in writing scripts for that query unless this was an initiative led by quality and performance improvement.

Of course, we all know this is where the future of healthcare is going:
Meaningful Use 3  is not too far away and we as clinicians must think long and hard about how to best care for not only the patient sitting across from you in the exam room, but also the whole population of patients. 

One way we’re expanding our work for stroke care is to focus on not only individually managing the patients who present with stroke symptoms in the hospital, but how to best care for a population of such patients who has already suffered from a stroke and need optimization of their secondary stroke prevention risk factors, as well as targeting patients with a bevy of different vascular comorbidities predispose them to an even higher risk of stroke. We’re working on proactively engaging patients to manage their own health.  Learn more about our program at the Clinical Excellence Research Center.

– Waimei Tai, MD
By |September 26th, 2013|Conference|0 Comments

Silent Ischemic Strokes Due to Septic Emboli in Patients with Infective Endocarditis Are Much More Common Than Previously Thought- Future Cognitive Impact?

Hassanain Toma, MD

Iung B, Tubiana S, Klein I, Messika-Zeitoun D, Brochet E, Lepage L, et al. Determinants of Cerebral Lesions in Endocarditis on Systematic Cerebral Magnetic Resonance Imaging: A Prospective Study. Stroke. 2013

Patients with Infective endocarditis (IE) are at risk of developing ischemic strokes and cerebral microbleeds presumably due to septic emboli. However, it is difficult to predict which of these patients are at risk of such ischemic events. In this prospective study, Iung et al. performed cerebral magnetic resonance imaging (MRI) on 120 consecutive patients with left-sided IE, and analyzed their echocardiographic characteristics.


MRI revealed cerebral abnormalities in 82.5% of IE patients, of which 84.4% were asymptomatic. Using multivariate analysis, they demonstrated that ischemic strokes were significantly associated with Staphylococcus aureus IE (odds-ratio 2.65,), and vegetation length (odds-ratio 1.10 per mm). Further more, they determined that vegetation length of >4 mm were associated with ischemic strokes (sensitivity of 74.6%, specificity of 51.5%). Finally, microbleeds were significantly associated with prosthetic IE (OR 8.01) irrespective of anticoagulation usage.

Their findings potentially create a dilemma with respect to applying the current standard of care in managing large vegetations. Generally, valvular surgery is reserved for vegetation length of >10 mm, because this was previously demonstrated to be associated with embolic strokes on CT scans. By using a more sensitive test to evaluate the brain (ie. MRI), it’s clear that embolic strokes are a lot more common than previously thought. One would wonder if a more aggressive approach (ie. Surgical) should be offered to patients with vegetation size >4 mm. The author sites multiple studies that suggest small emboli and microbleeds may lead to cognitive decline and dementia.

Interestingly, the authors revealed that acute and chronic microbleeds were significantly more common in prosethetic IE, irrespective of anticoagulation usage. It is difficult to draw conclusion from this, since no pathophysiological mechanisms are known to explain this. However it raise the question of weather valvular surgery is independently associated with cerebral microbleeds. This is important for patients at they need to be aware of the possible longterm cognitive impact of such surgeries.

By |September 25th, 2013|Uncategorized|0 Comments

35% Good Outcome Rate in IV-tPA treated Patients with CTA Confirmed Severe Anterior Circulation Occlusive Stroke


Sebina Bulic, MD

González RG, Furie KL,
 Goldmacher GV, Smith WS, Kamalian S, Payabvash S, et al. Good Outcome Rate of 35% in IV-tPA–Treated Patients With Computed Tomography Angiography Confirmed Severe Anterior CirculationOcclusive Stroke. Stroke 2013


González and colleagues evaluated retrospectively acquired data for 742 patients as part of Screening Technology and Outcomes Project in Stroke (STOPStroke) trial conducted at Massachusetts General Hospital and the University of California San Francisco Medical Center. 649 patients had admission NIH stroke scale scores (NIHSS), non-contrast CT, CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale (mRS). 188 patients had NIHSS >10 with anterior circulation occlusion (defined as occlusion of the terminal ICA and/or proximal MCA (M1, M2) segments), and 64 received-PA. Outcomes of these 64 patients were evaluated in this study (only patients resented within 3 hours from LTKW were included). Favorable outcome was defined as mRS less or equal to 2.


In summary, patients with NIHSS>10 and major anterior circulation occlusions who received IV-tPA had significantly better outcomes (17/49; 35%) than similar patients who did not receive IV-tPA (13/77; 17%, p=0.031). The proportion of good outcomes increased to 40% treated versus 17% untreated (p=0.05) if patients with CT ASPECTS of 7 or less were excluded. These results are similar with results of trials where endovascular treatment was combined with IV t-PA.

This paper highlights anterior circulation large vessel involvement and outcomes after t-PA administration, but overall mirrors results from recent studies. At this time there isn’t enough evidence to justify routine use of CTA prior to the decision weather to give t-PA or not. This paper is unlikely to change clinical practice, but adds to the accumulating evidence for t-PA in a range of clinical scenarios. For now, I am still going to make decision for t-PA administration and referral for the endovascular treatment based on individual presentation, applying standard inclusion and exclusion criteria. Routine use of ASPECTS score will help me in making those decisions. However, despite low numbers, this paper provides us with good quality data that could be used in discussion with patients about outcomes after t-PA administration when large vessel anterior circulation occlusion is identified on subsequent imaging.

By |September 24th, 2013|Uncategorized|0 Comments

Impact of hemoglobin range on clinical outcomes in acute ischemic stroke

Seby John, MD

Park YH, Kim BJ, Kim JS, Yang MH, Jang MS, Kim N, et al. Impact of Both Ends of the Hemoglobin Range on Clinical Outcomes inAcute Ischemic Stroke. Stroke. 2013


From a mechanistic and pathophysiological standpoint, stroke could be viewed as a sudden blockage of oxygen delivery to the brain. Hence, the oxygen carrying capacity of blood could affect outcomes, and anemia could render the brain more vulnerable to ischemia. Park et al studied the effect of hemoglobin concentrations on clinical outcome, examining both ends of the concentration range and different time points of measurement. 



A prospective registry identified 2681 patients with acute ischemic stroke. Hemoglobin initially, at nadir, time-averaged, discharge and hemoglobin drop was collected, and hemoglobin concentration was grouped in quintiles. Poor outcomes (higher mRS) and mortality at 3-months were related to the first quintiles (lower hemoglobin) of the initial, nadir, time-averaged, and discharge hemoglobin. With hemoglobin drop, mortality and higher mRS significantly increased only in the fifth quintile (largest hemoglobin drop). No significance was found with the remaining quintiles. They also accounted for blood pressure drop from baseline, and this didn’t change results. The authors concluded that poor outcome was related to the lower but not higher end of the hemoglobin range, regardless of when and how hemoglobin concentrations were measured.

So then, should we transfuse red blood cells in acute ischemic stroke? Is blood transfusion an option in our patients with lacunes or intracranial stenosis for example, having fluctuations despite hemodynamic optimization? If so, should we be restrictive or liberal in our transfusion thresholds? There are no randomized trials that have examined the outcome of transfusion in patients with acute ischemic stroke. Current practices extrapolate from studies in other populations such as myocardial infarction and subarachnoid hemorrhage. Even then, the data is not as straightforward and some evidence suggests transfusion itself being an independent predictor of worse outcomes. 

Blood transfusion in acute stroke is a useful treatment target to pursue, and randomized controlled trials are needed to understand when it can benefit the most.

By |September 23rd, 2013|Uncategorized|1 Comment

Comprehensive health disparity study of ICH patients well underway

Matthew Edwardson, MD

Woo D, Rosand J, Kidwell C, McCauley JL, Osborne J, Brown MW. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study Protocol. Stroke. 2013


Multiple epidemiological studies suggest that the incidence of non-traumatic intracranial hemorrhage (ICH) is higher among black and Hispanic populations than among non-Hispanic whites of similar age. The specific reasons for this disparity, however, are poorly understood. Woo and colleagues describe the methodology and recruitment progress of the ethnic/racial variations of intracerebral hemorrhage (ERICH) study, the most comprehensive health disparities study of ICH to date.



ERICH is a multicenter, prospective case-control study that seeks to recruit 1,000 non-Hispanic white, 1,000 black and 1,000 Hispanic ICH patients along with 3,000 demographically-matched control subjects. In addition to ICH risk factors, the study centers collect neuroimaging including an MRI on every fifth patient and blood samples for genetic analysis. Study recruitment has gone well in the ICH group and lagged slightly in the control group thus far. The end of recruitment is targeted for February, 2015.

The chosen methodology for the ERICH study is appropriate. Case-control studies are often viewed less favorably than prospective cohort or population based studies due to difficulty identifying appropriate control subjects and risk of recall bias. The authors allay these concerns, however, through persuasive arguments regarding the impracticality of alternative study designs and careful recruitment of control subjects from the same populations.

Opportunities to improve our understanding of ICH from the future ERICH results abound. Cerebral amyloid angiopathy (CAA) is challenging to diagnose on CT alone due to difficulty identifying old microbleeds. The large number of MRI studies planned for collection in ERICH promises to better answer whether rates of CAA truly vary across individuals of different ethnic/racial background and identify any associated risk factors. The planned genetic analysis in ERICH is rigorous, and will even determine the genetic ancestry of all study subjects enrolled. As a result, we may finally be able to answer what proportion of the increased rate of ICH among minority populations is genetic and what fraction is due to modifiable risk factors.

By |September 20th, 2013|Uncategorized|1 Comment

But are they well? Outcome measures and quality of life after stroke

Peter Hannon, MD

Myzoon Ali, Rachael Fulton, Terry Quinn, and Marian. Brady. How Well Do Standard Stroke Outcome Measures Reflect Quality of Life?:A Retrospective Analysis of Clinical Trial Data. Stroke. 2013

After a stroke patient leaves your care in the acute setting, how do you measure their level of improvement? Primary outcomes are often measured via scales of disability and dependence, but how does this correlate to a patient’s quality of life (QoL)? Ali and colleagues have utilized the Virtual International Stroke Trials Archive (VISTA) to examine whether commonly employed outcome measures capture aspects of a patient’s perceived QoL. 


4,946 patients who were enrolled into acute stroke trials within 6 hours of onset were included in the dataset. Data was extracted on patient age and initial stroke severity (NIHSS), and outcomes at 3 months were measured via European Quality of Life Scale (EQ-5D), two forms of the Stroke Impact Scale (SIS v3.0 and SIS-16), modified Rankin Scale (mRS), NIHSS and Barthel Index (BI). Associations were assessed using partial correlations, adjusting for age and initial stroke severity. Data subsets included assessments by the patient versus a proxy, and mismatches between primary outcome and QoL (for example, good primary outcome with a bad QoL) were specifically investigated. Overall, authors found that patient-assessed QoL had a stronger association with mRS, however proxy-assessed QoL correlated better with BI scores. This disparity may reflect caretaker-bias and/or subtle differences in the emphasis of the various measurement tools, and authors point out that the BI is based on activities that can be observed and assessed easily, such as basic ADLs.


This study reaffirms the importance of outcomes measures that reflect how patients (or proxies) interpret their quality of life, especially as we continue to utilize these scores to grade the success or failure of treatments and interventions. At the end of the day, how do our patients assess the success of their treatment after stroke? For many, it would be safe to say that quality of life tops the list. 
By |September 19th, 2013|Uncategorized|0 Comments

Mortality after MI associated Ischemic Stroke in Sweden

Vivek Rai, MD
Brammås A, Jakobsson S, Ulvenstam A, Mooe T. Mortality After Ischemic Stroke in Patients With Acute MyocardialInfarction: Predictors and Trends Over Time in Sweden. Stroke. 2013

Mortality after acute myocardial ischemia (AMI) complicated by ischemic stroke (IS) is considered high but reliable estimates are not available. Brammås and colleagues tried to answer this question based on analysis of data of 173,233 patients of AMI collected from Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) during the period of 1998-2008. They further dichotomized the study period in groups of 2 years to study trends of over time.

In brief, the results suggest the incidence of IS within one year of AMI is 4% and 36.5% of these patients died during that year. This is in contrast to 18.3% mortality in patients who did not suffer IS. Overall, patients who died, as also those who had IS, were older and had more co-morbid conditions. Heart failure, renal disease, peripheral arterial disease and diabetes had strongest association with death. 1-year mortality over the 10-year study period declined although it was consistently higher in women than men.
The large number of patients included in this study gives reliable estimate of numbers although the findings don’t come as a surprise to me. As such, this new information will not change my clinical practice. The information might be of use during discussions with family and patients about future directions of their care.
One interesting point to note is the difference in mortality between men and women. I think that this needs to be investigated a bit more to try and identify the reasons behind this disparity as we may find deficiencies in current clinical care that have potential for improvement in future. 

By |September 18th, 2013|Uncategorized|0 Comments