Jennifer Dearborn, MD
Krebs HI, Krams M, Agrafiotis DK, DiBernardo A, Chavez JC, Littman GS, et al. Robotic Measurement of Arm Movements After Stroke Establishes Biomarkers of Motor Recovery. Stroke. 2013
. Dynamic Permeability and Quantitative Susceptibility
Athappan G, Chacko P, Patvardhan E, Gajulapalli RD, Tuzcu EM, and Kapadia SR. Late Stroke: Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Multivessel Disease and Unprotected Left Main Disease: A Meta-Analysis and Review of Literature. Stroke. 2013
Quiz: A patient has left main CAD and can be treated with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Don’t worry, I’m not asking you to choose a procedure since our cardiology colleagues will take care of that. But, you should know the stroke risk with each procedure.
Notice how the PCI rate of stroke went up (0.6 -> 2.4)? The focus of this newly published meta-analysis was to look at a larger sample size and determine if the stroke rates really do equalize between the two interventions after ≥1 year follow up. The authors identified 80,000 patients with more than half of the patients were followed 2+ years out.
The PCI group persistently had a significantly lower cumulative stroke rate than the CABG group, even when looking at 1 vs. 2 vs. 3 vs. 4 vs. 5 years out. In the 5+ years group, there was no significant difference but there were only ~1600 patients. There was no significant difference among diabetics, but there was a trend favoring PCI. In looking at RCTs only, PCI did better in the 30 day perioperative period, but then had no difference with CABG in terms of stroke at 1 year. The authors suggest that the increased rates of stroke in PCI in the later period may be do to post-revascularization atrial fibrillation; or in my opinion, the ongoing vascular risks factors for the patient population overall.
Bottom line for me: there are more strokes after CABG than PCI, even >1 year post-op. However, determining the optimal coronary intervention will be patient dependent and incorporate all-cause mortality, recurrent MI, target revascularization, and cost effectiveness in addition to stroke.
At the end of the symposium participants endorsed the Merida Declaration, a call to action to physicians, hospitals, EMS providers, the public, NGOs and state and national governments to work together to develop stroke systems of care throughout the country. This is the first step in the development of a system of care that will identify stroke centres and promote the rapid and accurate identification of stroke patients, swift transport to hospitals, prompt attention in the emergency room, and access to effective treatments for patients with stroke in Mexico.
Cortijo E, Calleja AI, García-Bermejo P, Mulero P, Pérez-Fernández S, Reyes J, et al. PhD. Relative Cerebral Blood Volume as a Marker of Durable Tissue-at-RiskViability in Hyperacute Ischemic Stroke. Stroke. 2013