American Heart Association

Monthly Archives: July 2014

Lagoons vs. Lacunes – Understanding the depth of the matter.

Prachi Mehndiratta, MD

Elnan Kvistad CE, Oygarden H, Logallo N, Moen G, Thomassen L, Waje-Andreassen U, and Naess H. A Dark Side of Subcortical Diffusion-Weighted Lesions? Characteristics, Cause, and Outcome in Large Subcortical Infarction: The Bergen Norwegian Stroke Cooperation Study. Stroke. 2014

While we have all read plenty about small vessel disease infarcts or lacunar infarcts, less has been said about large subcortical infarcts (LSI) that can be colloquially referred to as lagoons. In this study the authors aimed to identify the differences in clinical characteristics, etiologic factors and outcome amongst patients with LSI when compared with lacunar infarcts (LI), cortical infarcts (CI) or infarcts elsewhere (no LSI).



All patients admitted to the Stroke unit between Feb 2006 and July 2013 were screened. In total, MRI scanning was performed on 1979 patients and 1886 with positive diffusion weighted lesions were included in the analysis. Infarcts were classified as subcortical >15mm and <15mm in size. LSI were found in 6.8% of the patients with the remainder being LI (16.8%), CI (28.8%) and no LSI (47.6). LSI infarcts were further classified as belonging to the following territories- lenticulostriate, anterior choroidal, thalamic and white matter. Clinically, patients with LSI had more severe strokes than those with LI, CI or no LSI. There was a significantly greater proportion of patients with atrial fibrillation (p=0.003) and fewer number of smokers in the LSI group (p=0.014).

Vascular imaging demonstrated that complete or partial occlusion of the proximal MCA segment was more frequent in the LSI group as compared to those with LI (39.1% vs. 1.6%, p<0.001), CI (15 [7.9%], p<0.001) and no-LSI (39.1% vs. 17.1%, p<0.001). Large artery disease and cardio-embolism was more common in patients with LSI as compared to those with LI. Cryptogenic stroke mechanism was found in 60.9% of LSI patients which was significantly higher than the number of cryptogenic strokes in all other groups. Intuitively, due the larger stroke size and higher likelihood of a proximal vessel occlusion, patients with LSI were more likely to have progressive symptoms and had a worse overall short term outcome (graded on the modified Rankin scale) and these results were statistically significant. Those with anterior choroidal artery infarcts did worse than others.

This study highlights how a large subcortical infarct may initially “look like a duck” but “not quack like one”. Clinically a LSI may appear to mimic a lacunar syndrome; however there is a higher likelihood for progression of symptoms and presence of a large vessel occlusion. These characteristics underscore the importance for early treatment with IV tpa and need for diffusion weighted imaging. Although a large proportion of these patients had unclear mechanism of stroke, I would have liked to know more about the extent of stroke workup that these patients were subjected to. Also, were the raters of clinical symptoms and MRI findings independent?  If not, there definitely could have been introduction of bias.  As one would have expected with a larger stroke size, these patients had worse short term outcome. But, how about long term outcome? I hope to see more literature in the near to help answer some of these questions.   


Predicting the addition of an insult to an injury: spontaneous intracerebral hemorrhage and pneumonia.

Mark N. Rubin, MD

Ji R, Haipeng H, Pan Y, Du W, Wang P, Liu G, Wang Y, et al. Risk Score to Predict Hospital-Acquired Pneumonia After SpontaneousIntracerebral Hemorrhage. Stroke. 2014


Unequivocally, our patients with intracerebral hemorrhage are quite ill. Clinical experience with this highly morbid and potentially fatal disease demonstrates that patients with this condition are at multisystem risk, including worsening hemorrhage, thromboembolism, cardiac complications, and infections including pneumonia. While it comes as no surprise that patients with intracerebral hemorrhage, who are often neurologically disabled if not comatose, experience hospital-acquired pneumonia on an all-too-frequent basis, it seems to happen in spite of our best multidisciplinary efforts to screen for dysphagia and adhere to infection precautions. This is a particularly important issue for hemorrhagic stroke patients because the development of pneumonia is a predictor of worse outcome overall and increased mortality. This is also of major health economic concern, as the development of hospital-acquired pneumonia is a heavily scrutinized aspect of hospital performance in the United States and tied to reimbursement for services. A group of Chinese investigators – who already brought us a pneumonia prediction score for acute ischemic stroke quite recently – have collaborated again with an eye toward pneumonia prediction in patients with spontaneous intracerebral hemorrhage.



The investigators put together a cohort of nearly 5000 patients with spontaneous intracerebral hemorrhage across many institutions in China, collectively referred to as the China National Stroke Registry. This cohort was split for derivation and validation of clinical features that might predict the development of pneumonia based on previously published risk factors. In brief, they derived a 20+ point risk score that reasonably predicted the development of pneumonia after intracerebral hemorrhage, irrespective of hematoma volume, particularly in patients admitted for greater than 48 hours. They found that older age, current smoking, chronic obstructive pulmonary disease, pre-stroke dependence, low admission Glasgow Coma Score, high National Institute of Health Stroke Scale score, and dysphagia were independently and significantly associated with the development of hospital-acquired pneumonia after intracranial hemorrhage.

The natural goal after the development of such scores is to predict so that we may prevent. This score requires  external validation, but the hope is that the score can inform clinical trials aimed at the prevention of pneumonia in these very ill patients, thus averting the addition of the proverbial insult to an already grave injury.

Comparison of stroke risk factor profiles in ischemic stroke v/s hemorrhagic stroke patients with type 1 diabetes as a guide to understanding pathophysiology

Chirantan Banerjee, MD

Hägg S, Thorn LM, Forsblom CM, Gordin D, Saraheimo M, Tolonen N, et al. Different Risk Factor Profiles for Ischemic and Hemorrhagic Stroke in Type 1 Diabetes Mellitus. Stroke. 2014

Risk factor epidemiology is the crux of cerebrovascular prevention. It guides us towards appropriate targets to ameliorate future strokes. Prospective cohort studies, albeit expensive, are one of the most effective ways to learn the most about stroke epidemiology in a population, as they give us the ability to ask varied questions within the same study framework. The Finnish Diabetic Nephropathy Study (FinnDiane) was founded to uncover the risk factors and mechanisms of diabetic micro and macro-vascular complications, with a focus on type 1 diabetes, and has previously reported associations between diabetic nephropathy as well as severe diabetic retinopathy and stroke.




In this issue of Stroke, Hagg et al attempt to identify and compare risk factors for stroke and its subtypes in the FinnDiane multicenter observational cohort. 4083 stroke free participants with type 1 diabetes were enrolled at baseline, and data on clinical as well as laboratory variables was collected. Outcome was ascertained by questionnaires, death certificates, and the Finnish National Hospital Discharge Register, and confirmed by medical records, neuroimaging. There were 149 incident strokes, with more than usual proportion of hemorrhage (30%) and lacunar (55% of ischemic) strokes. Diabetic nephropathy and higher systolic blood pressure were associated with both ischemic and hemorrhagic strokes. Although longer duration of diabetes, higher HbA1c, insulin resistance and history of smoking were associated with ischemic stroke, they were not associated with hemorrhagic stroke. Lower BMI was independently associated with hemorrhagic strokes. Sex, waist circumference, metabolic syndrome, triglycerides, LDL and HDL cholesterol were not associated with either stroke.

Several thoughts come to mind with these novel findings. The fact that higher systolic blood pressure is associated with stroke despite adjusting for nephropathy, hints that not all of the effect of high SBP on stroke risk is mediated by nephropathy in these patients. Also, the fact that metabolic syndrome, sex, triglycerides, as well as LDL and HDL cholesterol were not associated with any stroke suggest that the pathophysiology of stroke in Type 1 diabetics may be distinct from those in Type 2 diabetes patients. 

Although an association between glycemic control and microvascular complications has been demonstrated previously, there had been conflicting evidence with regard to macrovascular complications. This study found HbA1C levels to be independently associated with ischemic stroke in Type 1 diabetes patients. With regards to lower BMI being associated with hemorrhagic stroke, some of the effect may be driven by the fact that most of the hemorrhagic stroke patients had diabetic nephropathy, which has been associated with cachexia and platelet dysfunction. 

The study has several weaknesses. The findings cannot be generalized to Type 2 diabetes patients or the general stroke at risk population. Outcome assessment was based on questionnaires and the national register, where silent strokes would be missed, thus biasing towards null. Also, including subarachnoid hemorrhages in the composite hemorrhagic stroke outcome may be a confounder as the etiology of SAH is disparate from intraparenchymal hemorrhage.

Despite having a restricted cohort with a specific phenotype, this study generates several pathophysiological hypotheses, and stresses on the need for further inquiry into modifiable risk factors in diabetic patients. As stroke clinicians, we should tailor our preventative efforts to each patient!”

Lacunar Strokes in Diabetics

Rizwan Kalani, MD


Palacio S, McClure LA, Benavente OR, Bazan III C, Pergola P, and Hart RG. Lacunar Strokes in Patients With Diabetes Mellitus: Risk Factors, Infarct Location, and Prognosis: The Secondary Prevention of Small Subcortical Strokes Study. Stroke. 2014


Diabetes mellitus (DM) is a well established and an increasingly more prevalent risk factor for ischemic stroke. It confers a two-fold increased risk of cerebrovascular ischemia. Prior studies have demonstrated increased risk of initial lacunar stroke among diabetics as well as an increased prevalence of lacunes compared to other ischemic stroke subtypes in this patient population.


Palacio et al looked at 3020 patients from the SPS3 (Secondary Prevention of Small Subcortical Strokes) trial to compare baseline demographics, vascular risk factors, and neuroimaging findings in diabetics compared to non-diabetics. Data on vascular events (including recurrent ischemic stroke and their subtypes) over a mean 3.6 year follow-up period was also analyzed between the two groups.

Diabetes was independently associated with Hispanic ethnicity (36% vs 28%), ischemic heart disease (11% vs 6%), and peripheral vascular disease (5% vs 2%) compared to non-diabetics. Patients with DM also had significantly more posterior circulation territory lacunar strokes and more frequent intracranial arterial stenosis of 50% on baseline neuroimaging (23% vs 14% in non-DM patients). After adjusting for other predictors – the rate of recurrent ischemic stroke of any subtype (11.4% in diabetics and 5.9% in non-diabetics), disabling/fatal recurrent stroke, MI, all-cause mortality, and death from vascular (& uncertain) etiology were approximately two-fold higher in DM patients during follow-up.

This report adds to the literature that demonstrates worse clinical outcomes in patients with stroke and diabetes. A notable limitation of this study is that DM control during follow-up was not available. Regardless, this manuscript does raise some important and interesting questions that should be evaluated in future studies. What factors contribute to worse outcomes in diabetics with lacunar strokes? How can we effectively monitor and improve our secondary (and even primary) stroke prevention strategies in patients with DM? At this point, it is well worth considering more frequent and longer outpatient stroke neurology follow-up in this high-risk patient population and ensure aggressive risk factor control.

Spinal Cord AVMs Are Getting Attention They Deserve

Daniel Korya, MD

Lee YJ, Terbrugge KG, Saliou G, and Krings T. Clinical Features and Outcomes of Spinal Cord Arteriovenous Malformations: Comparison Between Nidus and Fistulous Types. Stroke. 2014

In the 1800’s, three of the most recognized names in medicine: Virchow, Emmanuel and Luschka, described their findings on intracranial arteriovenous malformations (AVMs), for the first time. Since then, AVMs have been discovered in the spinal cord as well; however, spinal cord AVMs are more rare than intracranial AVMs, and due to their infrequent occurrence in the general population, clear guidelines about an accepted approach to diagnosis and management are lacking. 

In the 1950’s, Actor Ricardo Montalbán was diagnosed with a spinal cord AVM that became aggravated when he was thrown from his horse during the filming of the film “Across the Wide Missouri”. This caused him pain for many years, which led to an elective 9 ½ hour surgery in 1993 that left him paralyzed and wheelchair bound.
For several decades now, experts have debated the nuances of spinal cord AVMs.  As more cases were reported, two subtypes of spinal cord AVMs emerged: the nidus and fistulous type.  Accordingly, the authors of this paper first sought to describe and differentiate between the two types of spinal cord AVMs.  They observed the occurrence rates and treatment modalities for these AVMs and reported on the obliteration rates, based on their experience.
Essentially, the authors explained, fistulous AVMs are located superficially and only rarely possess intramedullary components, while the nidus AVMs are located in the spinal cord parenchyma. 
The researchers were able to gather forty-four consecutive patients with spinal cord AVMs.  There were 26 patients with a nidus-type and 18 patients with a fistulous AVM. Treatments were performed with embolization (n=23), surgery (n=13), combined embolization-surgery (n=3), or conservative management (n=5).
Overall, patients with nidus-type AVMs were younger at presentation and had a higher rate of spinal cord hemorrhage than the fistulous-type. The researchers also confirmed that complete obliteration could be achieved more often in the fistulous-type (72%) than the nidus-type (27%).
Hemodynamics and depth of the lesions seamed to be important factors affecting clinical outcome and obliteration rates. The nidus-type AVMs were less likely to have complete obliteration and had more complicated hemodynamics resulting in higher rates of morbidity.
In short, the researchers had a respectable number of cases for a rare disease, and they reported their findings in a concise and clear manner. Although their results cannot be considered universal, they are certainly a step in the right direction and provide a foundation for clinicians to build on. 

Increase risk of stroke in middle aged Japanese women who are overqualified for their jobs.

Duy Le, MD

Honjo K, Iso H, Inoue M, Sawada N, Tsugane S.Socioeconomic Status Inconsistency and Risk of Stroke Among Japanese Middle-Aged Women. Stroke. 2014


Inconsistency of socioeconomic status has been implicated as a risk factor for poor cardiovascular health. Honjo et al undertook a prospective cohort study evaluating inconsistency of socioeconomic status as a risk for increased incidence of all types of “stroke.”



61,595 Japanese female residents, ages 40-59 located in 15 different districts were self-administered questionnaires in 1990. They were asked to report on socio-demographic information and past medical history. 82% of the participants responded to the questionaire.  14,742 participants were deemed to be eligible and constituted the cohort group. Patients who had a malignancy, baseline cardiovascular disease were excluded from the cohort. A large number of patients were otherwise excluded were not explicitly accounted for.

The patients were measured on a scale of 1-4 in terms of highest level of education; 1) junior high; 2) high school; 3) junior college; 4) college graduate. Occupations were treated in a similar fashion where a score of 1 was assigned for manual labor; 2) sales and service; 3) office work; 4) professional and management.  Status inconsistency indicated a difference of 2 points between the level of education and the occupation. Women who were qualified for the job had a difference of less than 2 between their job and education. Patients were followed out to 20 years and the endpoint was stroke (Intra parenchymal hemorrhage, ischemic stroke, SAH) was considered an endpoint.

Baseline comparisons showed that Japanese women with higher levels of education were likely to be married, have higher self-reported psychological stress, be more physical active, less likely to be overweight and have less incidence of HTN and DM.

The results showed that there was an overall trend of Japanese women with lower education to work a manual job. Those with higher education were likely to have a professional and management job. However, there were still plenty of Japanese women with high level of education working manual jobs. The mismatch between education and career in this study is likely a specific reflection of women in the Japanese culture taking a career break in their  20’s and 30’s for family reasons and rejoining the work force in labor during their 40’s. Cox proportional hazard regression analysis was employed on the data and showed that women who were overqualified for their job had a higher stroke risk compared to women who were qualified for their job (2.06 odds ratio with [1.13,3.78 95% CI]). Women who were qualified for their job as defined above had an odds ratio of having a stroke set to a standard of 1.0. Underqualified women had an OR of 1.01 (0.69, 1.48) of having a stroke.

While the study makes an interesting finding, the generalizability of the results may be limited due to the cohort being constrained to Japanese women. The idea nonetheless is that dissatisfaction and stress at a job can potentially increase vascular events such as stroke.

More good news: Encouraging results in long-term stroke survival

International Stroke Conference (ISC)
February 12-14, 2014

Lakshminarayan K, Berger AK, Fuller CC, Jacobs, DR Jr, Anderson DC, Steffen LM, et al. Trends in 10-Year Survival of Patients With Stroke Hospitalized Between 1980 and 2000: The Minnesota Stroke Survey. Stroke. 2014


At the 2014 International Stroke Conference, the AHA/ASA released a statement describing a decline in stroke mortality in the late 20thcentury and continuing into 2001-2010. This study by Lakshminarayan et al examines the outcomes of 6032 patients by stroke subtype. The time periods examined were 30 days, 1 year, 5 years, and 10 years.



Bottom line: there was a significant decrease in ischemic stroke mortality among both men and women, but only a trend in decrease for hemorrhagic stroke. The authors attribute this distinction to the smaller sample size of hemorrhagic strokes. I would also point out that over this time period, there has arguably been more widespread use of acute treatments for ischemic stroke like IV-tPA and thrombectomy. The acute treatment of hemorrhagic stroke has enjoyed fewer innovations in the last decade.


Other trends found in this study include a significant drop in the mean age of stroke from 64 in 1980 to 62 in 2000 (p=0.0002). However the proportion of non-Caucasian patients in the metropolitan area did concurrently decrease over time. Thus whether this is a combination of racial disparities or a “stroke in the young” phenomenon is unclear. Length of hospital stay also dropped significantly from a median of 12 to 8 days over the same time period.

Limitations of this study include it being based solely in the Minneapolis-St. Paul metropolitan area. The authors point out that the US does not have nationwide long-term surveillance system for stroke patients. The cause of death being stroke related or not depended on ICD-9 diagnosis codes, which are subject to reporting bias. Neuroimaging techniques have also improved in quality and availability. This may have increased sensitivity in picking up minor strokes and diluted the severity of the stroke pool in later decades. Life expectancy in the general population had also improved over time and was specifically confirmed in this population.

The explanations for these trends are debatable, but regardless the numbers are encouraging and show that our efforts in the field of vascular neurology have positively impacted patient outcomes. Further study on a national and international level is warranted.

– Ali Saad, MD

Desmopressin: keeping beds dry and keeping hemorrhages small.

Vikas Pandey, MD


The treatment of intracerebral hemorrhage currently involves a lot of “watchful waiting” and blood pressure management, with the exception of those with devastating bleeds requiring surgery or those with intraventricular hemorrhages requiring intraventricular thrombolytics. The ultimate goal in these patients is to minimize hematoma growth which is thought to improve overall patient outcome. What if, instead of clinical dismay at not being able to treat with tPA when seeing a hemorrhage on CT scan during an acute stroke evaluation, there was an option to improve platelet activity and prevent further hematoma expansion. The authors of this article had a similar dream.  Desmopressin, a vasopressin analogue, has been used for conditions such as nocturnal bed-wetting and central diabetes insipidus, however has also been used in coagulation disorders such as von Willebrand disease and Hemophilia A due to the interesting effect of stimulating release of vWF from endothelial cells and also increasing the survival of Factor VIII due to increased vWF complexing.



The authors prospectively enrolled 14 patients with either reduced platelet activity on point-of-care testing, or aspirin use, or both and they received desmopressin 0.4 mcg/kg intravenously over 30 minutes. The infusion was started 12.25 (5.7-23.1) hours after the symptom onset. They measured the change in platelet function assays and vWF antigen activity and found shortened Mean PFA-EPI results from 192 +/- 18 seconds to 124 +/- 15 seconds (improved platelet activity) one hour after infusion as well as increase in vWF antigen from 242 +/- 96 to 289 +/ 103 percent activity, both of which were significant results. Peculiarly, one patient had paradoxically increased PFA-EPI.  Hematoma volume was found to be decreased with a range of -1.4 to 8.4 mL (two had hematoma growth). Median change in hematoma volume was -0.5 mL.  Modified Rankin Scale at 3 months showed, out of 12 patients for whom follow-up was obtained, four had no disability, one had a mRS score of 3 and three had mRS of 4. Sodium decreases with the infusion were only in six patients and were in the range of 1-3 mEq/L. Of the seven patients who received the infusion within 12 hours of symptom onset, 2 had hematoma growth.

The article demonstrated safety and efficacy in improving measures of platelet activity and vWF antigen and, though with small numbers, demonstrated some effect of halting hematoma growth, especially if given within 12 hours of symptom onset. The article lacked measures of baseline hematoma volumes, GCS levels, hematoma location and intraventricular involvement. These “ICH score” markers should not be overlooked especially given their importance toward determining patient outcome. The obvious side effects of hypertension and hyponatremia due to water retention were not seen at high rates in this small trial but given the impact these may have toward hematoma expansion and herniation, larger trials are needed to determine if this will be a factor. The authors also allude to the PATCH trial testing platelet transfusions in intracerebral hemorrhage and if positive, this may be a possible co-therapy with desmopressin. The study provides the skeleton for a larger randomized prospective trial and the authors should be applauded for having the proper approach to an area where stroke neurologists feel somewhat helpless.

@DrVikasNeuro




Does Cerebral Amyloid Angiopathy increase ICH risk after rtPA?

Michelle Christina Johansen, MD

Reuter B, Grudzenski S, Chatzikonstantinou E, Meairs S, Ebert S, Heiler P, et al. Thrombolysis in Experimental Cerebral Amyloid Angiopathy and the Risk of Secondary Intracerebral Hemorrhage. Stroke. 2014


With an aging population facing the stroke neurologist and the increasing evidence that patients 80 years or older have a statistical benefit from IV tPA therapy, the understanding of the pathophysiology of cerebral amyloid and the impact it has on treatment of acute ischemic stroke grows more critical. Symptomatic intracranial hemorrhage (ICH) is a severe side effect that must be discussed with all patients prior to administration of tPA, but are patients with cerebral amyloid angiopathy at increased risk?



It is recognized that the deposition of amyloid in the cerebrovascular system increases the incidence of spontaneous lobar hemorrhage and advancing MRI techniques have made us increasingly aware of the presence of cortical microbleeds in these patients. Given the predisposition of the vessels towards dysfunction, Reuter and colleagues set out to investigate the risk of secondary intracerebral hemorrhage in an animal model after treatment with an adjusted dose of rtPA. In this study, APP23-transgenic mice and wildtype littermates underwent induced ischemic stroke via MCA occlusion, were treated with rtPA and functionally were assessed 24hrs after occlusion.  The brains of both cohorts underwent histological processing to evaluate infarct size and degree of acute intracerebral bleeding. 

In their study, the transgenic mice (9/13) displayed a higher risk (p=0.05) of developing ICH after stroke and thrombolytic therapy compared to the wildtype (3/11). A higher severity of bleeding (Grade 2 or 3) corresponded to an increased infarct burden in the amyloid cohort.  The authors appropriately raise a point of caution that the models were not evaluated in the absence of rtPA thereby potentially leading to an overestimation of the hemorrhagic burden caused by tPA.

Notably neurologic deficit and mortality were not statistically different between the amyloid and wildtype animals. The authors observed no intracranial hemorrhage after rtPA-treatment outside of the infarct area and offer this as an explanation for the lack of increased functional deficit in the amyloid cohort.

Although the n is small and the data is derived from an animal model, the study raises several points of discussion.  Would the results be influenced by a greater delay prior to administration of rtPA?  What if the study had been conducted using a model looking at posterior circulation stroke? Would the outcome scores have differed more than 24hrs after occlusion?

While the incidence of hemorrhage in patients with amyloid may be increased, it would appear from this data that there is no increased risk of mortality after administration of rtPA thereby freeing the clinician to use the last known normal and standard contraindications to guide care of the elderly. Certainly only further investigation can help us move towards a better understanding of using thrombolytics in patients with cerebral amyloid deposition but this study provides a launching point.  

Intracranial hemorrhage mortality in atrial fibrillation patients treated with dabigatran or warfarin

Rajbeer S. Sangha, MD

Alonso A, Bengtson LGS, MacLehose RF, Lutsey PL, Chen LY, and Lakshminarayan K. Intracranial Hemorrhage Mortality in Atrial Fibrillation Patients Treated With Dabigatran or Warfarin. Stroke. 2014


Warfarin has long been the agent of choice for the reduction of ischemic stroke secondary to AF.  Recently, new anticoagulant agents including dabigatrin, rivoxaraban and apixaban have been approved by the FDA for the reduction of stroke secondary to AF.  While these agents may be more effective in the reduction of stroke, the lack of commercially-available antidotes has been a limitation and a noted major disadvantage.  The authors of this study did a retrospective analysis of healthcare utilization date, in-hospital mortality in atrial fibrillation (AF) patients using oral anticoagulants who presented with intracranial bleeding (ICB).



Alonso et al. analyzed 2391 patients with AF who were admitted with ICB (2290 on warfarin and 101 on dabigatran), looking for in hospital mortality.  The results showed that in hospital mortality was similar in patients who were originally on warfarin (22%) vs dabigatran (20%).  Further statistical analysis showed that the propensity score-adjusted RR of morality in dabigatran users was 0.93.  The associations were similar for all varying subtypes of ICB.  Likely, due to a lack of data for all the patients the authors were not able to conduct analysis of patient outcomes following discharge and had to limit the study to in-hospital mortality. 

The authors of this study address an important issue which is at the center of debate for the prevention of stroke secondary to atrial fibrillation.  While the number of patients being analyzed in this analysis for dabigatran are low (101) – which the authors also recognize – the analysis is consistent with the RE-LY trial (Dabigatran versus Warfarin in patients with atrial fibrillation).  It would have been interesting however to see the analysis of patients regarding their outcomes of mortality in a one year period as well as three month outcomes of modified rankin scale.   Clinicians should continue to weigh this data when choosing an anti-coagulant while we await a commercially-available antidote.