Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Evolution of Practice During the Interventional Management of Stroke III Trial and Implications for Ongoing Trial. Stroke. 2014
Korja M, Bervini D, Assaad N, and Morgan MK. Role of Surgery in the Management of Brain Arteriovenous Malformations:Prospective Cohort Study. Stroke. 2014
Ruptured brain arteriovenous malformations (bAVM) are one of the most common causes of spontaneous intracerebral hemorrhage (ICH) under 40 years of age with a cumulative long-term risk of major morbidity or death for ruptured AVMs nearing 85%. However, the question remains: what is the best management approach for low and middle-grade bAVMs? Presently, interventional therapy for bAVM includes surgical resection, endovascular embolization, radiotherapy or a combination of these modalities, but the largest trial of unruptured bAVMs, ARUBA, mainly reflected embolization and radiotherapy outcomes, leaving surgical outcomes largely unexplored.
Between January 1989 and May 2014, 779 consecutively enrolled patients were assessed for inclusion in this prospective study, with outcome assessments performed using the modified Rankin scale (mRS) both pre-operatively and at follow up visits. Outcome variables were defined as overall adverse outcome from surgery mRS>1, major adverse outcome mRS>2, perioperative hemorrhage, or “deficit or near miss” (adverse outcome leading to mRS>1 or perioperative hemorhage). The 5-tier Spetzler-Martin grading (SMG) and 3-tier Spetzler- Ponce Class (SPC), measures of surgical risk, were utilized, assigning points for size, the presence of deep venous drainage, and location in “eloquent” brain.
For those patients who underwent surgery, adverse outcomes were seen to increase with increasing SPC grades. The mRS >1 surgical combined adverse outcome rates were 1.4% for SPC A, 19% for SPC B, and 39% for SPC C and adverse outcome rates leading to mRS >2 were 0.6%, 6%, and 19% for SPC A, B, and C, respectively. Complete bAVM resection was achieved in 99.1% of patients with SPC A and B bAVMS. Multiple logistic regression analyses identified possible risk factors for adverse outcomes, including patient age, preoperative hemorrhage, preoperative embolization, largest diameter of bAMV nidus, presence of deep venous drainage, eloquent location, lenticulostriate feeders, and surgical experience.
Battey T, Karki M, Singhal A, Wu O, Sadaghiani S, Campbell B, et al. Brain Edema Predicts Outcome After Nonlacunar Ischemic Stroke. Stroke. 2014
Schröder J, Cheng B, Ebinger M, Köhrmann M, Wu O, Kang DW, et al. Validity of Acute Stroke Lesion Volume Estimation by Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomographic Score Depends on Lesion Location in 496 Patients With Middle Cerebral Artery Stroke. Stroke. 2014
A large area of diffusion restriction seen on a MRI scan is predictive of increased risk of symptomatic intracranial hemorrhage. The ASPECTS score has been extensively studied and is used in clinical practice to estimate early ischemic changes and define a malignant infarct in the anterior circulation on a non-contrast CT scan. The authors of this study aimed to utilize the DWI ASPECTS score similarly to establish ischemic volume and predict a malignant infarct with volume >100ml.
Clinical, demographic and imaging data was obtained from the PRE FLAIR study database that was a multicenter observational study of patients with acute ischemic stroke that underwent a MRI scan within 12 hours of symptom onset. Only patients with MCA infarction were included and a stroke neurologist scored DWI ASPECTS. DWI lesion volumes were calculated utilizing a developed software tool in three MCA territories- deep MCA, superficial MCA and both superficial and deep MCA territories. Correlations between DWI-ASPECTS, DWI lesion volume and NIHSS were calculated using Pearson’s correlation coefficient. Receivers operating characteristic (ROC) curves were generated to determine the optimal DWI-ASPECTS cut off point to characterize a DWI lesion volume≥100 ml.
A total of 496 patients were included in the final analysis, mean age was 66+/1- 15 years and 47% of patients were female. The DWI volume of superficial MCA stroke lesions was higher as compared to those with deep MCA strokes (21.2ml vs. 7.2ml) while there was no difference between the two groups on median ASPECTS score. There was a significant negative correlation between DWI-ASPECTS and DWI lesion volume for all patients (r=-0.78, p<0.0001) as well as the DWI-ASPECTS and initial NIHSS (r=-0.49, p<0.0001). The negative correlation was stronger for patients with superficial MCA lesions as well as combination of both superficial and deep MCA lesions. ASPECTS score <6 was a predictor of a malignant MCA infarct with volume >100ml with a low positive predictive value but a high negative predictive value.
While ASPECTS was a good predictor of infarct volume in the patients with superficial MCA lesions, DWI ASPECTS inaccurately estimated the deep MCA stroke volume. A wide range of lesion volumes was identified per ASPECTS score value. The question arises – will we be using the DWI ASPECTS score in clinical practice for thrombolysis? Current guidelines recommend utilizing the non-contrast CT and the CT ASPECTS score has been validated in this regard. Additionally is it time efficient to obtain an MRI and calculate a DWI ASPECTS? We need to take a look at several aspects before we come to a conclusion about the DWI ASPECTS score.
Xu X, Chen X, Zhang J, Zheng Y, Sun G, Yu X, et al. Comparison of the Tada Formula With Software Slicer: Precise and Low-Cost Method for Volume Assessment of Intracerebral Hematoma. Stroke. 2014
Akoudad S, Darweesh SKL, Leening MJG, Koudstaal PJ, Hofman A, van der Lugt A, et al. Use of Coumarin Anticoagulants and Cerebral Microbleeds in the General Population. Stroke. 2014
The worst complication of anticoagulation use is intracerebral macro-hemorrhage. In this study, Akoudad et al evaluated the effect of coumarins on microbleeds (MB) from a large, prospective, population-based cohort study (Rotterdam Study).
Evaluating data on 4945 subjects with a baseline brain MRI (with T2*-GRE sequences) and 3069 with follow-up MRI’s, the prevalence and incidence of MB was compared between those on coumarin vs those who were never exposed to it. After adjusting for age, sex, and vascular risk factors, the association between coumarin use and MB’s was evaluated. The authors also looked at the relationship between maximum INR as well as its variability with MB presence.
8.6% of participants (427/4945) had used coumarin anticoagulants (at some time) prior to the first MRI and 19.4% (957) had ≧1 MB present. 5.9% (181/3069) of those with follow-up MRI’s had used them at some point prior to the second scan. The cumulative incidence was 6.9% over an average follow-up period of approximately 4 years. Anticoagulated subjects had a higher prevalence of deep or infratentorial MB (with or without lobar MB) compared to those who had never been exposed (OR 1.70, 95% CI 1.24-2.34). A trend toward increased risk of developing new MB was found in those using coumarin vs those who never had, but this was not statistically significant (OR 1.44, 95% CI 0.89-2.32). Results were similar even after excluding those who used other antithrombotics and those with infarcts on MRI. Deep/Infratentorial MB were more frequent in those with higher maximal INR compared to never-users. Amongst those using coumarin, higher INR variability was associated with deep/infratentorial MB.
This study is unique as it comes from a large cohort study involving a population from the suburbs of Rotterdam, making it more generalizable. Notable limitations from this observational study include – 1) some MB could have been present prior to anticoagulant use and; 2) participants more likely to be on coumarin were the same as those with increased risk of MB (i.e. those with vascular risk factors). Furthermore, as noted by the authors, results may not apply for novel oral anticoagulants (NOACs).
Future studies will have to evaluate the safety of anticoagulation over time in distinct cohorts that are separated by age, blood pressure control, APOe genotype, and suspected MB pathology (hypertensive, amyloid angiopathy). The effect of NOACs on MB will also need to be investigated.
Nevertheless, this study reaffirms the fact that we should be vigilant about blood pressure control and INR monitoring in patients on coumarin anticoagulants.
The poor face numerous staggering inequalities, and their health is no exception. Health outcomes by almost every metric are worse for those with lower socioeconomic status, and we know that the incidence of stroke is substantially higher in the poor.The authors of this study investigate the rates of mortality by socioeconomic position.
Individuals over 40 with no history of prior stroke were extracted from the Danish stroke registry leading to a population of over 56,000 patients studied. The authors divided patients by income quintile as well education level. Unsurprisingly patients with the lowest income and education levels suffered more severe strokes and had more preventable risk factors than richer patients. A dramatic relationship between income level and risk of death after stroke was demonstrated as well, and this was intact after adjustment for risk factors. This relationship was not evident with education level.
While the finding that the poorest patients are those most likely to die after stroke does not astonish, it should raise our concern. On a systems level we fail our most vulnerable citizens. This particular study was performed in Denmark, a rich (21st in GDP per capita) industrialized nation with public healthcare. Even so, it appears that the impoverished are set up for poor health outcomes, and often pay with their lives.
Jusufovic M, Sandset EC, Bath PMW, and Berge E, on behalf of the Scandinavian Candesartan Acute Stroke Trial Study Group. Blood Pressure–Lowering Treatment With Candesartan in Patients With Acute Hemorrhagic Stroke. Stroke. 2014
Gloede TD, Halbach SM, Thrift AG, Dewey HM, Pfaff H, and Cadilhac DA. Long-Term Costs of Stroke Using 10-Year Longitudinal Data From the North East Melbourne Stroke Incidence Study. Stroke. 2014
Previous attempts have been made to evaluate the economic burden of ischemic stroke. The NEMESIS study, an Australian based study, evaluated costs 3 to 5 years out from the original stroke event. Gloede et al push the envelope by attempting to quantify the cost of ischemic stroke (IS) and intracranial hemorrhage (ICH) 10 years out. They used The Model of Resource Utilization Costs and Outcomes for Stroke (MORUCS) which was also employed by the NEMESIS study. NEMESIS patients were evaluated in this study and followed out to 10 years. The cost of illness models for both IS and ICH were updated from a 2004 to 2010 reference year, adjusting for inflation. The Australian population was used in this model and currency translated to USD in terms of cost.