Declining Rate of IV Heparin Use in Acute Ischemic Stroke in Korea
Chung J-W, Kim BJ, Han M-K, Ko Y, Lee S, Kang K, et al. Impact of Guidelines on Clinical Practice: Intravenous Heparin Use for Acute Ischemic Stroke. Stroke. 2016
IV heparin has been available since the 1940’s and its role in ischemic stroke has been constantly debated. IV heparin has a clear indication in cardiac ischemia and many presume its efficacy should translate in acute ischemic stroke as well. However, numerous studies have failed to show benefit and American Stroke Association does not recommend anticoagulation acutely. Because heparin has been available for numerous years, there is little information on contemporary use and this study evaluated recent IV heparin trends across 12 hospitals in Korea in a 5 year span from 2008-2013.
Data was obtained from an acute stroke registry that included consecutive stroke patients. Information regarding stroke characteristics, recanalization treatment and antithrombotic treatment during hospitalization and post-discharge were collected. In total, 23,425 patients were included in the study. In the study period, the rate of recanalization treatment increased. Use of IV heparin decreased consecutively during the study period with use of 4.3% in 2013 compared to 9.7% initially. In the small proportion of patients that were treated with IV heparin, atrial fibrillation was associated with more frequent use.
This study shows declining rates of IV heparin use in acute ischemic stroke. This coincides with a 2009 publication of a Korean stroke clinical practice guideline and supports adherence to guidelines by neurologist. Interestingly, atrial fibrillation was associated with use of IV heparin. Typically, cardioembolic strokes are generally larger and acute anticoagulation is not pursued due to hemorrhage risk. Furthermore, subsequent short-term stroke risk following a cardioembolic stroke is relatively lower (unlike large vessel disease) and delaying anticoagulation until hemorrhage risk is lower has become the standard practice. Use of IV heparin is sometimes reserved for patients with critical carotid stenosis awaiting carotid endarterectomy but such decisions are made on case-by-case basis. This study further affirms that clinical guideline recommendations impact clinical decision making and have the ability to impact outcomes as well.
Limited Meta-analysis Suggests Patients with Asymptomatic Carotid Occlusion are at Low Risk of Ipsilateral Stroke, High Risk of Non-stroke Mortality
Hackam DG. Prognosis of Asymptomatic Carotid Artery Occlusion: Systematic Review and Meta-Analysis. Stroke. 2016
Although carotid artery occlusion is estimated to account for 10-15% of all ischemic strokes and transient ischemic attacks, there is little consensus regarding the long-term prognosis of asymptomatic carotid artery occlusion (ACAO), which is most often found incidentally during workup for cerebrovascular disease. Hackam sought to shed light on this issue by conducting a systematic review of studies that enrolled patients with ACAO that collected follow-up information on the occurrence of ipsilateral ischemic stroke as an outcome measure.
Heart Rate Variability and Incident Stroke Risk in the Atherosclerosis Risk in Communities Study
Hematoma Shape, but not Density, is Predictive of Clinical Outcomes in ICH from the INTERACT2 Study
Delcourt C, Zhang S, Arima H, Sato S, Al-Shahi Salman R, Wang X, et al. Significance of Hematoma Shape and Density in Intracerebral Hemorrhage: The Intensive Blood Pressure Reduction in Acute Intracerebral Hemorrhage Trial Study. Stroke. 2016
In patients with intracerebral hemorrhage (ICH), parameters such as hematoma volume has been shown to be predictive of hematoma growth and poor clinical outcomes; other characteristics, such as shape and density have been shown to be associated with growth, but evidence demonstrating its predictive value for clinical outcomes has been limited. Here, the authors used data from the INTERACT2 study and evaluated the association of hematoma shape (irregularity) and density (heterogeneity) on 90-day death or disability.
2066 subjects were included for analysis, with 946 subjects having irregular hematomas and 781 subjects having heterogenous hematomas. Of note, there were significant differences between patients with irregular versus regular hematomas, including older age, more severe neurological status, and lobar hemorrhages in the former group, among others. Similarly, patients with heterogenous hematomas, compared to those with homogenous hematomas, were more likely to have lobar hematomas and less likely to have intraventricular extension. Larger hematomas were more likely to be irregular and heterogenous, and this is likely reflected in the differences between each group and their comparators. In addition, the decision to withdraw treatment was more likely to be made among patients with irregular hematomas and among patients with heterogenous hematomas, when compared to their counterparts.
Genetic Factors that Impact White Matter Hyperintensities Increase Risk of Lacunar Stroke
Traylor M, Rutten-Jacobs LCA,Thijs V, Holliday EG, Levi C, Bevan S, et al. Genetic Associations With White Matter Hyperintensities Confer Risk of Lacunar Stroke. Stroke. 2016
Is Anticoagulation Safe in ENT/CNS Infection Associated Central Venous Thrombosis?
What Makes a Lacune?
The lacune, often used interchangeably with the definition of a stroke of small vessel atherosclerotic etiology, is traditionally based on a size definition of no greater than 15 mm. It is a classic feature of cerebral small vessel disease. However, despite its prolific use in the stroke literature, the exact characteristics and morphological features of a lacune are not well defined. Here, the authors analyzed the shape of incident lacunes in CADASIL, a genetically inherited small vessel arteriopathy, to better define the lacune’s morphological features.
Get With the Guidelines (GWTG) Participation is Associated with Improved Clinical Outcomes in Medicare Ischemic Stroke Patients
Early Appearance of Spot Sign on CT Perfusion Associated with Hematoma Expansion and Poor Outcome in Small Retrospective Study
Wang B, Yan S, Xu M, Zhang S, Liu K, Hu H, et al.Timing of Occurrence Is the Most Important Characteristic of Spot Sign. Stroke. 2016
Intracerebral hemorrhage (ICH) causes a significant amount of stroke-related morbidity and mortality. Of the various prognostic factors in ICH, hematoma expansion (HE) is one of the few potentially modifiable ones and as such has been a topic of increasing research. Unfortunately, large-scale randomized controlled trials aimed at preventing hematoma expansion have not shown robust results, possibly owing to the limited ability of clinicians to predict which patients are at greatest risk. The “spot sign,” a radiographic sign representing the leakage of contrast with a hematoma on CT scan has recently become a topic of extensive study with respect to its ability to predict hematoma expansion. As described previously, a recently published meta-analysis suggested that the sensitivity and positive predictive value of the spot sign was related to the time from ictus to scan acquisition and may not adequately predict HE when it is detected. Additionally, other studies have shown that using CT perfusion (CTP) improves the detection rate of the spot sign. Wang et al. sought to explore the relationship between spot sign characteristics on CTP (including number, timing, and maximum density) to evaluate the relationship between these characteristics and the risk of HE as well as clinical outcome.