American Heart Association

Monthly Archives: November 2017

Peri-Procedural Silent and Clinical Infarctions in Cardiovascular Procedures

Gurmeen Kaur, MBBS
@kaurgurmeen

Cho S-M, Deshpande A, Pasupuleti V, Hernandez AV, Uchino K. Radiographic and Clinical Brain Infarcts in Cardiac and Diagnostic Procedures: A Systematic Review and Meta-Analysis. Stroke. 2017

Cardiovascular procedures including Aortic Valve Replacement (AVR), coronary artery bypass grafting (CABG), and cardiac and cerebral catheterization have been associated with increased prevalence of peri-procedural acute ischemic brain lesions on magnetic resonance imaging (MRI).

In this systematic review, Cho et al compared the ratio of radiographic brain infarcts (RBI) to strokes and transient ischemic attacks across cardiac and vascular procedures. RBIs are common after invasive vascular procedures and are encountered a lot more frequently than clinical strokes or TIAs. Literature suggests that peri-procedural ischemic events might serve as a potential surrogate marker for optimizing invasive procedures, which is why an effort was made to compare the rates of RBIs to clinical events.

Physical Activity and Stroke Risk: A Role for Moderate Physical Activity

Mark R. Etherton, MD, PhD

Willey JZ, Voutsina J, Sherzai A, Ma H, Bernstein L, Elkind MSV, et al. Trajectories in Leisure-Time Physical Activity and Risk of Stroke in Women in the California Teachers Study. Stroke. 2017

In this entry, I discuss a recent publication by Joshua Willey and colleagues regarding the protective effects of physical activity on stroke risk.

A beneficial role of physical activity in the prevention of cardiovascular disease and ischemic stroke has been consistently demonstrated. An outstanding question, however, is how changes in physical activity impact incident stroke risk. The authors of this manuscript, therefore, set out to investigate the association between changes in self-reported physical activity at two time points and incident stroke risk.

The authors used the California Teachers Study cohort, which is a large prospective cohort of female teachers in the state of California, and examined self-reported physical activity at two time points (1995 and 2005-6). In total, 61,256 participants were included in the analysis with notable exclusion criteria, including history of stroke or age less than 26 years old. Exercise was reported as moderate (e.g. brisk walking) or strenuous (e.g. swimming, running) and quantified as hours per week and months per year in the past 3 years. The authors used this data to then establish average minutes/week and dichotomized the measures by the AHA recommendations for moderate (150 minutes/week) or strenuous (75 minutes/week) activity. Using these metrics of physical activity, the authors assessed incident stroke risk.

Is Circuit Training Useful After Stroke?

Stephen Makin, PhD
@StephenMakin

English C, Hillier S, Lynch E. Circuit Class Therapy for Improving Mobility After Stroke. Stroke. 2017

There are few things in life I find more boring than going to the gym. Running on a treadmill or lifting weights for what seems like hours just doesn’t interest me.

Circuit class can be fun though. You get to try lots of different exercises and move onto the next one before they get boring.

But could they also work in the stroke unit gym? After all, that’s nothing like a usual gym.

This is something people have been asking for a while. The first study of circuit training in stroke rehabilitation was carried out in 2000. English and colleagues have updated the Cochrane review on circuit training after stroke.

Remote Ischemic Conditioning May Improve Outcomes of Patients With Cerebral Small-Vessel Disease

Alexis N. Simpkins, MD, PhD

Wang Y, Meng R, Song H, Liu G, Hua Y, Cui D, et al. Remote Ischemic Conditioning May Improve Outcomes of Patients With Cerebral Small-Vessel Disease. Stroke. 2017

Cerebral small vessel disease (sCVD) is an important cause of both vascular dementia and lacunar infarction. Accumulation of white matter lesions and lacunar infarcts from sCVD is associated with cognitive dysfunction, increased risk of stroke, and worsened neurologic outcome after stroke. Here the authors test the hypothesis that remote ischemic conditioning (RIC) can improve cognitive outcomes in patients with mild cognitive impairment and cSVD as a follow up to the pilot study in which they showed that cSVD can reduce white matter disease and increase mean velocity of the middle cerebral arteries.

This study was a 1-year, single-center, prospective, double-blinded, randomized, placebo controlled study of consented patients of Han Chinese decent between 45 and 80 years of age with mild cognitive impairment defined by a pre-treatment MMSE and MOCA score, sCVD as defined by the Standards for Reporting Vascular Changes on Neuroimaging criteria on pre-treatment brain MRI and automated measurements of white matter disease of MRI-fluid-attenuated inversion recovery sequences. Patients were excluded if they did not complete > 80 % of the therapy, had significant cardiac disease, medical illness, medical contraindication to having RIC performed, intracerebral hemorrhage, stroke within the past 6 months, or an alternate etiology of small vessel disease such as vasculitis, genetic disorder, > 50% stenosis of intracranial vessel, or atrial fibrillation. The difference between the RIC and placebo group was the pressure of the cuff inflation from the automated device (200 mmHg in RIC cycling for 5 cycles of inflation and deflating for 5 minutes vs. 50mmHg in control).

Cost Effectiveness and Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke

Sami Al Kasab, MD

Sevick LK, Ghali S, Hill MD, Danthurebandara V, Lorenzetti DL, Noseworthy T, et al. Systematic Review of the Cost and Cost-Effectiveness of Rapid Endovascular Therapy for Acute Ischemic Stroke. Stroke. 2017

Stroke remains one of the most devastating neurological illnesses and the leading cause of long-term disability in the U.S. It’s projected that the total cost of stroke from 2005 to 2050 will be $1.52 trillion for non-Hispanic whites, $313 billion for Hispanics, and $379 billion for African Americans. Until 2015, intravenous alteplase (rtPA) was the only proven treatment for acute ischemic stroke. In 2015, a series of five randomized controlled trials demonstrated the effectiveness of mechanical thrombectomy for patients presenting with acute ischemic stroke due to anterior circulation large vessel occlusion within 6 hours of symptom onset.

In this study, Sevick et al perform a systematic review to evaluate cost effectiveness of endovascular therapy (EVT) for acute ischemic stroke. The authors also aim to synthesize all the publicly available economic literature regarding EVT.

Benchmarking Telestroke Proficiency

Abbas Kharal, MD, MPH, and Richa Sharma, MD, MPH

Jagolino-Cole AL, Bozorgui S, Ankrom CM, Bambhroliya AB, Cossey TD, Trevino AD, et al. Benchmarking Telestroke Proficiency: Page-to-Needle Time Among Neurovascular Fellows and Attendings. Stroke. 2017

Telestroke management is built into the curriculum of many vascular neurology fellowships and affords fellows (NVF) the opportunity to achieve proficiency in this modality. This study demonstrates that the page-to-needle time, or PTNT, is higher among NVFs compared to NVAs. As a result, the authors are suggesting that PTNT is a metric of proficiency. Given lower PTNT among NVAs compared to NVFs, there is an assumption that further training may decrease PTNT and, transitively, increase proficiency. As such, there may be a benefit in greater emphasis of dedicated telestroke training during fellowship.

There is an inherent truth in the logic that additional training can result in decreased PTNT just by sheer procedural repetition to learn the logistics of data-gathering by the phone, video, and imaging from an outside institution. However, perhaps the process is also faster for NVAs compared to fellows due to the attendings’ greater body of experiences seeing numerous patients with each stroke syndrome, treating them acutely, and then following the clinical course in the rehabilitation and subacute phase. Thus, proximal care of stroke patients longitudinally may aide in faster decision-making for remote, telestroke patients. Given that most vascular neurology fellowships are only one clinical year, it is thus critical that telestroke training does not supersede rotations, which require direct patient contact throughout the spectrum of the disease, since it is this contact which informs the decision-making process in the practice of telestroke.

Location of Brain Infarct and Gender is Associated with Risk of Dementia: A Review of AGES-Reykjavik Study

Shashank Shekhar, MD, MS
@Artofstroke

Sigurdsson S, Aspelund T, Kjartansson O, Gudmundsson EF, Jonsdottir MK, Eiriksdottir G, et al. Incidence of Brain Infarcts, Cognitive Change, and Risk of Dementia in the General Population: The AGES-Reykjavik Study (Age Gene/Environment Susceptibility-Reykjavik Study). Stroke. 2017

The recent published longitudinal study by Sigurdsson and colleagues highlights the types of infarction that are associated with cognitive decline, as well as the sex factor that can contribute to dementia after ischemic strokes.

This study is based on the longitudinal data gathered from an Icelandic population-based cohort of men and women from 2002 to 2006, in which 5764 participants were examined. A total of 3316 patients were followed up from 2007 to 2011. The study utilized the MRI to get the baseline and follow-up imaging to define the location of the stroke. All types of infarcts were included and categorized into Cortical infarcts, subcortical infarcts, and cerebellar infarction. Of 3316 participants from the follow-up, 2612 participants (1070 male and 1542 female) were included. Rejection of the rest was based on exclusion criteria. Cognition was assessed regarding memory, processing speed, and executive function. The cognitive screening was done with mini-mental and digital symbol substitution test and later confirmed using a diagnostic battery of neuropsychological tests. For each infarction type, the sample was categorized into four groups based on a combination of incidence and prevalence to find gender-based differences.

Real-world Data on Safety and Efficacy of NOACs in Asians

Andrea Morotti, MD

Cha M-J, Choi E-K, Han K-D, Lee S-R, Lim W-H, Oh S, et al. Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Asian Patients With Atrial Fibrillation. Stroke. 2017

Novel oral anticoagulants (NOACs) represent a valuable alternative to warfarin for embolism prevention in patients with non-valvular atrial fibrillation (AF). Multiple studies showed that NOACs use significantly reduces mortality compared to warfarin, with a lower risk of intracranial bleeding being the main mediator of this association.

Using a large National Insurance Database, Dr. Myung-Jin Cha and colleagues analyzed the risk of ischemic stroke, intracerebral hemorrhage (ICH), and all-cause mortality in Korean subjects with AF comparing NOACs versus warfarin users.

A total of 11611 NOACs users and 23262 on warfarin qualified for the analysis after CHA2DS2-VASc-based propensity score matching with a 1:2 ratio. The risk of ischemic/hemorrhagic stroke and death associated with warfarin versus NOACs treatment was investigated with time-to-event analysis.

By |November 13th, 2017|clinical|0 Comments

History of Aneurysmal Subarachnoid Hemorrhage

Tapan Mehta, MBBS, MPH

Korja M, Kivisaari R, Rezai Jahromi B, Lehto H. Natural History of Ruptured but Untreated Intracranial Aneurysms. Stroke. 2017

Over the past fifty years, understanding of the natural course of aneurysmal subarachnoid hemorrhage (aSAH) has concurrently transformed the standard management approaches. With the awareness of risk related to aneurysm re-rupture (about 15% within few hours and overall cumulative risk of 40%–50% at 6 months) among patients who survive the initial event, securing the aneurysm as soon as possible has become the standard of care. Korja et al present an interesting retrospective observational study that depicts the natural course of untreated ruptured intracranial aneurysms.

By |November 10th, 2017|clinical|0 Comments

Using CT Perfusion to Predict Hemorrhagic Transformation

Brian Marcus, MD

Li Q, Gao X, Yao Z, Feng X, He H, Xue J, et al. Permeability Surface of Deep Middle Cerebral Artery Territory on Computed Tomographic Perfusion Predicts Hemorrhagic Transformation After Stroke. Stroke. 2017

The authors of this study utilized CT perfusion (CTP) to assess blood brain barrier integrity and to help predict which patients are at risk of hemorrhagic transformation after receiving tPA and/or mechanical thrombectomy. They note that patients who have proximal MCA-M1/distal ICA occlusions are at an increased susceptibility of hemorrhagic transformation, particularly in the deep MCA territory supplied by the lenticulostriate arteries. They aimed to explore the relationship and potential risk factors between permeability and hemorrhagic transformation in the deep MCA territory by utilizing CT perfusion imaging.

The authors performed a multisite retrospective study, specifically looking at patients that were found to have a deep MCA territory hemorrhagic transformation at 24 hours (and had received CT perfusion and CT angiography on admission). In their study, they noted that patients with a proximal MCA/distal ICA and poor collateral circulation had increased permeability in the deep MCA territory.