American Heart Association

Monthly Archives: December 2017

Improved Diagnostic Accuracy of Non-Occlusive Intracranial Vasculopathies With the Use of Vessel Wall Imaging

Sami Al Kasab, MD

Mossa-Basha M, Shibata DK, Hallam DK, de Havenon A, Hippe DS, Becker KJ, et al. Added Value of Vessel Wall Magnetic Resonance Imaging for Differentiation of Nonocclusive Intracranial Vasculopathies. Stroke. 2017

The term intracranial vasculopathy denotes any disease affecting the blood vessels of the brain and meninges. This includes vascular abnormalities due to inflammatory, metabolic, or hereditary conditions; coagulopathy-related disorders; and functional disorders of the blood vessels. Differentiating the type of vasculopathy is important, as treatment is different depending on the type of vasculopathy. Most common intracranial vasculopathies include intracranial atherosclerosis (ICAD), reversible cerebral vasoconstriction syndrome (RCVS), and infectious/inflammatory vasculopathies (IVas).

Recently, intracranial vessel imaging with magnetic resonance imaging (MRI) has emerged as a promising modality to characterize intracranial vasculopathies. Intracranial vessel imaging with MRI has been used to characterize vessel wall as well as vessel lumen. In this study, Mossa-Basha and colleagues compare the diagnostic accuracy of intracranial vessel wall MRI (IVWI) with luminal imaging to luminal imaging alone in non-occlusive vasculopathy differentiation such as ICAD, RCVS, and IVas.

Management of Symptomatic Post tPA Hemorrhage in Acute Ischemic Strokes: An Expert Consensus Guideline

Gurmeen Kaur, MBBS
@kaurgurmeen

Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2017

The American Heart Association/American Stroke Association recently published a consensus statement on treatment guidelines for management of symptomatic intracranial hemorrhage (sICH), chaired by Dr. Yaghi. After extensive review of the existing literature, the consensus committee devised this guideline based on the current available evidence.

Different authors and trials have used varying definitions of what is classified as symptomatic ICH. Based on the definitions, there was a 2.5-5-fold variation in the rates of ICH noted. The incidence of sICH after alteplase in the modern era at the standard dose of 0.9 mg/kg administered over 1 hour with a 10% bolus varies from 2% to 7% in clinical trials and prospective stroke registries.

To standardize and make the various trials comparable, the group suggested that stroke centers should classify the appearance of hemorrhagic transformation according to radiographic criteria as described in ECASS II (hemorrhagic infarction [HI] type 1, HI-2, parenchymal hematoma [PH] type 1, PH-2, or remote ICH), assess the degree of neurological worsening by National Institutes of Health Stroke Scale (NIHSS) point change, and provide an attribution of causality for the worsening. The natural history of patients with sICH, particularly the PH-2 radiological subtype, is very poor, approaching 50% mortality and significant morbidity with survival.

By |December 27th, 2017|clinical|0 Comments

What’s New in Stroke Diagnosis and Prognosis

Terry Quinn, MD
@DrTerryQuinn

We are living in an exciting period of change in stroke practice. Keeping up to date with the latest stroke research is a challenge for clinicians and is even more difficult for the non-specialist. Stroke offers a monthly Literature Synopses, which aims to describe the most important and interesting stroke research from other journals. When I took on editing the Clinical Science Synopses, I was keen that we tried to reach the broadest possible audience, including those who are not from a healthcare background. So, in this blog I will (try to) give a non-technical and easy-to-read account of the papers I discuss in the main Synopses feature. The conversation does not need to be in one direction and, through comments and tweets, I would be really interested to hear your thoughts both on the blog and on the research discussed.

Quinn TJ. Stroke Literature Synopses: Clinical Science. Stroke. 2017

Often the synopses has focused on new medications, new devices or new methods of rehabilitation.  These areas are all important, but they are only part of the complex encounter between patients and stroke clinicians. In this month’s synopses, I wanted to focus my attention on research that looked at making the diagnosis of stroke and on the related area of making predictions about what will happen (prognosis).

By |December 22nd, 2017|clinical|0 Comments

Should We RESPECT PFO Closure?

Tapan Mehta, MBBS, MPH

Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, et al. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. New England Journal of Medicine. 2017

Literature on PFO (Patent Foramen Ovale) as an underlying etiology for acute ischemic stroke and outcomes of PFO closure hit an important landmark when recently CLOSE, REDUCE and RESPECT trials were reported in the New England Journal of Medicine. All three trials had difference in methods of randomization, treatment protocols, outcomes, and patient population, to an extent. This post will focus on the RESPECT trial (Saver et al).

RESPECT was a multicenter, randomized, and open-label with blinded adjudication of end point event trial with 1:1 randomization to PFO closure and medical (antiplatelet or anticoagulation) groups. Important inclusion criteria included age 18–60 years and ischemic stroke within 9 months (defined with imaging or neurological deficit attributed to ischemic stroke lasting for more than 24 hours) that is determined to be not related to any other cause but PFO. All patients included had a PFO determined with transesophageal echocardiogram; however, PFO characteristics including type of shunt and presence of atrial septal aneurysm were not a part of inclusion criteria, unlike the CLOSE trial. Although all of these patients received extensive investigations to determine etiology of their stroke, including hypercoagulable workup, they were not required to have 30-day or long-term cardiac monitoring.

By |December 20th, 2017|clinical|0 Comments

Successful Closure of Patent Foramen Ovale Result in Less Risk of Stroke — A Brief Review

Shashank Shekhar, MD, MS

Mas J-L, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. NEJM. 2017

The successful outcomes from three open-label, randomized, multicenter clinical trials looking for benefit from the clinical closure of Patent Foramen Ovale (PFO) is going to receive a rapturous welcome from the cardiology community and possibly from the stroke community. PFO is present in >25% of general population; however, it can account for up to 50% in cryptogenic stroke group (Homma S, Circulation 2005). Until recently, there were no recommended guidelines as for how to treat patients with a cryptogenic stroke suspicious of PFO as an etiology. Previous trials including primary analysis of the RESPECT trial did not show a significantly lower risk of stroke after PFO closure when compared to anticoagulation (Furlan, NEJM 2012; Carroll, NEJM 2013; Meier, NEJM 2013). However, the recent long-term outcome of RESPECT and two additional trials, namely CLOSE and REDUCE, has been published in the New England Journal of Medicine, in the September 2017 edition. All three trials showed the benefit of PFO closure, but surprisingly all trials had the higher rate of atrial fibrillation in patients with PFO closure. Let’s discuss in brief the results from the CLOSE trial.

By |December 18th, 2017|clinical|0 Comments

Could Bypassing Primary Stroke Centers for Thrombectomy-Capable Centers Lead to Improved Outcomes?

Gurmeen Kaur, MBBS
@kaurgurmeen

Froehler MT, Saver JL, Zaidat OO, Jahan R, Aziz-Sultan MA, Klucznick RP, et al. Interhospital Transfer Prior to Thrombectomy is Associated with Delayed Treatment and Worse Outcome in the STRATIS Registry. Circulation. 2017

Since “Time is Brain” when it comes to ischemic strokes and large vessel occlusions (LVO), the authors designed the STRATIS trial, which is a multicenter, observational, single-world perspective on real-life issues faced during transfers of patients for tPA and mechanical thrombectomy.

1000 patients with anterior circulation LVOs were included over a 22-month period. About half of the patients were transferred to a comprehensive stroke center which is capable of mechanical thrombectomy, and the remaining half was transferred from an outside hospital to an endovascular-capable center. IV-tPA was administered to 628 patients; 329/539 (61.0%) of direct patients and 299/445 (67.2%) of transferred patients (p=0.044).

By |December 15th, 2017|clinical|0 Comments

Endovascular Therapy for Stroke Can Be Translated from Ideal World to Real World

Kaustubh Limaye, MD
@kaustubhslimaye

Mueller-Kronast NH, Zaidat OO, Froehler MT, Jahan R, Aziz-Sultan MA, Klucznik RP, et al. Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke: Primary Results of the STRATIS Registry. Stroke. 2017

It is possible to match “benchmark” workflow timings and clinical outcomes in a community setting for acute stroke patients with large vessel occlusion needing endovascular therapy.

The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry sought to compare real-world patient workflow and outcome of patients with intracranial large vessel occlusion (LVO) requiring endovascular therapy (EVT). A total of 984 eligible patients with large vessel occlusion were enrolled at 55 different sites with an enrolling cap of 75 patients. Patients with pre-treatment modified Rankin score of 0-1, confirmed LVO, NIHSS≥8 with an intention to be treated with a Medtronic market-released neurothrombectomy device (Solitaire and Mindframe) as an initial device for stent assisted thrombectomy within 8 hours from symptom onset.

Out of 1000 patients enrolled, 16 were deemed to be screen failure resulting in intention to treat analysis of 984 patients. 64% of the patients enrolled received intravenous thrombolysis and mean NIHSS of the enrolled patients was 17. 45.2% of patients were transferred from another facility to the enrolling center. Mean distance from field to the enrolling site was 29 miles with 2/3rd of the patients <25 miles distance from enrolling site. The clinical trials for LVO needing EVT set a few important “benchmarks” for patient workflow: 1) onset to puncture time; 2) door to puncture time (DTP); 3) puncture to reperfusion time (PTR); and 4) the quality of substantial reperfusion (TICI ≥ 2b).

Intracerebral Hemorrhage Shape Predicts the Risk of Intracerebral Hematoma Expansion

Andrea Morotti, MD

Li Q, Liu Q-J, Yang W-S, Wang X-C, Zhao L-B, Xiong X, et al. Island Sign: An Imaging Predictor for Early Hematoma Expansion and Poor Outcome in Patients With Intracerebral Hemorrhage. Stroke. 2017

Intracerebral Hemorrhage (ICH) is a dynamic disease, with up to half of the patients experiencing active bleeding in the acute phase. Hematoma growth represents a potential therapeutic target to improve patients’ outcome. Rapid identification of subjects at high risk of hematoma growth is, therefore, crucial in clinical practice and in the setting of clinical trials testing anti-expansion treatments. The CT angiography (CTA) spot sign is a robust marker of ICH expansion. However, CTA is not available in many institutions, and a large proportion of ICH patients do not receive a CTA as part of their diagnostic workup 1. This highlights the need for novel markers of hematoma growth that do not require a CTA.

Using a well-characterized cohort including 252 ICH patients, Qi Li and colleagues described the island sign, a novel marker of hematoma growth that can be evaluated on baseline non-contrast CT (NCCT). The island sign was defined as presence of at least 3 scattered small hematomas all separate from the main hemorrhage or at least 4 small hematomas, some or all of which may be connected with the main hemorrhage. An illustrative example of the island sign is provided in Figure 1. ICH expansion was defined as hematoma growth > 6mL or > 33% from baseline hematoma volume.

Figure 1. Illustration of island sign. Axial noncontrast computed tomography (CT) images of 4 patients with CT island sign.

Figure 1. Illustration of island sign. Axial noncontrast computed tomography (CT) images of 4 patients with CT island sign.

Administration of Statin on Acute Ischemic Stroke Patient (ASSORT) Trial

Aristeidis H. Katsanos, MD, PhD

Yoshimura S, Uchida K, Daimon T, Takashima R, Kimura K, Morimoto T, on behalf of ASSORT Trial Investigator. Randomized Controlled Trial of Early Versus Delayed Statin Therapy in Patients With Acute Ischemic Stroke ASSORT Trial (Administration of Statin on Acute Ischemic Stroke Patient). Stroke. 2017

Even though the role of statins in both primary and secondary stroke prevention has been well established, with a considerable number of acute ischemic stroke (AIS) patients receiving statin treatment during the first days of ictus, the usefulness of statin therapy in the acute phase of cerebral ischemia still remains debatable.

The Administration of Statin on Acute Ischemic Stroke Patient (ASSORT) Trial is a multicenter, Japanese, open-label, randomized clinical trial (RCT) with the aim to determine the efficacy of early (≤24 hours) versus delayed (7th day) statin initiation in AIS. After randomizing a total of 257 patients (early: 131, delayed: 126), authors concluded that there is no superiority of early statin administration for AIS, as no significant differences were found on the 3-month functional outcome, stroke recurrence or mortality between patients receiving early or delayed statin therapy. As highlighted by the authors, the low dose of statins that were administered in the current trial (atorvastatin 20mg/d, pitavastatin 4mg/d or rosuvastatin 5mg/d) could partially account for the aforementioned lack of efficacy, concluding that higher doses should be attested in future studies.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization

Pouya Tahsili-Fahadan, MD

Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, et al. Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis. Stroke. 2017

This article tackles a very important and popular question since the introduction of Mechanical Thrombectomy (MT) for treatment of acute ischemic stroke: Sedation. Endotracheal intubation and anesthesia may be indicated regardless of MT for airway protection and in those with acute respiratory failure after stroke. In other patients, however, risks versus benefits of general anesthesia (GA) versus conscious sedation are less clear. Multiple earlier reports had pointed towards the choice of sedation as a potential factor in patients’ outcomes after MT with a majority of them favoring GA. Accordingly, the American Heart Association recommended “it might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke” (Powers et al., Stroke 2015).

Twenty-two previous reports, including 3 randomized control trials, with a total of 4716 patients, were included in this meta-analysis. 1819 patients (38.5%) underwent GA. The primary end-point of the study was good functional outcome defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days after MT. GA group was associated with lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48–0.64) along with higher odds of mortality (OR 2.02; 95% CI, 1.66–2.45), vascular complications (OR, 1.43; 95% CI, 1.01–2.03), and respiratory complications (OR, 1.70; 95% CI, 1.22–2.37) in comparison to patients in the non-GA group. Although symptomatic hemorrhagic conversion was more common among patients in the GA group, it did not reach statistical significance (OR, 1.43; 95% CI, 0.85–2.39).

By |December 6th, 2017|clinical|0 Comments