American Heart Association

Monthly Archives: January 2018

Stressing Over Sugar: Prognostic Implications of Stress Hyperglycemia After Stroke

Kevin S. Attenhofer, MD

Pan Y, Cai X, Jing J, Meng X, Li H, Wang Y, et al. Stress Hyperglycemia and Prognosis of Minor Ischemic Stroke and Transient Ischemic Attack: The CHANCE Study (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events). Stroke. 2017

Diabetes is becoming increasingly prevalent worldwide, with over 30 million people diagnosed in the United States as of 2015. It is no secret that diabetes is an independent risk factor for stroke. In fact, mortality is higher and post-stroke outcomes are poorer in patients with stroke and uncontrolled glucose levels.

In some patients, a phenomenon of stress hyperglycemia is observed at the time of stroke. This is a relative increase in glucose during an acute critical illness. It is an ill-defined metric with no consistent definition in the literature. Previous studies have shown that stress hyperglycemia is a better predictive biomarker of critical illness than absolute hyperglycemia. The authors of this paper sought to determine an association between stress hyperglycemia and incidence of new stroke or TIA following index ischemic stroke.

So You’ve Found Some Microbleeds, What Now?

Stephen Makin, PhD
@StephenMakin

Shoamanesh A, Charidimou A, Sharma M, Hart RG. Should Patients With Ischemic Stroke or Transient Ischemic Attack With Atrial Fibrillation and Microbleeds Be Anticoagulated? Stroke. 2017

Anyone who has been to a stroke unit’s imaging meeting will know this situation.

Someone has performed an MRI on their patient with atrial fibrillation, someone who is at high risk of a further stroke, and would usually be started on anticoagulation. Now it shows some microbleeds, and they are considering whether they should still offer anticoagulation.

Someone else will tell you that a meta-analysis of observational studies suggests that CMB is associated with an increased risk of both haemorrahgic and ischaemic stroke.

Someone mutters that maybe the MRI has just caused more trouble, and wonders why you requested it in the first place; after all, we have always managed to diagnose stroke without MRI for decades.

Someone else will say that as none of the trials of anticoagulation required MRI at study entry, so patients with microbleeds must have been included in these studies.

By |January 8th, 2018|clinical|0 Comments

The Role of MIST in Recanalization Times for Large Vessel Occlusion

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

Wei D, Oxley TJ, Nistal DA, Mascitelli JR, Wilson N, Stein L, et al. Mobile Interventional Stroke Teams Lead to Faster Treatment Times for Thrombectomy in Large Vessel Occlusion. Stroke. 2017

This retrospective analysis of the expediency of Mobile Interventional Stroke Teams (MIST) in the treatment of acute ischemic stroke (AIS) patients with large vessel occlusions (LVO) introduces an interesting method of delivering acute stroke care in a densely populated urban setting. Contrary to previously adapted AIS treatment models of drip-and-ship (transfer of patients from PSC to CSC) and mothership (transfer directly to CSC while bypassing nearby PSC), the trip-and-treat model introduces the concept of transferring the interventional team — including a neurointerventionalist attending, fellow and radiological technologist — to the PSC where the patient presents. Patients were treated by the trip-and-treat model or the drip-and-ship model based on relative availability of operating rooms and neurosurgical intensive care unit beds at the peripheral hospital and CSC. Interestingly, mean initial door-to-puncture time was shorter in the trip-and-treat model compared to the historic drip-and-ship model {143 mins vs. 222 mins, respectively (P<0.0001)}. Although there was a trend in longer puncture-to-recanalization times for trip-and-treat (P=0.0887), initial door-to-recanalization was still 79 minutes faster for trip-and-treat.

When Should We Anticoagulate Atrial Fibrillation Patients After an Intracranial Hemorrhage?

Hatim Attar, MD

Pennlert J, Overholser R, Asplund K, Carlberg B, Rompaye BV, Wiklund PG, et al. Optimal Timing of Anticoagulant Treatment After Intracerebral Hemorrhage in Patients With Atrial Fibrillation. Stroke. 2017

To answer this question, Pennlert et al completed a large observational study in Swedish patients. The timing for anticoagulation (AC) after Intracerebral Hemorrhage (ICH) has been brought up several times, with a recent systemic review and meta-analysis published in Stroke by Murthy et al (Restarting Anticoagulant Therapy After Intracranial Hemorrhage: A Systematic Review and Meta-Analysis). Further, the specific time point at when it is considered safe to restart anticoagulation is in flux without any current international guideline. However, this paper by Pennlert et al provides clarity specifically targeting AC in A. fib patients who have had an ICH and at what time is it optimal to start anticoagulation.

The authors used the national Swedish Stroke Register, Riksstroke, which included first-time ICH with concurrent diagnosis of atrial fibrillation between July 1, 2005 and December 31, 2012 who survived their hospitalization. Patients with a first-time ICH with a concomitant diagnosis of AF were included. Two primary outcome events were defined; the first was overall ischemic stroke events and deaths related to any vascular thrombotic event. The second outcome was recurrent ICH, as well as death attributable to other hemorrhages. Follow-up was initiated only after day 28 of the first event. Patients on dual therapy antiplatelet and anticoagulant agents were excluded. Patients were then stratified into two groups, low risk and high risk, based on patient demographics and co-morbidities via the CHA2DS2-VASc scoring system.