American Heart Association

Monthly Archives: March 2018

Predicting Blood in the Real World

Kevin S. Attenhofer, MD

Hilkens NA, Li L, Rothwell PM, Algra A, Greving JP. External Validation of Risk Scores for Major Bleeding in a Population-Based Cohort of Transient Ischemic Attack and Ischemic Stroke Patients. Stroke. 2018

You can’t discuss stroke prevention without talking about antiplatelet drugs. Drugs like Aspirin and Clopidigrel are frequently used by stroke neurologists as the secondary prevention treatment of choice for patients with TIA and non-cardioembolic ischemic strokes. However, we must remember that bleeding is a clinically important and potentially life-threatening side effect of these agents. Reliably predicting who is most likely to bleed would dramatically inform the clinician’s decision-making process and likely result in improved patient outcomes.

To that end, the S2TOP-BLEED score was derived from patient data from six randomized trials (CAPRIE, ESPS-2, MATCH, CHARISMA, ESPRIT, and PRoFESS). It is a 28-point score that incorporates readily available patient characteristics: Sex, Smoking history, Type of antiplatelet, Outcome (mRS), Prior stroke, Blood pressure, Low BMI, Elderly, Ethnicity, Diabetes. It was validated in the PERFORM trial (Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin Terutroban in Patients with a History of Ischemic Stroke or Transient Ischemic Attack Study). In this paper, Hilkens et al. externally validate the S2TOP-BLEED score in observational data from a real-world setting.

Optical Coherence Tomography: New Insights into Cerebral Vasculature

Aristeidis H. Katsanos, MD

Chen CJ, Kumar JS, Chen SH, Ding D, Buell TJ, Sur S, et al. Optical Coherence Tomography: Future Applications in Cerebrovascular Imaging. Stroke. 2018

Optical coherence tomography (OCT) uses low-coherence interferometry to produce two-dimensional images of optical scattering with promising clinical and research applications in the evaluation of vasculature in different regions and settings. Despite an imaging depth of only a few millimeters, OCT can produce significantly higher resolution images than ultrasound due to the inherent properties of light waves to provide higher quality transverse imaging compared to sonic waves.

Post-Marketing Observations From the Use of Apixaban in the Real-World Setting

Gurmeen Kaur, MBBS
@kaurgurmeen

Proiette M, Romanazzi I, Romiti GF, Farcomeni A, Lip GYH. Real-World Use of Apixaban for Stroke Prevention in Atrial Fibrillation. Stroke. 2017

The approval of NOACs for stroke prevention in atrial fibrillation has revamped the way anticoagulation is managed. NOACS have practically replaced the use of warfarin for non valvular atrial fibrillation. Currently, 4 NOACs are approved: apixaban, dabigatran, rivaroxaban and edoxaban. Among those, apixaban is the most widely used NOAC in the United States at this time.

For this systematic analysis, all observational studies with use of apixaban, comparison with other NOACS or warfarin with at least 100 patients and 3 month follow up data were selected. The systematic review and meta-analysis were performed according to PRISMA recommendations. A literature search was performed using PubMed and Scopus databases up to 6 March, 2017.

By |March 26th, 2018|clinical|0 Comments

Insights from Modeling Stroke Systems of Care in Philadelphia

Neal S. Parikh, MD
@NealSParikhMD

Mullen MT, Pajerowski W, Messe SR, Mechem CC, Jia J, Abboud M, et al. Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies. Stroke. 2018

Dr. Mullen and colleagues performed a geographic modeling study to understand the implications of several pre-hospital triage strategies on transport times. The rationale for this and related studies is that optimizing stroke systems of care requires accounting for regional and local constraints. Because most of the U.S. population lives in urban areas, investigating urban stroke systems of care is worthwhile.

Philadelphia has only one EMS provider. So, the researchers were able to use EMS data to identify and geocode all ambulance-transported patients with possible stroke and then use a maps application programming interface (API) to estimate travel times. They also had actual travel times as reported by EMS.

Newer Hydrogel Coils Show Promising Results for the Treatment of Small and Medium Size Intracranial Aneurysms

Sami Al Kasab, MD

Taschner CA, Chapot R, Costalat V, Machi P, Courthéoux P, Barreau X, et al. Second-Generation Hydrogel Coils for the Endovascular Treatment of Intracranial Aneurysms: A Randomized Controlled Trial. Stroke. 2018

Following the results of the ISAT trial (International Subarachnoid Aneurysm Trial), which showed better functional with endovascular treatment compared to surgical clipping, endovascular therapy became the preferred method for treating most intracranial aneurysms. Incomplete aneurysm occlusion or aneurysm recurrence, however, are among the main limitations of the endovascular approach. The use of detachable coils with or without balloon and/or stent is the most common endovascular approach treating intracranial aneurysms. Bare platinum coils are commonly used to treat intracranial aneurysms; however, given the relatively high recurrence rate, efforts have been made to evaluate the efficacy of newer generation detachable coils. Few new generation coils that aim at providing better packing and aneurysm embolization have been evaluated. Platinum coils coated with polyglycolic acid/polylactic acid polymers that provide inflammatory response at the aneurysm neck failed to prove efficacy. The use of platinum coils coated with hydrogel, which expands once in contact with liquids, leading to increased packing density, was studied in a previous trial and proved to be effective with lower rate of major recurrence; however, its use has been limited by technical limitation. In this trial (German-French Randomized Endovascular Aneurysm Trial), the authors evaluate the use of softer, second generation hydrogel coils for the treatment of intracranial aneurysms.

Extension of Therapeutic Time Window for Acute Ischemic Stroke and its Implications — Highlighting the DEFUSE 3 Trial

Shashank Shekhar, MD, MS
@Artofstroke

Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. New England Journal of Medicine. 2018

The last few months have been very exciting in the stroke world. DEFUSE 3, a multicentral, randomized, open-label clinical trial, showed the successful outcome after mechanical thrombectomy in ischemic stroke 6-16 hours and shared the same success of the DAWN trial, which supports mechanical thrombectomy 6-24h. Over 300 U.S. hospitals and 38 centers participated in the trial and were funded by NIH through StrokeNet. The trial compared medical therapy (MT) against endovascular therapy plus standard medical therapy (ET+MT). Patient were randomized in a 1:1 ratio to both treatment groups after matching for the baseline characteristics.

Inclusion criteria were initial ischemic volume <70 ml, ratio of the volume of ischemic/initial infarct volume > 1.8, the absolute penumbra of 15ml or more, the presence of occlusion of the cervical or intracranial internal carotid artery or proximal, middle cerebral artery confirmed on CT/MR angiography. Similar to DAWN, a CT perfusion or MRI perfusion or diffusion scan was calculated using the RAPID software. Any FDA-approved thrombectomy device was allowed for mechanical thrombectomy at the discretion of the neurointerventionalist. The protocol required groin puncture to occur within 90 minutes after qualifying image.

By |March 16th, 2018|clinical|0 Comments

Lower Rates of Intravenous Thrombolysis in Acute Stroke Patients with Comorbid Mental Illness

Andrea Morotti, MD

Bongiorno DM, Daumit GL, Gottesman RF, Faigle R. Comorbid Psychiatric Disease Is Associated With Lower Rates of Thrombolysis in Ischemic Stroke. Stroke. 2018

Stroke and cardiac diseases are major determinants of morbidity and mortality in patients with mental illness.1 Previous studies showed that presence of psychiatric disease independently associated with higher chances of poor outcome after stroke, and one of the mechanisms mediating this association may be the underuse of reperfusion therapies such as intravenous thrombolysis (IVT). Using a large national sample of stroke patients, Dr. Bongiorno and colleagues investigated whether the presence of comorbid psychiatric disease was associated with lower odds of receiving IVT.

Patients were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. The authors focused on the following psychiatric diseases: schizophrenia or other psychoses, bipolar disorder, depression, or anxiety. The association between mental illness and the rate of IVT was investigated using a multivariable regression model.

By |March 14th, 2018|clinical|0 Comments

Can We Manage Intracranial Aneurysm Medically?

Tapan Mehta, MBBS, MPH

Can A, Castro VM, Yu S, Dligach D, Finan S, Gainer VS, et al. Antihyperglycemic Agents Are Inversely Associated With Intracranial Aneurysm Rupture. Stroke. 2018

Aneurysmal subarachnoid haemorrhage (aSAH) is a medical emergency with a grim epidemiological profile. In spite of advancement in its diagnosis and management, mortality remains as high as 50%, and half of the patients affected are under the age of 50 years. In attempting to identify risk factors, there has been an increasing interest in association between diabetes mellitus and aSAH. Several studies have stated that diabetes mellitus may have a protective effect on aSAH; however, owing to their methodological flaws and lack of a supportive biological plausibility, the association remains unclear. Also, in previous studies, there is inconsistency in diagnostic testing of diabetes mellitus and lack of reliability of blood glucose level measurements as a measure of long-term glucose control. To explore the association between chronic hyperglycemia and risk of aSAH, in their study, Can et al tested the hypothesis that regardless of the self-reported diagnosis of diabetes mellitus, higher HbA1c values increase the risk of rupture of intracranial aneurysms and that the use of antihyperglycemic agents is protective against rupture. This study contributes to existing literature through its strengths over previous studies, which include adjusting for confounding risk factors hypertension and smoking, use of a large sample size, and use of HbA1c instead of blood glucose measurement as an indicator of blood glucose control in the patient population.

By |March 12th, 2018|clinical|0 Comments

Elevated Troponin Levels After Ischemic Stroke: Take a Look at the Heart!

Aristeidis H. Katsanos, MD, PhD

Yaghi S, Chang AD, Ricci BA, Jayaraman MV, McTaggart RA, Hemendinger M, et al. Early Elevated Troponin Levels After Ischemic Stroke Suggests a Cardioembolic Source. Stroke. 2018

In the perpetual search for potential biomarkers that could be used for ischemic stroke diagnosis and etiological classification, the authors tested the hypothesis that early positive troponin elevation after ischemic stroke may be independently associated with the presence of a cardiac embolic source.

Using data from a prospective ischemic stroke database during a 22-month period, they identified intermediate (0-0.06 ng/mL) and positive (≥0.1 ng/mL) troponin levels in 25.1% and 11.9% of the total 1129 acute ischemic stroke patients having available troponin levels on admission. Troponin-positive patients were found to present with more severe strokes, were more likely to undergo mechanical thrombectomy, but were less likely to have favorable functional outcomes at 90 days.

A Non-Invasive Approach to Monitor Mechanical Thrombectomy Patients Using Near-Infrared Spectroscopy

Shashank Shekhar MD, MS
@Artofstroke

Ritzenthaler T, Cho T-H, Mechtouff L, Ong E, Turjman F, Robinson P, et al. Cerebral Near-Infrared Spectroscopy: A Potential Approach for Thrombectomy Monitoring. Stroke. 2017

The recently published article in Stroke highlights a rather novel and non-invasive way to monitor thrombectomy patients after large vessel occlusion. Monitoring recanalization and reperfusion during and after mechanical thrombectomy is a therapeutic and diagnostic challenge. In the past, the use of ultrasound and Electroencephalogram devices has been explored with some success. Using functional imaging like Near-infrared spectroscopy (NIRS) allows us to monitor the cerebral regional oxygen saturation continuously. This study is an attempt to answer the question if NIRS could be a better way to monitor mechanical thrombectomy patients.

This pilot study was performed in France using NIRS to find a correlation between regional brain oxygen saturation (rSO2) and MRI perfusion based parameters, reperfusion and clinical outcome. A total of 17 patients were included in the study out of 749 consecutive ischemic admissions. The selection was based on occlusion in the anterior circulation on multimodal MRI with perfusion-weighted imaging. Patients were treated with standard thrombolysis and mechanical thrombectomy with successful recanalization defined as TICI score 2B and 3. NIRS optodes were placed on the bilateral forehead immediately after MRI and kept during mechanical thrombectomy and up to 24 hours. The NIRS device measures the interhemispheric differences (IHD) during this period.