Monthly Archives: July 2018

Shashank Shekhar, MD, MS
@Artofstroke

Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018

The long-anticipated POINT trial has recently been presented at the 4^th European Stroke Organization Conference 2018, and subsequently published in NEJM, in May 2018. After the CHANCE trial, many centers started using dual antiplatelet for lacunar strokes and TIA; there remained uncertainty over the validity of the non-Chinese population. The POINT trial results add validity to the five-years-old questions since the CHANCE trial.

The POINT trail is a multinational, randomized, placebo-controlled trial. The patients were assigned in 1:1 ratio between treatment and control arm. The treatment arm in the trial received a loading dose of 600mg Clopidogrel, followed by daily 75mg with daily aspirin (50mg-325mg). The control arm received same range of daily Aspirin with Placebo. The trial enrolled 4881 patients at 269 international sites in 10 different countries.

Aristeidis H. Katsanos, MD, PhD

Groot AE, Vermeij J-DM, Westendorp WF, Nederkoorn PJ, van de Beek D, Coutinho JM. Continuation or Discontinuation of Anticoagulation in the Early Phase After Acute Ischemic Stroke. Stroke. 2018

Stroke clinicians frequently are confronted with the dilemma of not only weighting the thrombembolic risk to the risk of bleeding in acute ischemic stroke (AIS) patients with indication for anticoagulation, but they should also decide the optimal timing for anticoagulation resumption. Even though numerous studies have investigated so far the optimal timing of anticoagulation resumption in AIS patients, no study has directly compared anticoagulant continuation (without cessation) to discontinuation in patients suffering an AIS while on anticoagulation.

Muhammad Zeeshan Memon, MD

Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, et al. First Pass Effect: A New Measure for Stroke Thrombectomy Devices. Stroke. 2018

Currently, the American Heart Association/American Stroke Association recommends mechanical thrombectomy as the standard of care for acute stroke patients with proximal artery occlusions. Multiple studies have shown complete or near-complete reperfusion achieved in a timely manner leads to improved clinical outcomes and reduced adverse effects; however, complete reperfusion is achieved in <50% of cases, and often requires many thrombectomy attempts and the use of multiple devices. This not only delays time to achieve recanalization, but also incurs additional risk of vessel spasm, injury, and rupture. Design improvement of mechanical thrombectomy devices, particularly the advent of stent retrievers, has improved recanalization rates and decreased the complication rates leading to this notion that achieving complete revascularization with a single pass should be the new angiographic goal.

Richard Jackson, MD

Wu F, Song H, Ma Q, Xiao J, Jiang T, Huang X, et al. Hyperintense Plaque on Intracranial Vessel Wall Magnetic Resonance Imaging as a Predictor of Artery-to-Artery Embolic Infarction. Stroke. 2018

Despite the prevalence of symptomatic intracranial stenosis, there has been little progress into biomarkers that may identify patients at the highest risk of stroke recurrence. This article attempts to find an imaging biomarker for symptomatic intracranial atherosclerotic plaques.

From a prospectively enrolled MCA infarct population, a retrospective analysis was undertaken in a small cohort of 74 Asian patients with symptomatic intracranial stenosis of the middle cerebral artery (MCA). Whole brain high resolution pre and post-contrast magnetic resonance imaging (MRI) was used to evaluate MCA plaques. Patients were divided into A-to-A and non-A-to-A embolic infarction groups based on MR diffusion-weighted imaging infarct patterns. Patients with a previous history of stroke or transient ischemic attack on the symptomatic side, history of ipsilateral MCA or internal carotid artery occlusion, significant occlusion or plaque on the ipsilateral extra-cranial internal carotid artery, non-atherosclerotic vasculopathy and risk factors for cardiac embolism were excluded. Quantitative data were analyzed using t-test and chi squared testing. Hyperintense plaques (HIP) were more frequently observed in the A-to-A embolism group (75% versus 21.1%; p<0.001). In the A-to-A embolism patients, two thirds of HIPs were located adjacent to the lumen and one third of HIPs were located within the plaque (Figure 1).

Figure 1. Different types of hyperintense plaques (HIPs) and plaque surface. High-resolution magnetic resonance imaging (HRMRI) demonstrated HIPs with hyperintense areas (arrow) located adjacent to the lumen (A)/within the plaque (B) and irregular (C)/regular (D) plaque surface (arrowhead).

Kristin Miller, MD

Merkler AE, Gialdini G, Lerario MP, Parikh NS, Morris NA, Kummer B, et al. Population-Based Assessment of the Long-Term Risk of Seizures in Survivors of Stroke. Stroke. 2018

Post-stroke seizures are a well-described potential complication of stroke. However, the long-term risk of seizures in stroke survivors in relation to the characteristics of stroke subtypes and demographics has not been fully explored. Authors Merkler et al endeavored to explore this particular long-term risk in a large, multistate retrospective review using administrative claims data and Medicare claims data.

Using ICD-9 codes from multistate claims data for ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), the investigators identified 777,276 patients who were hospitalized with an index stroke. Among those patients, 45,708 (5.88%) developed a new seizure with an annual incidence of 1.68% in the all-stroke group compared to 0.15% in the general population. The annual incidence of seizures and the cumulative rate of seizures were highest in ICH subtypes. Younger patients (<65 years) and nonwhite patients were more likely to develop seizures after stroke. A similar pattern was seen when analyzing Medicare beneficiary claims data in 81,984 patients; however, there was no difference in the annual incidence of post-stroke seizure based on race and no analysis was performed on age (due to the age of Medicare patients).