American Heart Association

Monthly Archives: August 2018

Association of Renal Impairment and Cerebral SVD is Exclusive for Younger Individuals After Adjusting for Vascular Risk Factors: Genetic Predisposition or a Separate Vascular Entity?

Victor J. Del Brutto, MD

Liu B, Lau KK, Li L, Lovelock C, Liu M, Kuker W, et al. Age-Specific Associations of Renal Impairment With Magnetic Resonance Imaging Markers of Cerebral Small Vessel Disease in Transient Ischemic Attack and Stroke. Stroke. 2018

In this article, Bian Lui and colleagues assessed the association of renal impairment with imaging markers of small vessel disease (SVD). As shown in previous studies, small vessel disease usually coexists with renal damage and it has generally been considered that this association is related to simultaneous damage of both the cerebral and the renal microvasculature. The authors presented the results of a population-based study in which they studied age-specific associations of renal impairment and SVD burden adjusting for demographics and traditional vascular risk factors including premorbid blood pressure.

The study was conducted using the Oxford Vascular Study registry from Oxfordshire, United Kingdom. The analysis included 1028 patients with a transient ischemic attack or minor brain infarct that underwent brain MRI and baseline renal function measurement. Patients with systemic vasculitis, CADASIL and Fabry’s disease were excluded. The burden of SVD was determined by the presence of lacunar infarctions, cerebral microbleeds, enlarged basal ganglia perivascular spaces and white matter hyperintensities on brain MRI. Renal impairment was defined by an eGFR <60 mL/min per 1.73 m2. Remarkably, the authors used the premorbid creatinine within a year to avoid the influence of a recent vascular event in the measurement of baseline renal function.

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

Article Commentary: “Virtual Reality for Stroke Rehabilitation”

Burton J. Tabaac, MD
@BurtonTabaac

Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty MC. Virtual Reality for Stroke Rehabilitation. Stroke. 2018

This review examined the efficacy of virtual reality, compared with an alternative intervention or no intervention, on upper limb function and activity. The publication is an update of the authors’ review first published in 2011 and then revised in 2015. The initial review, published in 2011, identified only 19 studies. For this iteration, 11 databases and trial registries were searched, including randomized and quasi-randomized trials of virtual reality in adults after stroke. A total of 72 trials (with 2470 participants) were included in the review.

While most recovery after stroke is thought to be made in the first few weeks, patients may make improvements on functional tasks many months after having a stroke. Prior research has shown that repetitive task training is effective in some aspects of rehabilitation, such as improving walking distance and speed and improving upper limb function. Virtual reality is a relatively recent approach that may enable simulated practice of functional tasks at a higher dosage than traditional therapies. Virtual reality has been defined as the “use of interactive simulations created with computer hardware and software to present users with opportunities to engage in environments that appear and feel similar to real-world objects and events.”

By |August 6th, 2018|clinical|0 Comments

More Than Meets the MRI: Texture Analysis Shows Normal Appearing White Matter is Not So Normal in SVD, Predicts Cognitive Impairment and Decline

Danny R. Rose, Jr., MD

Tozer DJ, Zeestraten E, Lawrence AJ, Barrick TR, Markus HS. Texture Analysis of T1-Weighted and Fluid-Attenuated Inversion Recovery Images Detects Abnormalities That Correlate With Cognitive Decline in Small Vessel Disease. Stroke. 2018

Cerebral small vessel disease (SVD) is a well-established but relatively poorly understood cause of lacunar stroke and vascular dementia. While the complex structural changes underpinning this disease process have yet to be fully elucidated, several MRI imaging markers have been identified in association with SVD, including white matter hyperintensities (WMH), cerebral microbleeds, and evidence of lacunar infarction. While these imaging markers have been useful in assessing severity of disease, they are less strongly associated with cognitive impairment. One particular area of interest as further imaging research into SVD has progressed is the so-called “normal appearing white matter” (NAWM), specifically the areas of white matter on traditional MRI that do not show the typical T2/FLAIR hyperintense changes.

Safety and Efficacy of Intravenous Thrombolysis for Non-Disabling Strokes Through the PRISM: “Primum Non Nocere” vs. “Remorseful Regretting”

Aristeidis H. Katsanos, MD, PhD

Khatri P, Kleindorfer DO, Devlin T, Sawyer Jr. RN, Starr M, Mejilla J, et al. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. JAMA. 2018

The Potential of rtPA for Ischemic Strokes With Mild Symptoms (PRISMS) trial was designed as a phase 3, randomized, double-blind clinical trial with the aim to test the safety and efficacy of intravenous thrombolysis (IVT) administered within 3 hours of symptom onset in acute ischemic stroke (AIS) patients with mild, non-disabling neurological deficits [baseline National Institutes of Health Stroke Scale (NIHSS) score equal or less than 5]. The study was prematurely terminated by the sponsor (Genentech Inc.) after recruitment of 313 patients (one third of the initially planned sample size) due to low recruitment rates. Data analysis revealed comparable 3-month favorable functional outcome [FFO, defined as modified Rankin Scale (mRS) score of 0 or 1] rates between patients receiving IVT and aspirin (78.2% vs. 81.5%; adjusted absolute risk difference: -1.1%; 95%CI: -9.4% to 7.3%) and functional improvement in the ordinal analysis of mRS scores at 3-months (OR: 0.81; 95% CI: 0.5 to 1.2). However, patients randomized to IVT had increased sICH rates within 36 hours following rtPA bolus (3.2% vs. 0%; absolute risk difference: 3.3%; 95% CI: 0.8% to 7.4%) and serious adverse events (26.0% vs. 13.1%;  absolute risk difference: 12.9%, 95% CI: 4.1 to 21.7%), when compared to antiplatelet treated patients.

By |August 1st, 2018|clinical|1 Comment