Monthly Archives: September 2018

Kevin S. Attenhofer, MD
@KAttenhofer

Le Bouc R, Clarençon F, Meseguer E, Lapergue B, Consoli A, Turc G, et al. Efficacy of Endovascular Therapy in Acute Ischemic Stroke Depends on Age and Clinical Severity. Stroke. 2018

Today, we are seeing a more and more expanded role of endovascular therapy (EVT) in acute ischemic stroke. Despite the ever-growing body of research describing indications for EVT, we continually see patients in practice who do not “fit the mold” of the various trials’ inclusion criteria. Weighing heavily on many stroke practitioners is how to best approach and manage the patient with an apparent large vessel occlusion with a mild corresponding clinical syndrome. How can we predict if these patients will incur more benefit or risk from EVT? While some clinical trials are pending, this observational study describes a prediction score based on age and stroke severity which they called the Stroke Checkerboard (SC) score.

Bahar M. Beaver, MD

Heldner MR, Li L, Lovett NG, Kubiak MM, Lyons S, Rothwell PM. Long-Term Prognosis of Patients With Transient Ischemic Attack or Stroke and Symptomatic Vascular Disease in Multiple Arterial Beds. Stroke. 2018

Patients with ischemic stroke or transient ischemic attack (TIA) due to intracranial atherosclerosis often have disease in other vascular territories within the body. As neurologists, we prescribe secondary preventive agents for these patients following a stroke, in hopes of decreasing their risk for future vascular events. In this article, Mirjam Heldner et al. set out to better delineate the relationship between atherosclerosis in other vascular beds and the intracerebral vasculature and how the number of vascular territories effected impacts patients’ overall risk of recurrent vascular events.

In a population-based study, the authors sampled patients from a pool of 92,728 patients in Oxfordshire, United Kingdom (part of the OXVASC study) who had a stroke or TIA from 2000 to 2014. The authors investigated patients who had symptomatic disease in their coronary and/or peripheral vasculature in addition to their stroke/TIA. Additionally, they compared atherosclerotic risk factors (hypertension, hypercholesterolemia, diabetes, smoking) among patients and correlated these with the severity of systemic vascular disease. These patients underwent thorough clinical evaluation and were followed up at 1, 6, 12, 60, and 120 months for identification of any further vascular events. Statistical analysis compared the number of atherosclerotic risk factors to the number of vascular territories affected, as well as the rate of recurrence or prevalence of symptomatic vascular disease.

Terry Quinn, MD
@DrTerryQuinn

Stroke publishes a regular review of recent, important clinical research from other journals. This Literature Synopses feature is intended for those working in stroke and related fields. However, important science should be shared with everyone who is interested, and not just the experts. When writing the Synopses, I complement the journal article with a plain language summary intended for a non-expert readership. 

You can read the original Synopses article here: Quinn TJ. Stroke Literature Synopses: Clinical Science. Stroke. 2018

Stroke researchers, and indeed clinical researchers in general, are often guilty of focusing on a single aspect of a person’s physiology. Stroke researchers are primarily interested in the brain and its blood vessels, and so we may sometimes forget that those same blood vessels supply all the other organs of the body. People living with stroke rarely have stroke in isolation. In clinical practice, it is common to see a combination of stroke disease, heart disease, and kidney disease.

In this Literature Synopses published in Stroke, I looked at recent research papers that considered stroke and kidney disease together. I specifically chose the topic of kidney disease as it is a common, chronic condition and the number of people with kidney disease is increasing all the time.

Aristeidis H. Katsanos, MD, PhD

Kaesmacher J, Giarrusso M, Zibold F, Mosimann PJ, Dobrocky T, Piechowiak E, et al. Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment. Stroke. 2018

This elegant cohort study from the Bernese Stroke registry provides invaluable data on the prevalence rates and reperfusion quality of acute ischemic stroke patients with large vessel occlusion (LVO) after intravenous tissue-type plasminogen activator (tPA) administration and before endovascular treatment (ET). After analyzing data from a total of 627 LVO patients, the authors found that tPA treatment results in occlusion site changes (defined as any change of the proximal thrombus end between initial imaging and the first angiographic run) in one out of ten LVO patients. Additionally, tPA-induced reperfusion with Thrombolysis in Cerebral Infarction (TICI) scores of ≥2a and ≥2b was found in 6.2% [Number Needed to Treat (NNT): 9] and 2.9% (NNT: 20) of all cases. In multivariable analysis, intravenous tPA was found to be independently related with a 11-fold increase on the likelihood of ≥TICI 2a reperfusion score, while in turn ≥TICI 2a reperfusion score was independently associated with a 2-fold increase on the probability of long-term favorable outcome (modified Rankin Scale ≤2 at three months). Of specific note is that pre-ET reperfusion was found to be associated with more favorable clinical outcomes independently of subsequent ET. However, in proximal occlusions (internal carotid artery or proximal M1) intravenous tPA was found to be associated not only with very low rates of successful recanalization but also with increased likelihood of perfusion worsening.