American Heart Association

Monthly Archives: December 2018

The Association of C-Reactive Protein and Amyloid Blood Biomarkers with Advanced Imaging Markers

Lin Kooi Ong, PhD
@DrLinOng

Hilal S, Ikram A, Verbeek MM, Franco OH, Stoops E, Vanderstichele H, et al. C-Reactive Protein, Plasma Amyloid-β Levels, and Their Interaction With Magnetic Resonance Imaging Markers. Stroke. 2018

The Rotterdam Study is a population-based prospective cohort study among middle age and elderly persons living in the Ommoord district in the city of Rotterdam, the Netherlands. In this study, Hilal et al. examined whether the levels of plasma C-reactive protein (CRP), an inflammation marker, are associated with Magnetic Resonance Imaging (MRI) markers such as lacunes, white matter hyperintensities, cerebral microbleeds, perivascular spaces, and atrophy of brain structures in a population of 2814 participants. Hilal and colleagues then measured the levels of plasma amyloid- β (Aβ) isoforms in a subsample of 736 individuals, and examined their interaction with CRP levels and MRI markers. The team observed higher levels of plasma CRP were associated with higher lacunar counts, larger volume of white matter hyperintensities, changes in microbleed counts, enlarged perivascular space and reduced gray matter volume. Further, the team found that effects such as lacunar counts, enlarged perivascular space and microbleed counts were augmented by an interaction between CRP and Aβ levels.

Large Analysis Confirms Poor Outcome of Intracerebral Hemorrhage in Patients on Treatment with Antiplatelets and Vitamin K Antagonists

Raffaele Ornello, MD

Sprügel MI, Kuramatsu JB, Gerner ST, Sembill JA, Beuscher VD, Hagen M, et al. Antiplatelet therapy in primary spontaneous and oral anticoagulation–associated intracerebral hemorrhage. Stroke. 2018

The exact effect of antiplatelet therapy (APT) on the characteristics and outcome of intracerebral hemorrhage (ICH) is interesting especially among patients treated with oral anticoagulation (OAC).

The present pooled analysis of two retrospective cohort studies and a prospective single-center study assessed the influence of APT on the characteristics and functional outcome of ICH in patients with primary spontaneous ICH, vitamin K antagonist (VKA)-associated ICH, and non-VKA-OAC (NOAC)-associated ICH. Compared with patients with VKA-associated ICH not under APT, those with VKA-associated ICH under APT had a lower proportion of 3-month favorable outcome, defined as modified Rankin Scale scores 0-3, higher 3-month mortality, and larger hematoma volume; on the other hand, APT did not influence the characteristics and outcome of ICH among patients with primary spontaneous or NOAC-associated ICH.

Stroke Mechanism Suggested by Thrombus Permeability on CT Angiography

Kara Jo Swafford, MD

Berndt M, Friedrich B, Maegerlein C, Moench S, Hedderich D, Lehm M, et al. Thrombus Permeability in Admission Computed Tomographic Imaging Indicates Stroke Pathogenesis Based on Thrombus Histology. Stroke. 2018

Mechanical thrombectomy for treatment of an acute ischemic stroke caused by a large vessel occlusion provides the possibility of histological study of the thrombus, which is composed of fibrin, platelets, red blood cells and white blood cells. Higher fibrin content is associated with a cardiogenic origin. Clot permeability or perviousness depends on its constituents and can be assessed by the quantity of contrast present within the thrombus on CT angiography (CTA).

Berndt et al. assessed the correlation between the histological composition of clot retrieved by mechanical thrombectomy and the perviousness of the clot on CTA. They hypothesized that clot perviousness could assist in determining the stroke pathogenesis, guiding clinical decisions related to secondary stroke prevention. They found that permeable thrombi consist of mainly fibrin-platelet conglomerations and fewer red blood cells and were associated with cardioembolic stroke. Conversely, they found that lower perviousness was associated with thrombi containing mostly red blood cells and were most likely of noncardioembolic origin.

Accuracy vs. Reproductibility in the National Institutes of Health Stroke Scale: When the NIHSS Does Not Assess All the Symptoms

Elena Zapata-Arriaza, MD
@ElenaZaps

Eskioglou E, Huchmandzadeh Millotte M, Amiguet M, Michel P. National Institutes of Health Stroke Scale Zero Strokes: Immeasurable but Not Innocent. Stroke. 2018

The National Institutes of Health Stroke Scale (NIHSS) is the most widely employed deficit rating scale in modern neurology and has became the gold standard for stroke severity rating in recent published clinical trials. However, it is essential to know that the scale was not designed to serve as a bedside rating tool for widespread use outside of research trials. The goal of NIHSS is to assure reproducibility, not accuracy.

The authors performed a retrospective analysis of all acute ischemic stroke patients admitted to the stroke unit and intensive care unit of the Lausanne University Hospital from 2003 to 2013. The main goal of this paper was to highlight the characteristics of ischemic strokes with a NIHSS = 0, as well as to determine the long-term evolution of these patients. The originality of the paper is the aim itself, which makes us wonder whether the NIHSS is a sufficiently accurate scale to determine the severity of all ischemic strokes. The authors included all patients with a suspected stroke according to the classical World Health Organization definition. The sample was divided between NIHSS=0 and NIHSS > or equal to 1, and brain and vascular state was assessed mostly by computed tomography. During follow-up, mortality, stroke or transient ischemic attack recurrence and functional outcome (3 and 12 months) were collected.

By |December 19th, 2018|clinical|0 Comments

Direct Transfer to Angio-Suite May Improve the Outcome of Large Vessel Occlusion Ischemic Stroke

Raffaele Ornello, MD

Mendez B, Requena M, Aires A, Martins N, Boned S, Rubiera M, et al. Direct Transfer to Angio-Suite to Reduce Workflow Times and Increase Favorable Clinical Outcome: A Case-Control Study. Stroke. 2018

Direct transfer to angio-suite (DTAS) of patients with suspected large vessel occlusion (LVO) ischemic stroke selected before hospital admission may reduce the times and improve the outcomes of endovascular treatment (EVT).

The authors of the present single-center case-control study compared the EVT times and outcomes of 76 patients with LVO and DTAS with those of 145 matched control patients with LVO and no DTAS. Compared with the non-DTAS group, the DTAS group had a 38 minutes shorter time from symptom to recanalization, a 13% increased probability of favorable outcome (modified Rankin Scale score of 0–2) at 90 days, and similar rates of clinical worsening and symptomatic intracranial hemorrhage after EVT.

By |December 18th, 2018|clinical|0 Comments

Thrombectomy is Successful, and the Artery is Open. Should I Worry About Reperfusion Injury?

Mohammad Anadani, MD

Gauberti M, Lapergue B, Martinez de Lizarrondo S, Vivien D, Richard S, Bracard S, et al. Ischemia-Reperfusion Injury After Endovascular Thrombectomy for Ischemic Stroke. Stroke. 2018

Ischemic reperfusion injury after flow restoration is an extensively studied but not well-understood phenomena. The prominent mechanism of reperfusion injury is a molecular (non-ischemic) cell death in the absence of circulatory disturbance. Preclinical studies demonstrated that reperfusion injury is responsible for up to 70% of the infarct volume; therefore, it can be hypothesized that restoring reperfusion with mechanical thrombectomy in humans could lead to infarct expansion and worsening ischemic injury. There is overwhelming evidence that supports the direct association between degree of reperfusion after mechanical thrombectomy with functional independence. In fact, complete reperfusion (mTIC=3) was associated with better outcome than successful but incomplete reperfusion (mTICI >=2b).1

In this study, Gauberti and colleagues underwent a post-hoc analysis of the ASTER trial to investigate the effect of complete reperfusion on early lesion growth. Patients were included in this study if they achieved complete reperfusion at the end of the procedure (defined as modified Treatment in Cerebral Ischemia score=3) and had MRI pre- and post-mechanical thrombectomy. Patients with hemorrhagic transformation (hemorrhagic infarction type 2 or any parenchymal hemorrhage) were excluded from this study. The authors measured the ischemic lesion size on DWI both before and at day 1 after endovascular treatment.

By |December 17th, 2018|clinical|0 Comments

SSRIs after Ischemic Stroke: Not Exactly a Magic Pill

Bahar M. Beaver, MD

Kraglund KL, Mortensen JK, Damsbo AG, Modrau B, Simonsen SA, Iversen HK, et al. Neuroregeneration and Vascular Protection by Citalopram in Acute Ischemic Stroke (TALOS): A Randomized Controlled Study. Stroke. 2018

The issue of whether SSRIs are beneficial in overall post-stroke recovery is a yet unsettled question. The FLAME (Fluoxetine for Motor Recovery after Acute Ischemic Stroke) study in 2011 demonstrated that fluoxetine may help with improved motor recovery 3 months after stroke. However, the small sample size (118) was only one of many limitations of that trial. The authors of the TALOS study, published in the November issue of Stroke, set out to evaluate another SSRI (citalopram) and its effects on post-stroke recovery. In this double-blind, randomized, placebo-controlled study, 642 patients with ischemic stroke were randomly assigned to either citalopram 20mg (or 10mg if clinically indicated) or placebo once daily for 6 months. Study medication was started within 7 days after last known normal. Patients were followed for a total of 6 months using both in-person clinical evaluations and phone interviews. In the final analysis population, the citalopram group consisted of 268 patients, and the placebo group consisted of 284 patients. The mean age was 68 in both groups. The mean mRS score was 0.3 in each group. The mean NIHSS score was 5.3 in the citalopram group, and 4.8 in the placebo group.

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

Evaluation and Treatment Issues of a Cancer-Related Stroke Patient

Lina Palaiodimou, MD

Neilson LE, Rogers LR, Sundararajan S. Evaluation and Treatment of a Patient with Recurrent Stroke in the Setting of Active Malignancy. Stroke. 2018

This article by Neilson et al. reports a case of a 75-year-old female patient presenting with multiple ischemic lesions with temporal dispersion and localization in multiple arterial territories. The patient was newly diagnosed with lung cancer, more specifically mucinous adenocarcinoma, found randomly in MRI of cervical spine, which was performed as part of differential diagnosis of transient left arm weakness and numbness. Smoking was reported as a predisposing factor for lung cancer, as well as ischemic stroke.

NAVIGATE Through the Current Treatment Options in Secondary Stroke Prevention of ESUS Patients with Patent Foramen Ovale

Aristeidis H. Katsanos, MD, PhD

Kasner SE, Swaminathan B, Lavados P, Sharma M, Muir K, Veltkamp R, et al. Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. Lancet Neurol. 2018

NAVIGATE ESUS was a double-blinded, randomized, phase 3 clinical trial comparing rivaroxaban 15mg to aspirin 100mg in the secondary stroke prevention of patients with embolic strokes of undetermined source (ESUS). In the present pre-specified subgroup analysis, NAVIGATE ESUS Investigators assessed further the safety and efficacy of rivaroxaban 15mg to aspirin 100mg in ESUS patients with patent foramen ovale (PFO). PFO was uncovered in a total of 534 patients (7.4% of the total NAVIGATE ESUS trial population) after investigation with either transthoracic or transesophageal echocardiography.

After a mean follow-up of 11 months, ESUS patients with PFO randomized to rivaroxaban treatment were found to have a half, although non-statistically significant, risk for stroke recurrence compared to ESUS patients with PFO randomized to aspirin treatment (hazard ratio=0.54; 95%CI: 0.22–1.36). Interestingly, the treatment effect of rivaroxaban was found to be more pronounced in patients over 60 years of age, which were excluded from the majority of trials on PFO closure. However, rivaroxaban treatment was associated with a double, although again non-statistically significant, risk of major bleeding compared to aspirin (hazard ratio=2.05; 95% CI: 0.51–8.18).

Transcranial Doppler Helps with Understanding of Cerebral Hemodynamics After Endovascular Recanalization

Victor J. Del Brutto, MD

Kneihsl M, Niederkorn K, Deutschmann H, Enzinger C, Poltrum B, Horner S, et al. Abnormal Blood Flow on Transcranial Duplex Sonography Predicts Poor Outcome After Stroke Thrombectomy. Stroke. 2018

Early recanalization with mechanical thrombectomy gives stroke patients with large vessel occlusion the best chance to achieve a good functional outcome. Successful angiographic reperfusion as determined by a good TICI score implies restoration of cerebral blood flow to ischemic tissue, thus preventing neuronal death, which result in a better functional recovery after stroke. However, this happy ending story could be distorted in the post interventional course by abnormal cerebral hemodynamics including no-reflow phenomena, vessel reocclusion, focal vessel stenosis, or hyperperfusion with high risk of hemorrhagic conversion.

By |December 10th, 2018|clinical|0 Comments