American Heart Association

Monthly Archives: December 2018

When More Isn’t More: Increasing Stent Retriever Passes Associated with Futile Recanalization

Kat Dakay, DO

Baek J-H, Kim BM, Heo JH, Nam HS, Kim YD, Park H, et al. Number of Stent Retriever Passes Associated With Futile Recanalization in Acute Stroke. Stroke. 2018

Mechanical thrombectomy has been recognized as the standard of care in acute ischemic stroke due to proximal large vessel occlusion. However, despite best efforts, it is not always successful: According to the authors, about 20-30% of clots are refractory to stent retriever thrombectomy. However, even if the vessel is eventually recanalized, the patient may still not necessarily have a favorable outcome, often termed “futile recanalization”; rates of futile recanalization vary widely depending on the definition used. Additionally, there are risks to a long and complex thrombectomy procedure in cases with refractory clots. In this article, the authors examine the number of stent retriever attempts, or passes, as a marker for futile recanalization.

In this multicenter, retrospective study [1], patients with a proximal anterior circulation large vessel occlusion treated with stent retriever thrombectomy were included. Additionally, patients needed to have an NIHSS of 4 or greater and be treated within 10 hours of last known well. The number of stent retriever passes required to achieve successful recanalization of TICI 2b or 3 was measured. A total of 467 patients were included in the study, with a median age of 67.3 years, median NIHSS of 15, and median ASPECTS of 8. The median number of stent retriever passes was 2, although rates ranged from 1 to 7.

Transthoracic Echocardiography: Can We Eliminate Unnecessary Testing?

Robert W. Regenhardt, MD, PhD
@rwregen

Yaghi S, Chang AD, Cutting S, Jayaraman M, McTaggart RA, Ricci BA, et al. Troponin Improves the Yield of Transthoracic Echocardiography in Ischemic Stroke Patients of Determined Stroke Subtype. Stroke. 2018

Throughout my training, I have had several mentors dissuade me from ordering tests that are unlikely to change management during the admission of patients with ischemic stroke. Transthoracic echocardiography (TTE) is one of the studies that is not uncommonly cut, especially if the stroke etiology is clear without it. Indeed, the recent 2018 American Heart Association guidelines do not mandate TTE, but recommend the clinician use his or her judgement. This recent article in Stroke by Yaghi et al. set out to test the yield of TTE in these patients and the utility of troponin levels to improve its yield. They examined 578 patients (mean age 74) admitted to their single center over an 18-month period with ischemic stroke “whose etiologic subtype could be obtained without the need for TTE.” Of these patients, TTE changed clinical management in 11.1%, but identified intracardiac thrombus in only 0.7%. The authors also identified an association between positive troponin levels and TTE changing management (adjusted OR 4.26, 95% CI 2.17-8.34, P<0.001).

By |December 5th, 2018|clinical|0 Comments

In Search of an IV-tPA Biomarker for LVO

Richard Jackson, MD

Yoo J, Baek J-H, Park H, Song D, Kim K, Hwang IG, et al. Thrombus Volume as a Predictor of Nonrecanalization After Intravenous Thrombolysis in Acute Stroke. Stroke. 2018

Now that endovascular thrombectomy has been shown to be beneficial in large vessel occlusions, there is a question of distribution of resources and triage of patients. Yoo et al. recognized this need and began to look at a possible imaging biomarker for response to IV-tPA.

They began with a retrospective analysis of a CT-based thrombus cohort of 214 patients from three university hospitals between 2006 and 2009. Mean thrombus volume was found to be 129mm3 and density 53.5 HU with a median time to tPA of 52 minutes. Of the 214 patients, 162 (76%) failed to re-canalize, which was defined as TICI grade 1-2a. Using statistical analysis, the upper range of the calculated reference range was 181.9 mm3 thrombus volume, and, therefore, a cut-off volume of 200mm3 was determined to be optimal to predict non-recanalization.

Are Aphasia and Visual Neglect Good Prehospital Predictors for Large Vessel Occlusion in Acute Stroke?

Kara Jo Swafford, MD

Beume L-A, Hieber M, Kaller CP, Nitschke K, Bardutzky J, Urbach H, et al. Large Vessel Occlusion in Acute Stroke: Cortical Symptoms Are More Sensitive Prehospital Indicators Than Motor Deficits. Stroke. 2018

A simple yet sensitive tool that can be applied in the prehospital setting to identify patients with an acute stroke due to large vessel occlusion (LVO) would be a helpful aid to optimize selection of candidates for mechanical thrombectomy (MT) who would benefit from direct transport to a Comprehensive Stroke Center (CSC). Most screening assessments focus on motor deficits, which can be related to lesions in the internal capsule, motor cortex or brainstem and be due to either small vessel disease or LVO. Cortical symptoms, such as aphasia and visuo-spatial neglect, may be better predictors of LVO.

Beume et al. performed a single-center retrospective analysis of patients arriving within 4.5 hours of stroke symptom onset. To represent the prehospital setting, those with acute ischemic stroke, transient ischemic attack, intracranial hemorrhage and stroke mimics were included. Aphasia was assessed by asking patients to name an object, follow verbal commands and produce spontaneous speech. Visuo-spatial neglect was evaluated by testing of conjugate horizontal eye movements and presence of gaze and/or head deviation. Patients had cerebrovascular imaging to screen for presence of LVO.

By |December 3rd, 2018|clinical|0 Comments