American Heart Association

Monthly Archives: January 2019

Head of the Bed Flat: What is the Big Deal?

Victor J. Del Brutto, MD

Anderson CS, Olavarría VV. Head Positioning in Acute Stroke: Down but Not Out. Stroke. 2018;50:224–228.

Early in my neurology training, two cases changed my perspective on the importance of patients’ head positioning during the acute phase of cerebral ischemia. The first was a man in his 60s who presented with a right MCA syndrome associated with an acute occlusion of the ipsilateral cervical ICA. When the patient was transitioned to the CT scan table (flat positioning), initial left homonymous hemianopia, left hemi-neglect, left hemiplegia, and right gaze deviation (NIHSS 17) resolved, leaving just a residual left face droop and left arm drift (NIHSS 3). Once the patient was back to the ED, and despite a constantly elevated blood pressure, the variations on his exam associated with the head of bed flat versus elevated was reproducible.

A few weeks later, I was called to evaluate a lady on her eighth decade of life who developed acute onset right-sided weakness. Initial examination showed right ataxic hemiparesis (NIHSS 4). Brain MRI and MR angiogram showed a tiny DWI-positive lesion on the left ventral pons, as well as diffuse intracranial atherosclerosis including a narrow basilar artery. The patient was loaded with antiplatelet agents and admitted to the Stroke Unit. During the wait time in the ED, the patient stood up from the bed in an attempt to go to the bathroom. According to the nurse report, when the patient stood up, she immediately developed right hemiplegia and right gaze preference. On re-examination, the new worsening deficits persisted (NIHSS 11), and a repeated brain MRI showed progression of the infarct involving now the whole left paramedian pons.

By |January 30th, 2019|clinical|0 Comments

The Added Value of CTA Spot Sign for Prediction of Intracerebral Hemorrhage Expansion

Andrea Morotti, MD

Al-Shahi SR, Frantzias J, Lee RJ, Lyden PD, Battey TWK, Ayres AM, et al. Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. Lancet Neurol. 2018;17:885–894.

Intracerebral Hemorrhage (ICH) expansion is common, independently associated with poor outcome and potentially preventable, representing, therefore, an appealing target for acute ICH treatment.

In this large (n = 5435) meta-analysis of individual patient data,1 the authors identified the following four independent predictors of ICH expansion: time from symptom onset to baseline non-contrast CT (NCCT) (odds ratio 0.50, p<0∙0001), baseline hematoma volume (odds ratio 7.18, p<0∙0001), antiplatelet treatment (odds ratio 1.68, p=0∙026), and anticoagulant use (3.48, p<0∙0001). These predictors had a good discrimination for hematoma expansion (c statistic 0.78). A small proportion (around 16%) of the included patients had CT angiography (CTA) images available for spot sign detection. In this subgroup, the presence of spot sign provided a small but significant additional diagnostic value compared to a model based only on the four predictors described above (c statistic 0.83).

By |January 29th, 2019|clinical|0 Comments

Article Commentary: “Comparative Effectiveness of Aspirin and Clopidogrel Versus Aspirin in Acute Minor Stroke or Transient Ischemic Attack”

Philip Chang, MD

Kim J-T, Park M-S, Choi K-H, Cho K-H, Kim BJ, Park J-M, et al. Comparative Effectiveness of Aspirin and Clopidogrel Versus Aspirin in Acute Minor Stroke or Transient Ischemic Attack. Stroke. 2018;50:101–109.

In this study, Kim et al. studied and replicated the CHANCE protocol in stroke patients via a prospective registry database in South Korea. Patients were enrolled with acute minor stroke defined as NIHSS≤3 or lesion positive TIA with a non-cardioembolic stroke mechanism based on imaging. Among the 5590 patients enrolled, they found that combination of clopidogrel-aspirin had significantly less major adverse cardiac events compared to aspirin alone (14% vs 10%, p=0.008). This was mostly due to significantly reduced risk of stroke in the 90-day follow-up period in the dual antiplatelet group (13% vs 9%, p=0.008). This would be another confirmation of the validity of early dual antiplatelet therapy in reducing recurrent stroke risk. With the publication of CHANCE and POINT, along with all this subsequent data, I suspect there will be a change in guideline recommendations to more strongly encourage early use of dual antiplatelet therapy in minor strokes. They did 6 per-defined subgroup analyses, among which showed lesser benefit associated if people were already on antiplatelet therapy, were >75 years of age, and had a non-small vessel disease stroke mechanism.

By |January 28th, 2019|clinical|0 Comments

(Re)affirming the Importance of Kidney Function in Ischemic Stroke Outcomes

Raffaele Ornello, MD

El Husseini N, Fonarow GC, Smith EE, Ju C, Sheng S, Schwann LH, et al. Association of Kidney Function With 30-Day and 1-Year Poststroke Mortality and Hospital Readmission: Get With The Guidelines-Stroke. Stroke. 2018

Several reports indicate that abnormal kidney function is an important predictor of poor outcome in patients with stroke; however, those previous reports included relatively few patients or did not stratify the outcomes according to the stage of kidney disease.

In the present cohort study of 204,652 patients included in the Get With The Guidelines registry, the authors found a correlation between the estimated glomerular filtration rate and 30-day and 1-year poststroke mortality or hospital readmission, with the poorest prognosis in patients with end-stage kidney disease, after adjusting for demographic characteristics and a wide set of vascular risk factors. Although not considering the impact of acute treatments for ischemic stroke, the data of the present study strongly reaffirm the importance of assessing kidney function to predict ischemic stroke outcomes and suggest the possibility of including the estimated glomerular filtration rate in stroke prognostic models.

By |January 25th, 2019|clinical|0 Comments

The Tale of High Cortisol Levels, Shrinking Brain and Cognitive Impairment Among Adults in Their 40s

Lin Kooi Ong, PhD
@DrLinOng

Echouffo-Tcheugui JB, Conner SC, Himali JJ, Maillard P, DeCarli CS, Beiser AS, et al. Circulating cortisol and cognitive and structural brain measures: The Framingham Heart Study. Neurology. 2018

Chronic stress has been shown to have detrimental effects on the brain structure and functions in pre-clinical studies. These negative effects are partially attributable to the hypothalamic-pituitary-adrenal axis dysregulation indexed by high cortisol levels. However, there are limited human studies in general population. In this study, Echouffo-Tcheugui et al. used data from the Framingham Heart Study, a large community-based study, to examine the association of early morning serum cortisol with cognitive performance including memory, abstract reasoning, visual perception, attention and executive function in a population of 2231 young and middle-aged adults (mean age 48.5 years) without dementia. Brain Magnetic Resonance Imaging (MRI) was performed on eligible 2018 individuals for volume of brain structures, and integrity of white matter and gray matter. Interestingly, the team observed higher levels of serum cortisol were significantly associated with lower total cerebral brain and occipital and frontal lobar gray matter volumes, as well as poorer cognitive performance in memory and visual perception, with the association being prominent in women. Further, the team identified that higher cortisol was associated with decreased integrity of the white matter tracts.

By |January 22nd, 2019|clinical|0 Comments

Early Reocclusion after Mechanical Thrombectomy: Prevalence, Predictors, and Impact on Long-Term Outcome

Sami Al Kasab, MD

Mosimann PJ, Kaesmacher J, Gautschi D, Bellwald S, Panos L, Piechowiak E, et al. Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients. Stroke. 2018

Mechanical thrombectomy (MT) is now the standard of care for patients presenting with anterior circulation LVO, who otherwise have small core infarct defined by ASPECTS score or perfusion scans admission. Rapid and complete revascularization have been shown to predict good functional outcome. Data on the rate of early revascularization are scares. In this article, Mosimann et al. evaluate the prevalence and predictors of early reocclusion following successful MT and its impact on long-term functional outcome.

A total of 711 patients were included in this study; all patients underwent MT and had revascularization score of TICI2b or 3 at the end of the procedure; intravenous thrombolysis was administered when indicated. Post-thrombectomy care was performed according to the standard institutional guidelines. Etiology for stroke was documented according to the TOAST classification system. Early reocclusion was defined as reocclusion seen on CTA or MRA during the first 48 hours following MT.

By |January 18th, 2019|clinical|0 Comments

Intracranial Carotid Artery Calcification and Effectiveness of Endovascular Thrombectomy and Functional Outcome in Acute Ischemic Stroke

Kara Jo Swafford, MD

Compagne KCJ, Clephas PRD, Majoie CBLM, Roos YBWEM, Berkhemer OA, van Oostenbrugge RJ, et al. Intracranial Carotid Artery Calcification and Effect of Endovascular Stroke Treatment: MR CLEAN Subgroup Analysis. Stroke. 2018

Endovascular thrombectomy (EVT) is an effective treatment for patients with acute ischemic stroke caused by a large vessel occlusion. The pattern and quantity of intracranial carotid artery calcification (ICAC) may influence the effectiveness of EVT and functional outcome. There are two recognized patterns of ICAC: intimal and medial calcification patterns. Compagne et al. performed a post hoc analysis of data from MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment of Acute ischemic stroke in the Netherlands) investigating the effect of ICAC volume and pattern on treatment success and functional outcome. Intervention and control groups were included.

There was no modification of the EVT treatment effect by ICAC volume, and no association between ICAC volume and functional outcome. There, however, was a treatment effect modification by ICAC pattern (P interaction=0.04). Patients with a medial ICAC pattern had larger infarct volumes and poorer outcomes in the control group, but tended to benefit more from EVT compared to patients with an intimal ICAC pattern. One explanation for a greater EVT treatment effect in patients with a medial calcification pattern is that this pattern can lead to arterial stiffening, causing impaired regulation of distal flow and development of microcollaterals. Another proposed explanation is that the thrombus is different in patients with intimal versus medial calcifications and EVT is not as effective in removing thrombus in those with an intimal calcification pattern.

By |January 16th, 2019|clinical|0 Comments

Hemoglobin A1C and Clinical Outcomes After Thrombectomy

Robert W. Regenhardt, MD, PhD
@rwregen

Choi K-H, Kim J-H, Kang K-W, Kim J-T, Choi S-M, Lee S-H, et al. HbA1c (Glycated Hemoglobin) Levels and Clinical Outcome Post-Mechanical Thrombectomy in Patients With Large Vessel Occlusion. Stroke. 2018

Mechanical thrombectomy has revolutionized the acute care of patients suffering from stroke secondary to large vessel occlusions. With its proven efficacy up to 24 hours after stroke onset, current research endeavors include broadening the inclusion criteria for this powerful therapy, preventing complications such as reperfusion injury, and increasing favorable outcomes after successful recanalization. Admission hyperglycemia is a known predictor of poor outcomes and increased mortality in patients suffering from acute stroke, including those treated with intravenous thrombolysis and mechanical thrombectomy.

This recent manuscript by Choi et al. published in Stroke analyzed relationships between hemoglobin A1C (HbA1C), a marker of average blood glucose during the preceding 3 months, and clinical outcomes after thrombectomy. The authors examined HbA1C in 534 patients with acute ischemic stroke from large vessel occlusions that underwent thrombectomy in a prospective cohort study. The primary outcome was disability (mRS) at 3 months. Secondary outcomes included 3-month mortality. In addition, several other outcomes were examined within the first 7 days: intracranial hemorrhage, early neurologic deterioration (worsening by ≥2 NIHSS points), and early clinical improvement (by ≥4 NIHSS points).

By |January 15th, 2019|clinical|0 Comments

A New Tool to Quantify Severity, Extent and Course of Focal Cerebral Arteriopathy of Childhood Could Be Used for Treatment Trials

Alejandro Fuerte, MD
@DrFuerte1

Fullerton H, Stence N, Hills N, Jiang B, Amlie-Lefond C, Bernard T, et al. Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History. Stroke. 2018

Focal cerebral arteriopathy (FCA) of childhood is an acute disease causing unilateral stenosis of the cerebral arteries. It appears to be caused by an inflammatory process, and corticosteroids are used in its treatment in the absence of clinical trial data. Because it is one of the most common causes of arterial ischemic stroke (AIS) in healthy children and it increases the risk of recurrent stroke, a Delphi consensus identified this issue as the highest priority for a clinical trial in the field of childhood stroke.

The main goal of Fullerton et al. was to develop a severity score for this disease (Focal Arteriopathy Childhood Severity Score; FCASS). For this they used data from the VIPS study (Vascular Effects of Infection in Pediatric Stroke), a large, international, prospective cohort study that enrolled 355 children (29 days to 18 years of age) with AIS and collected clinical, imaging data and serum samples.

The ARISTOPHANES Study: Real-World Evidence About Oral Anticoagulants

Lina Palaiodimou, MD

Lip GYH, Keshishian A, Li X, Hamilton M, Masseria C, Gupta K, et al. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients: The ARISTOPHANES Study. Stroke. 2018

The ARISTOPHANES study is a large retrospective observational study with real-world data pooled from 5 data sources in the United States, in order to compare stroke/systemic embolism (SE) and major bleeding (MB) among nonvalvular atrial fibrillation patients treated with either non-vitamin K antagonist oral anticoagulants (NOACs) or warfarin.

The researchers of this study collected data about a total of 321182 patients with a diagnosis of AF, who had an active medical and pharmacy health plan enrollment and were prescribed treatment with either NOAC or warfarin according to pharmacy claims. Exclusion criteria were the following: evidence of valvular heart disease, venous thromboembolism, previous oral anticoagulant treatment, transient AF due to treatable causes (pericarditis, hyperthyroidism, thyrotoxicity), heart valve replacement or transplant, pregnancy and recent surgical operations. Demographic data, Charlson Comorbidity Index score, baseline bleeding and stroke/SE history, comorbidities, baseline comedication and dose of NOAC were recorded about all patients. In contrast, reason for lose-dose NOAC prescription, creatinine clearance, international normalized ratio (INR) measurements in warfarin-treatment group and patient adherence data were not available. The outcome measures were time to stroke (either ischemic or hemorrhagic) or systemic embolism and time to major bleeding, either gastrointestinal or intracranial or at other key sites (eyes, pericardium, urinary tract, joints). Identification of these events were based just on hospitalization incidence with stroke/SE or MB as the principal diagnosis according to International Classification of Diseases, Ninth Revision (ICD-9). Mortality due to all-causes was also evaluated, but just for the patients enlisted in only one out of five data sources. Patients were followed up each for a different period, according to drug discontinuation date, switch to another drug date, death, end of medical and pharmacy health plan enrollment, or end of study period, whichever occurred first. In the conducted sensitivity analysis, the follow-up period was restricted to 1 year, to better achieve balance between the cohorts.