American Heart Association

Monthly Archives: January 2019

TCD Evaluation of Autoregulation as a Predictor of Stroke Functional Outcome

Richard Jackson, MD

Chi N-F, Hu H-H, Wang C-Y, Chan L, Peng C-K, Novak V, et al. Dynamic Cerebral Autoregulation Is an Independent Functional Outcome Predictor of Mild Acute Ischemic Stroke. Stroke. 2018

Nai-Fang Chi et al. published a study on the evaluation of autoregulation in ischemic stroke.  The purpose of this study was to investigate whether dynamic cerebral autoregulation (dCA) indices constitute an independent functional outcome predictor of acute ischemic stroke.

Cerebral autoregulation (CA) regulates vascular tone to compensate hypoperfusion after during ischemia but no concrete guidelines for blood pressure targets are currently known. The impact of cerebral autoregulation is associated with infarct volume but outcome is currently confounded by other comorbid variables. Dynamic cerebral autoregulation (dCA) is a way to quantify CA by analyzing the relationship between transient changes in cerebral blood flow and blood pressure. This study attempted to assess whether resting state dCA was a functional predictor of outcome.

By |January 9th, 2019|clinical|0 Comments

Post-Thrombolysis Recanalization in Patients with Large Vessel Occlusions

Mohammad Anadani, MD

Seners P, Turc G, Naggara O, Henon H, Piotin M, Arquizan C, et al. Post-Thrombolysis Recanalization in Stroke Referrals for Thrombectomy: Incidence, Predictors, and Prediction Scores. Stroke. 2018

Since the publication of the pivotal trials in 2015, mechanical thrombectomy (MT) has become the standard of care for patients with large vessel occlusions. Intravenous thrombolysis (IVT) before MT (bridging therapy) remains the standard of care in eligible patients; however, there is an ongoing debate on the benefit of IVT prior to MT, especially that IVT administration can delay MT, which could be harmful.

In this study, PREDICT-RECANAL investigators conducted a retrospective multicenter study to: 1) determine the incidence and predictors of early recanalization (ER); and 2) develop and validate an ER prediction score.

The derivation cohort included patients from 4 MT-capable centers. Inclusion criteria were: 1) acute stroke due to large vessel occlusion (LVO) of the anterior circulation; 2) patients received IVT; and 3) ER evaluation before MT. The validation cohort consisted of 4 prospectively collected MT databases. MRI was used as first line imaging in this study, and CT/CT angiography was used as a second line in patients with contraindication to MRI. MRIs were reviewed to collect the following variables: 1) occlusion site; 2) length of the susceptibility vessel sign (SVS); and 3) DWI lesion extent using the DWI-ASPECTS. ER was evaluated <=3 hours after initiation of IVT. ER was defined as mTICI (modified Thrombolysis In Cerebral Infarction) 2b-3 for ICA T/L or M1 occlusion and Arterial Occlusive Lesion scale (AOL) 3 for the remaining occlusion sites.

By |January 8th, 2019|clinical|0 Comments

Early Reocclusion: A Predictable Enemy

Elena Zapata-Arriaza, MD
@ElenaZaps

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

Obtaining and maintaining TICI 2b-3 recanalization grade is one of the most important modifiable predictors related to a good functional outcome in stroke patients due to large vessel occlusion.

The authors performed a retrospective analysis obtained prospectively from the institutional Bernese Stroke Registry. All patients with acute ischemic stroke (n=972) treated by mechanical thrombectomy between January 2010 and July 2017 with a Solitaire stent retriever ± distal aspiration catheters were reviewed. The main goal of this paper was to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies. The originality of the paper is the possibility to know the reocclusion rate after a successful thrombectomy in a real-life prospective cohort. In addition, predictors of reocclusion and the relation with clinical outcomes entail an interesting point to predict some cases of futile recanalization. The authors included in the analysis all the patients with successful recanalization grade (TICI 2b-3 score) and magnetic resonance or computed tomography angiography images available at follow-up within 48 hours (N= 711).

By |January 7th, 2019|clinical|0 Comments

Endovascular Thrombectomy Appears to be Effective Treatment for Acute Ischemic Stroke Associated with Cervical Artery Dissection

Muhammad Zeeshan Memon, MD

Li S, Zi W, Chen J, Zhang S, Bai Y, Guo Y, et al. Feasibility of Thrombectomy in Treating Acute Ischemic Stroke Because of Cervical Artery Dissection. Stroke. 2018

Acute ischemic stroke associated with cervical artery dissection is traditionally treated with anticoagulants or antiplatelet agents. However, hyperacute stroke patients with large artery occlusion because of cervical artery dissection may not have good outcomes even if treated with intravenous thrombolysis. The feasibility of thrombectomy in treating acute ischemic stroke because of cervical artery dissection has not been probed well.

In this multicenter study from China, the investigators compared outcomes of 48 patients treated with endovascular treatment matched by propensity score to 48 historical control managed with medical treatment only. Patients were included in the study if they had a large artery occlusion (ICA,M1) which was attributed to cervical artery dissection. The diagnosis of cervical artery dissection was based on typical radiologic characteristics, on magnetic resonance angiography, CT angiography, or digital subtraction angiography. Only patients with thrombectomy performed within 6 hours with stent retrievers were included in the interventional arm. For single artery occlusion, a stent retriever was usually used first; for tandem artery occlusions, priority to treat the proximal or the distal occlusion was decided by the operator depending on the lesion profiles. The authors reported that the proportion of favorable outcome (modified Rankin Scale score of 0–2) was higher in patients with thrombectomy than in those without (66.7% versus 39.6%; P=0.008). There were no significance differences about the incidence of symptomatic intracranial hemorrhage (8.3% versus 4.2%; P=0.677) and the 90-day mortality (10.4% versus 6.3%; P=0.714) between matched patients with and without thrombectomy.

By |January 4th, 2019|clinical|1 Comment

Article Commentary: “A Systematic Literature Review of Patients With Carotid Web and Acute Ischemic Stroke”

Ravinder-Jeet Singh, MBBS, DM

Zhang AJ, Dhruv P, Choi P, Bakker C, Koffel J, Anderson D, et al. A Systematic Literature Review of Patients With Carotid Web and Acute Ischemic Stroke. Stroke. 2018

A carotid web is a fibro-intimal membrane which projects into the lumen of the internal carotid artery immediately after the bifurcation. Histologically an intimal variant of fibromuscular dysplasia, it has characteristic angiographic appearance seen as septum on axial imaging (CTA, MRA or carotid ultrasound) and as a shelf on sagittal reformats of CTA/MRA or lateral projections of catheter angiogram. Although initially considered to be an uncommon cause of stroke, its prevalence was reported to be about 1.2% among unselected consecutive stroke/TIA patients in one CTA-based study to as high as 37% in another study, which included young Afro-Caribbean patients with stroke of cryptogenic etiology in the carotid distribution. Natural history and treatment options for the carotid web are poorly defined.

In the present review, the authors performed a systematic search of the literature on patients with carotid web and acute ischemic stroke to define clinical characteristics, natural history, treatment options and outcome of these individuals.

By |January 2nd, 2019|clinical|0 Comments