American Heart Association

Monthly Archives: March 2019

Stent Retriever: Does the Size Really Matter?

Elena Zapata-Arriaza, MD
@ElenaZaps

Zaidat OO, Haussen DC, Hassan AE, Jadhav AP, Mehta BP, Mokin M, et al. Impact of Stent Retriever Size on Clinical and Angiographic Outcomes in the STRATIS Stroke Thrombectomy Registry. Stroke. 2019;50:441–447.

The introduction of stent retriever has involved a great advance in the reperfusion treatment of acute ischemic stroke with large vessel occlusion. Stent retriever has increased procedural success, leading the American Heart Association/American Stroke Association guidelines to recommend the use of stent retrievers for mechanical thrombectomy within 8 hours of symptom onset. However, some concerns related to the safety and efficacy of the stent retriever are maintained regarding its diameter and size.

To answer the question, Zaidat et al. performed a retrospective ad hoc analysis of data from the STRATIS registry (a prospective, multicenter study of patients with large vessel occlusion treated with the Solitaire stent retriever). Main angiographic end points were first-pass effect (FPE), defined as modified thrombolysis in cerebral infarction (mTICI) ≥2c recanalization grade after the first pass without the use of rescue therapy, and rates of modified FPE (mFPE), defined as meeting all criteria for FPE but achieving mTICI ≥2b after first pass. The primary clinical endpoint was functional independence (modified Rankin scale, 0–2) at 3 months as determined on-site. Rates of distal embolization, embolization into new territory, and final mTICI among others were evaluated as well.

By |March 11th, 2019|clinical|0 Comments

The Heart of All Matters: Atrial Cardiopathy

Hatim Attar, MD

The etiologies of cerebral infarcts have always been under scrutiny. As it stands today, about a third of strokes are still cryptogenic. The impact of stroke does not need to be emphasized to the audience of this blog. Despite staggering data with modern technological advances, a significant percentage of stroke patients remain a mystery. The solace is that we have made some advances, wherein I can introduce this hot topic of discussion: atrial cardiopathy.

The term atrial cardiomyopathy was first published in 1972, to describe a familial syndrome affecting the atria and atrioventricular system with resultant rhythm abnormalities. The term has percolated through the years, evolving in its definition. The current definition for atrial cardiopathy, created by the European Heart Rhythm Association, is the most accepted one: any complex structural, architectural, contractile or electrophysiological changes affecting atria with potential to produce clinically relevant manifestations. This suggests that the various markers of atrial cardiopathy include Left Atrium (LA) size, Left Atrial Appendage (LAA) function and morphology, P wave terminal force on EKG, atrial ectopy and serum BNP.

By |March 8th, 2019|clinical|1 Comment

Statins for Chronic Subdural Hematoma

Kat Dakay, DO

Jiang R, Zhao S, Wang R, Feng H, Zhang J, Li X, et al. Safety and efficacy of atorvastatin for chronic subdural hematoma in Chinese patients: A randomized clinical trial. JAMA Neurol. 2018;75:1338-1346. [1]

Statins are a commonly used treatment in patients with hyperlipidemia, coronary artery disease, and ischemic stroke; however, the role of statins in intracranial hemorrhage is less clear. More recently, the role of statins in chronic subdural hematoma has been investigated.

Chronic subdural hematoma increases with aging and represents a clinical challenge; while surgical management with burrhole drainage can be successful, patients can also experience recurrence in approximately 1/3 of cases [2]. Additionally, the risk of surgery may be a concern, particularly in elderly patients or those with medical comorbidities. At this time, there is no clear established medical treatment for chronic subdural hematoma, but statins have been posited as a possible nonsurgical option for treatment of chronic SDH. In this study published in JAMA Neurology, Jiang and colleagues present the results of a randomized controlled trial of low-dose atorvastatin in patients with chronic subdural hematoma [1].

Author Interview: Prof. Turgut Tatlisumak, MD, PhD, on “Nontraumatic intracerebral haemorrhage in young adults”

Prof. Turgut Tatlisumak

Prof. Turgut Tatlisumak

A conversation with Turgut Tatlisumak, MD, PhD, from the Department of Clinical Neuroscience and Neurology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.

Interviewed by Shashank Shekhar (@ArtofStroke), MD, MS, Assistant Professor, Division of Vascular Neurology, University of Mississippi Medical Center.

They will be discussing the article “Nontraumatic intracerebral haemorrhage in young adults,” published in Nature Reviews Neurology.

Dr. Shekhar: First, I would like to thank Prof. Tatlisumak for agreeing to do this interview. This is an interesting review paper in which you have discussed in detail nontraumatic intracerebral hemorrhage (ICH) in young adults. Could you tell the readers why you decided to write about hemorrhage in young adults?

Prof. Tatlisumak: We have long been investigating stroke in young adults, but most of our attention went to ischemic strokes. I wished to extend our research to ICH in young adults and found only few original patient series. Sometime later, I noticed that there is not a single review on this topic, and there is an unmet need. Then we set up a small group of experts sharing the tasks. That is how we started.

Rising Incidence of Stroke in Pregnancy: What’s to Blame?

Kara Jo Swafford, MD

Liu S, Chan W-S, Ray JG, Kramer MS, Joseph KS, and for the Canadian Perinatal Surveillance System (Public Health Agency of Canada). Stroke and Cerebrovascular Disease in Pregnancy: Incidence, Temporal Trends, and Risk Factors. Stroke. 2018;50:13–20.

Stroke is the most common cause of long-term disability in women after pregnancy. In Canada, the incidence of stroke at delivery was 4.8 per 100,000 deliveries between 2003-2007, with an associated case fatality of 9.4%. In the United States, the rate of stroke during the antepartum period increased from 15 to 22 per 100,000 deliveries between 1994-1995 and 2006-2007, with the rate during the postpartum period increasing from 12 to 22 per 100,000 deliveries over the same time period.

Liu et al. investigated the incidence, trends and risk factors associated with stroke in pregnancy in Canada by performing a retrospective population-based cohort study including antenatal, delivery and postpartum admissions within 42 days between 2003-2016. Stroke incidence was 13.4 cases per 100,000 deliveries between 2003-2016; 60% hemorrhagic and 30% ischemic stroke, with a 7.4% case fatality rate. Over half (51.7%) of cases occurred during the postpartum period. The rate of stroke increased from 10.8 to 16.6 cases per 100,000 deliveries between 2003-2004 and 2015-2016. Risk increased with increasing gestational duration, advanced maternal age, gestational hypertension, preeclampsia, eclampsia, connective tissue disorders, sepsis, postpartum hemorrhage requiring blood transfusion, congenital heart disease, HIV infection and thrombophilia. Several potential confounders, such as smoking, body mass index, ethnicity and socio-economic status, were not available.

A New Way to Think About Moyamoya

Richard Jackson, MD

Yin H, Liu X, Zhang D, Zhang Y, Wang R, Zhao M, et al. A Novel Staging System to Evaluate Cerebral Hypoperfusion in Patients With Moyamoya Disease. Stroke. 2018

Moyamoya disease is one of those rare diseases that we come across infrequently and are uncertain what to do about when we do.  The syndromic disease is easily recognizable, and the work-up largely revolves around ruling out secondary moyamoya syndrome from an identifiable cause that can be modified.  Primary moyamoya vasculopathy has remained a surgical disease due to lack of understanding of its etiology.

I was excited to see Hu Yin et al. had collected a large cohort of 506 patients with primary moyamoya disease and attempted to stratify them radiographically into who would respond best to treatment.  The group used Gao et al.’s CT-Perfusion scale system of stages of pre-infarction in moyamoya disease (MMD) to explore perfusion differences in pre-surgical intervention with direct or combined bypass techniques and to explore the perfusion difference between hemorrhagic and ischemic patients.