Monthly Archives: June 2019

Elena Zapata-Arriaza, MD
@ElenaZaps

Kim BM, Baek J-H, Heo JH, Kim DJ, Nam HS, Kim YD. Effect of Cumulative Case Volume on Procedural and Clinical Outcomes in Endovascular Thrombectomy. Stroke. 2019;50:1178–1183.

Stroke thrombectomy is here to stay. We have enough evidence to treat anterior circulation strokes in different scenarios, and this evidence grows to go further, treating patients with worse ASPECTS score, longer evolution or older age. This implies increasingly complex patient management, and their assessment in experienced centers will be fundamental. The available literature suggests a powerful direct correlation between endovascular volume and outcomes, both for individual practitioners and for institutions.

With the aim of testing cumulative case volume (CCV) effect on clinical outcomes in stroke patients who underwent endovascular treatment(EVT), the authors included anterior circulation stroke, with intracranial internal carotid artery, M1 and proximal M2 occlusion from January 2011 to December 2015. Seventeen stroke centers participated in this study. Tandem atherosclerotic or dissecting cervical internal carotid artery occlusion accompanied by intracranial large vessel occlusion (LVO) was included. Multifocal LVO (bilateral anterior or involvement of both anterior and posterior circulations) was excluded. Eligible patients received intravenous tPA. EVT was performed under local anesthesia with or without conscious sedation. Stentriever (SR) or contact aspiration (CA) were used for EVT. Two neuroradiologists independently assessed the images for Alberta Stroke Program Early Computed Tomography Score, and 2 interventional neuroradiologists independently assessed whether recanalization was achieved on the catheter angiograms. The reviewers were blind to the clinical outcome. Recanalization success was defined as modified Thrombolysis In Cerebral Ischemia grade 2b or 3 on the final control angiogram. A good outcome was defined as modified Rankin Scale of 0 to 2 at 3 months.

Ravinder-Jeet Singh, MBBS, DM

Rudilosso S, Urra X, Amaro S, Llull L, Renú A, Laredo C, et al. Timing and Relevance of Clinical Improvement After Mechanical Thrombectomy in Patients With Acute Ischemic Stroke. Stroke. 2019;50:1467–1472.

Several studies in the past looked at the factors which would predict outcome in patients with ischemic stroke. The prognostic usefulness of some of the clinical variables is now well established; for example, age, stroke severity, admission glucose, cardiac comorbidity. Recent interest is in investigating imaging predictors of functional outcomes, especially infarct volume and intraparenchymal hemorrhage. Some of these clinical and imaging variables are combined to form prognostic scale to predict functional outcome or mortality. While few of the available scales can be applied to the general acute stroke population (for example, ASTRAL, iScore, VISTA), others are more suited for population treated with intravenous thrombolysis (like DRAGON, SEDAN, SPAN-100) or mechanical thrombectomy (POST). In the JURaSSiC study, a validated tool performed better than clinician in predicting the outcomes.¹ Therefore, the evidence suggests the usefulness of a validated prognostic tool to predict outcome and also a need to further improve these prediction tools.

In the study by Rudilosso et al.,² the authors were interested in the question of if a common clinical variable, the stroke severity, could be used to predict outcome when measured longitudinally. They investigated the association between timing of clinical improvement after mechanical thrombectomy (MT) and the long-term outcome (modified Rankin Scale score at 90 day). The cohort included consecutive patients with acute ischemic stroke having a proximal occlusion in the anterior cerebral circulation and treated with MT using stent retriever or distal aspiration devices. The stroke severity was measured on the National Institutes of Health Stroke Scale (NIHSS) before MT, within 30 minutes from the end of MT (d0), at day 1 after MT (d1), and at day 7 or at discharge if it occurred before day 7. Using absolute difference (ΔNIHSS) and percentage changes (%NIHSS) of NIHSS scores between the pretreatment and at different time points after treatment, the authors derived useful cutoffs of ΔNIHSS and %NIHSS for outcome prediction (good outcome defined as modified Rankin Scale score of 0–2 at 90-day). 

Richard Jackson, MD

Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, et al. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update: A Policy Statement From the American Stroke Association. Stroke. 2019

Three years ago, I started a large community hospital’s stroke program, which recently received primary stroke center certification. The first piece was the inpatient side by necessity to be in compliance with Get With The Guidelines, which is based on the national Stroke Guidelines. The “Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update” by Adeoye et al. focuses on the pre- and post-hospital care of stroke patients.

After establishing compliant inpatient metrics, we have now started to focus on the follow-up in the clinic and have found that we have around 20% follow-up from discharge to clinic, problems making room for follow-up among scheduled general neurology patients, difficulty with coordination of care among rehab modalities, difficulty with standardization among providers, and difficulty with widespread education of the community .

Andrea Morotti, MD

Casolla B, Moulin S, Kyheng M, Hénon H, Labreuche J, Leys D, et al. Five-Year Risk of Major Ischemic and Hemorrhagic Events After Intracerebral Hemorrhage. Stroke. 2019;50:1100–1107.

Intracerebral hemorrhage (ICH) survivors are at high risk of stroke recurrence. Most of the available studies focused on the risk of future cerebrovascular events whether the occurrence of extracranial vascular diseases remains poorly characterized. In this single center prospective cohort study, Dr. Casolla and colleagues described the incidence and predictors of cerebral (ischemic and hemorrhagic) and extracranial (ischemic and hemorrhagic) vascular events in patients alive at 30 days after acute ICH.

A total of 310 patients met the inclusion criteria and were followed for a median of 6 years. The overall cumulative incidence of major vascular events was 20%. The long-term natural history of ICH in terms of vascular events was remarkably different in deep versus lobar ICH survivors, with deep ICH being associated with greater ischemic risk (subhazard ratio, 1.85; 95% CI, 1.01–3.40) and lobar ICH having a higher risk of future hemorrhagic events (subhazard ratio, 2.38; 95% CI, 1.17–4.86).