American Heart Association

Monthly Archives: June 2019

When More is Better: Article Commentary on “Effect of Cumulative Case Volume on Procedural and Clinical Outcomes in Endovascular Thrombectomy”

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.

The T3 Trial of Acute Stroke Care in Emergency Departments: Negative, but Interesting

Raffaele Ornello, MD

Middleton S, Dale S, Cheung NW, Cadilhac DA, Grimshaw JM, Levi C, et al. Nurse-Initiated Acute Stroke Care in Emergency Departments: The Triage, Treatment, and Transfer Implementation Cluster Randomized Controlled Trial. Stroke. 2019;50:1346–1355.

The implementation of rapid and effective treatment of stroke in the emergency department (ED) is key to improving outcomes. However, establishing the best evidence-based ED protocol of stroke care is difficult.

In the T3 trial, which was performed in Australia, the authors tested the implementation of a nurse-initiated ED stroke care protocol, which included adequate triage, treatment of fever, hyperglycemia, and swallowing difficulties, and rapid transfer to stroke units (hence the 3 T’s of the trial name). The protocol was implemented by educational strategies and strict follow-up.

At the end of the 3-year trial period, there was no improvement of patient outcomes or of ED clinical behavior; this surprising result might be explained by the suboptimal implementation of ED stroke processes of care, but also by the general improvement of stroke care in recent years, which was independent of the trial.

By |June 26th, 2019|clinical|1 Comment

The Earlier, the Better: Predicting Functional Outcome After Thrombectomy Using Clinical Improvement

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). 

Ischemic Stroke Incidence in Young Adults

Kathryn S. Hayward, PhD, PT
@kate_hayward_

Aparicio HJ, Himali JJ, Satizabal CL, Pase MP, Romero JR, Kase CS, et al. Temporal Trends in Ischemic Stroke Incidence in Younger Adults in the Framingham Study. Stroke. 2019;50:1558–1560.

Stroke incidence has been decreasing over time. It is acknowledged that a reduction is occurring in older adults (age >65 years), but trends in younger adults remain less clear. Long-term cohort studies, such as the Framingham Study, provide the opportunity to characterize trends in rates of ischemic stroke. Such work can inform prevention efforts, both nationally and internationally. 

In this paper, Aparicio and colleagues report on the trends in 10-year incidence of ischaemic stroke among participants of the Framingham Heart Study. They divided participants into 35 to 54 years of age (younger adults) and ≥55 years of age (older adults). Individuals that attended exams at the Study clinic during four epochs from 1962 through 2005 were included.

Plasma, but Not Endothelial Fn-EDA, Promotes Ischemic Thrombo-Inflammation

Kristina Shkirkova, BSc

Dhanesha N, Chorawala MR, Jain M, Bhalla A, Thedens D, Nayak M, et al. Fn-EDA (Fibronectin Containing Extra Domain A) in the Plasma, but Not Endothelial Cells, Exacerbates Stroke Outcome by Promoting Thrombo-Inflammation. Stroke. 2019;50:1201–1209.

Reperfusion with mechanical thrombectomy and recombinant tissue plasminogen activator is a standard of care for patients with ischemic stroke. However, there is evidence from animal and clinical studies that the process of reperfusion contributes to vascular inflammation, secondary thrombosis and oxidative stress. The molecular mechanisms of this thrombo-inflammatory injury are not well understood.

The recent study by Dhanesha et al. published in Stroke examined the role of cellular fibronectin containing extra domain A (Fn-EDA) in thrombo-inflammatory injury. Fn-EDA is a glycoprotein that is present in a cellular form on the endothelial cells of the arteries and in a non-cellular form in the blood plasma. Previous studies have shown a significant elevation in the levels of plasma Fn-EDA in patients with cardiovascular disease. Additionally, severe vascular dysfunction in stroke is associated with increased expression of cellular Fn-EDA in activated endothelial cells. The aim of this study was to investigate contribution of plasma versus cellular Fn-EDA on stroke injury.

Endovascular Treatment and Diffusion-Weighted Imaging Reversal

Kara Jo Swafford, MD

Yoo J, Choi JW, Lee S-J, Hong JM, Hong J-H, Kim C-H, et al. Ischemic Diffusion Lesion Reversal After Endovascular Treatment: Prevalence, Prognosis, and Predictors. Stroke. 2019;50:1504–1509.

Animal models and clinical studies show that partial or complete reversal of diffusion-weighted imaging (DWI) lesions occurs following reperfusion, including with intravenous thrombolysis. Endovascular thrombectomy (EVT) can also reduce infarct expansion and potentially reverse DWI lesions; however, further clinical studies are needed. Yoo et al. performed a retrospective analysis of patients with acute ischemic anterior circulation stroke receiving EVT who were prospectively enrolled in a multicenter registry. They determined the odds of DWI reversal after EVT, clinical outcomes, and independent predictors of DWI reversal.

Baseline (pre-EVT) and follow-up (post-EVT) DWI volumes were measured. If the follow-up DWI volume decreased from baseline, the DWI lesion was considered reversible. Onset-to-baseline DWI time for patients with and without DWI reversal was 277±214 versus 257±209 minutes (P=0.487). Mean onset-to-puncture time was 338±222 minutes. Time from baseline to follow-up DWI was 4.7±2.4 days. Of 404 patients, 63 (15.5%) had DWI reversal. Initial stroke severity based on the National Institutes of Health Stroke Scale (NIHSS) score was similar, but the score was lower in the DWI reversal group at 7 days. Patients with DWI reversal had better functional outcomes at 3 months.

“Creating a Stroke System is More Difficult Than Creating Stroke Care”

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 .

By |June 18th, 2019|clinical|1 Comment

Balloon Guided Catheter Use Predicts Functional Independence in Mechanical Thrombectomy

Kat Dakay, DO

Zaidat OO, Mueller-Kronast NH, Hassan AE, Haussen DC, Jadhav AP, Froehler MT, et al. Impact of Balloon Guide Catheter Use on Clinical and Angiographic Outcomes in the STRATIS Stroke Thrombectomy Registry. Stroke. 2019;50:697–704.

Mechanical thrombectomy has emerged as the standard of care for patients with large vessel occlusion; however, the optimal method of re-canalizing a large vessel occlusion is up for debate. A recent JNIS article illustrated the wide practice heterogeneity between neurointerventionalists, with no less than twelve different techniques for endovascular treatment of stroke mentioned [1]. Use vs. nonuse of a balloon guide catheter is an example of one such practice variation between different centers and neurointerventionalists.

A balloon guide catheter is a supportive catheter typically placed into the internal carotid artery (or sometimes the common carotid if there is extensive stenosis of the internal carotid) and then inflated to cause flow arrest during mechanical thrombectomy, or in some cases, contact aspiration thrombectomy [2]. The theory behind placing a balloon guide catheter to cause flow arrest, which may aid in the procedure by two mechanisms: to reduce the risk of distal clot embolization [3, 4], and to decrease the systemic arterial pressure impacting the clot to enhance the effect of stent retriever thrombectomy [5]. 

In this recently published study in Stroke, Zaidat et al. reported on the use of balloon guide catheter in the STRATIS registry, a multicenter prospective registry of patients who underwent mechanical thrombectomy with the Solitaire device. For purposes of the study, patients with posterior circulation large vessel occlusion were excluded as balloon guide catheter is used less frequently in these occlusions; additionally, patients who underwent a proximal carotid intervention such as angioplasty or stenting were excluded. Patients meeting inclusion criteria were grouped into three categories based on procedural technique (Figure 1): conventional guide catheter (CGC), distal access catheter (DAC), and balloon guide catheter (BGC). There were between-group differences such as a lower baseline ASPECTs in the DAC group compared to the BGC group (8.2 vs 8.3, p = 0.023), more carotid occlusions in the DAC group compared to the BGC group (p = 0.018), and less general anesthesia in the DAC group compared to the BGC group (p = 0.001).  

Figure 1. Adjunctive techniques in the STRATIS Registry.
Figure 1. Adjunctive techniques in the STRATIS Registry. A, Illustration of middle cerebral artery clot treated with Solitaire stent retriever. The different adjunctive techniques are shown. B, Study flowchart. Some subjects met multiple exclusion criteria, and hence individual category N do not sum to total of exclusions. BGC indicates balloon guide catheter; CGC, conventional guide catheter; DAC, distal access catheter; and STRATIS, Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke.

Long-Term Vascular Risk in Intracerebral Hemorrhage Survivors

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).

Post-Sepsis Stroke: What Are the Risk Factors?

Kara Jo Swafford, MD

Shao IY, Elkind MSV, Boehme AK. Risk Factors for Stroke in Patients With Sepsis and Bloodstream Infections. Stroke. 2019;50:1046–1051.

Sepsis is associated with increased risk for stroke; however, the mechanisms remain unknown. Shao et al performed a retrospective review of a California inpatient database to identify patients at greatest risk of stroke within 1 year of hospitalization for sepsis. Stroke occurred rarely in this patient population, with 0.5% having either an ischemic or hemorrhagic stroke within the first year. Risk factors more prevalent in patients with stroke post-sepsis were valvular heart disease, renal failure, congestive heart failure, coagulopathy, peripheral vascular diseases, pulmonary circulation disorders, and lymphoma.

Based on an adjusted multivariable logistic model including these risk factors as covariates, a composite risk score was developed by assigning an integer to each risk factor based on the odds ratios. Absolute risk of stroke increased as the composite risk score increased. For each point increase in the score, odds of stroke were slightly higher for patients 18-45 years of age when compared to patients older than 45 years. For all groups, risk of stroke was highest in those with coagulopathy (coagulopathy included antithrombotic coagulation defects, qualitative platelet defects, and thrombocytopenia).