American Heart Association

Monthly Archives: July 2019

Explicit Diagnostic Criteria: Gaining Ground in the Perpetual Struggle to Elucidate TIA

Matthew Maximillian Padrick, MD, BA

Dolmans LS, Lebedeva ER, Veluponnar D, van Dijk EJ, Nederkoorn PJ, Hoes AW, et al. Diagnostic Accuracy of the Explicit Diagnostic Criteria for Transient Ischemic Attack: A Validation Study. Stroke. 2019;50:2080–2085

The diagnosis of Transient Ischemic Attack (TIA) has remained one of the murkier diagnoses a physician can encounter, and yet it yields a disproportionately large impact on patient wellbeing. Diagnoses can be given haphazardly, say in a busy emergency department, for brief dizziness, confusion, tingling, or just not feeling quite right. I have seen a patient who was given the diagnosis after less than a minute of isolated whole body shivering. ED neurology consults are a luxury, not the rule, and “follow up with neuro” discharge action plans may never materialize.

With the growing acceptance and implementation of the POINT and CHANCE trials, these TIA diagnoses carry significant weight. Patients with no clear indication may suddenly find themselves on dual antiplatelet therapy, which is certainly not without risk. On the other end of the spectrum, missing the diagnosis significantly increases our patients’ risk of stroke within 6 months. There have been multiple scales created to help with risk stratification, and the quest for reliable biomarkers is well underway. 

Chronic Hypertension: The Silent Killer for Leptomeningeal Collateral Status in Acute Ischemic Stroke

Charlotte Zerna, MD, MSc 

Fujita K, Tanaka K, Yamagami H, Ide T, Ishiyama H, Sonoda K, et al. Detrimental Effect of Chronic Hypertension on Leptomeningeal Collateral Flow in Acute Ischemic Stroke. Stroke. 2019; 50:1751–1757

Now that endovascular treatment for acute ischemic stroke due to large vessel occlusion is the new standard of care, imaging features that are associated with the success of the procedure and the functional outcome of the patient are of great interest. Leptomeningeal collaterals status has been found to determine both recanalization rate and clinical outcome many years ago.1 However, our understanding of the variability of leptomeningeal collateral status is still in progress. Prior studies found that metabolic syndrome, hyperuricemia, older age and statin use corresponded to poorer leptomeningeal collateral status, but these studies have pre-dated the era of proven endovascular treatment for acute ischemic stroke.2, 3 With improved workflow and faster treatment times in recent years, these demographic and patient-related factors that might influence leptomeningeal collateral status need to be re-evaluated. 

Do Long Work Hours Increase the Risk of Stroke? An Observational Study From the CONSTANCES Cohort

Anusha Boyanpally, MD

Fadel M, Sembajwe G, Gagliardi D, Pico F, Li J, Ozguler A, et al. Association Between Reported Long Working Hours and History of Stroke in the CONSTANCES Cohort. Stroke. 2019;50:1879–1882

Long working hours (LWH) may be a risk factor for cardiovascular diseases and stroke (1). There is limited evidence on the association of LWH and increased risk of stroke (2, 3). Fadel et al. have reported association of LWH and risk of stroke in a large French population-based cohort.

The study included randomly selected adults aged 18 to 69 years from the CONSTANCES cohort. Data was obtained from self-administered questionnaires, health examinations, and physician diagnosed stroke cases at affiliated health-screening centers. The authors have categorized working years of exposures as >1 year, 1 – <10 years, and ≥10 years. Variables included are; age, sex, smoking, occupation, history of stroke, age occurrence of stroke, diabetes, high blood pressure, dyslipidemia (both hypercholesteremia or hypertriglyceridemia), family history of cardiovascular events and body mass index. The study has excluded patients with part-time jobs, and history of stroke.

Article Commentary: “Disparities and Temporal Trends in the Use of Anticoagulation in Patients With Ischemic Stroke and Atrial Fibrillation”

Wayneho Kam, MD

Sur NB, Wang K, Di Tullio MR, Gutierrez CM, Dong C, Koch S, et al. Disparities and Temporal Trends in the Use of Anticoagulation in Patients With Ischemic Stroke and Atrial Fibrillation. Stroke. 2019;50:1452-1459.

Race-ethnic and sex disparities in stroke incidence and stroke-related death and disability are well-documented and persist in the modern health care system. The factors that contribute to these disparities are many, and stem from the biosocial complexities of the disease and the prevailing inequalities that exist in the continuum of stroke care.

The study by Sur et al., published in the June issue of Stroke, sought to examine yet another potential disparity in stroke care: differences in oral anticoagulant prescription pattern between blacks vs whites and women vs men for secondary stroke prevention. Data was drawn from the Florida-Puerto Rico Collaboration to Reduce Stroke Registry, which included 24040 patients with ischemic stroke and atrial fibrillation (AF).

Article Commentary: “Sex Differences in Management and Outcomes of Acute Ischemic Stroke With Large Vessel Occlusion”

Jennifer Harris, MD

Uchida K, Yoshimura S, Sakai N, Yamagami H, Morimoto T, and RESCUE-Japan Registry 2 Investigators. Sex Differences in Management and Outcomes of Acute Ischemic Stroke With Large Vessel Occlusion. Stroke. 2019;50:1915–1918.

Stroke affects men and women. We know that sex differences affect many aspects of stroke and have profound implications for effective prevention and treatment. However, how sex differences are affected in the management and outcomes of acute ischemic stroke with large vessel occlusion in the era of endovascular therapy (EVT) has been largely unknown.

This is the aim of the study by Uchida et al. In this study, data was analyzed from the RESCUE (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism)-Japan Registry 2 database. The RESCUE trial was a prospective, multicenter registry that enrolled 2420 consecutive patients with acute ischemic stroke with LVO from 46 centers across Japan. Among 2399 patients enrolled in the registry, females accounted for 1087 (45.3%) patients.

Thrombectomy-Ready Status and Critical Access Hospitals

Richard Jackson, MD

Harrington RA. Prehospital Phase of Acute Stroke Care: Guideline and Policy Considerations as Science and Evidence Rapidly Evolve. Stroke. 2019;50:1637–1639.

Robert Harrington, MD, wrote a commentary in the July issue of Stroke on the Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update: A Policy Statement From the American Stroke Association, which is pertinent to many issues being experienced by many of us involved in the direction and coordination of stroke systems of care. He focuses his commentary mainly surrounding the triage for treatment of large vessel occlusions with thrombectomy and states that it is thought that the suburban/urban boundary setting is the area which will be most difficult to create EMS triage protocols and that thrombectomy-ready centers might be a solution for the rural setting despite the controversy in its role. 

UTIs: Not So Uncomplicated

Rachel Forman, MD

Sebastian S, Stein LK, Dhamoon MS. Infection as a Stroke Trigger: Associations Between Different Organ System Infection Admissions and Stroke Subtypes. Stroke. 2019

When I read the title of this article the first thing that came to mind was endocarditis. This is the infection type that we typically worry about when a stroke patient is febrile or appears to have an infection. This article, titled “Infection as a Stroke Trigger,” looks further into the connection between other types of infections and the risk of stroke.

The study evaluates the link between different types of stroke (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) and various infections. Specifically, it looked at urinary tract infections (UTIs), skin infections, septicemia, abdominal infections, and respiratory infections. The group hypothesized that there would be a temporal relationship between the risk of stroke and infection. The data was obtained from a New York State database between 2006 and 2013. Statistical analysis was done using a case crossover analysis using control periods one year prior. 

Interview: Dr. Noortje Maaijwee, MD, PhD, on Highlights from ESOC 2019

Dr. Noortje Maaijwee
Dr. Noortje Maaijwee

An interview with Dr. Noortje Maaijwee, MD, PhD, a neurologist specializing in neurorehabilitation. She is a full-time faculty member in the Department of Neurology and Neurorehabilitation at the Lucerne Cantonal Hospital in Switzerland. She completed her medical school and residency at Radboud University Nijmegen Medical Centre in the Netherlands. Her primary area of research interest includes stroke in young adults, long-term consequences of stoke, and quality of life issues after suffering a stroke. During her PhD, Dr. Maaijwee defended a thesis on “Long-term neuropsychological and social consequences after stroke in young adults.”

Interviewed by Dr. Rohan Arora, MD, Assistant Professor of Neurology, director of stroke fellowship at the Hofstra Northwell School of Medicine and medical director of the stroke program at LIJ Forest Hills, a part of Northwell Health, New York.

In this interview, Dr. Maaijwee discusses highlights from the European Stroke Organization Conference, held May 22–24 in Milan, Italy.

Dr. Arora: At ESOC 2019, what were some major breakthroughs? 

Dr. Maaijwee: The indications and contra-indications for acute treatment of ischemic stroke by IV thrombolysis and endovascular therapy are ever-changing. For example, the time-window when treatment is successful. In the Large Clinical Trials session on the first day of ESOC, a meta-analysis was presented that showed that intravenous thrombolysis increases the percentage of good clinical outcome (modified Rankin Score (mRS) 0-1) at 3 months, if treatment is started between 4.5–9 hours after onset of symptoms in select patients with CT or MRI perfusion mismatch.1

Stereotactic Radiosurgery Performance in Brain AVMs: Risk Factors for Hemorrhage

Elena Zapata-Arriaza, MD
@ElenaZaps

Ding D, Chen C-J, Starke RM, Kano H, Lee JYK, Mathieu D, et al. Risk of Brain Arteriovenous Malformation Hemorrhage Before and After Stereotactic Radiosurgery: A Multicenter Study. Stroke. 2019;50:1384–1391.

Stereotactic radiosurgery (SRS) has emerged as an alternative to neurosurgery or endovascular treatment for selected brain arteriovenous malformations (bAVM) management. Localization, size or perioperative risk are some of the selection criteria for SRS employment. Hemorrhagic risk of bAVM after SRS is based on single center studies. This study aims to obtain scientific evidence about bAVM hemorrhage rates before and after SRS and identify predictors of pre-post SRS AVM hemorrhage.

Patients with AVM treated with SRS in a single session from 1987 to 2014 were collected for the International Radiosurgery Research Foundation, formed by 8 institutions. For each AVM, Spetzler-Martin(SM) grade, virginia Radiosurgery AVM scale and modified radiosurgery-based AVM score were collected. In terms of SRS variables, margin dose, maximum dose and number of isocenters were analyzed. Radiological follow-up (with magnetic resonance image with/without contrast and computed tomography as alternative) was performed every 6 months for the first 2 years after SRS, and yearly thereafter. If the patient developed new or symptoms worsening, additional neuroimagen was performed.

Article Commentary: “Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcomes”

Matthew Maximillian Padrick, MD, BA

Petersen NH, Ortega-Gutierrez S, Wang A, Lopez GV, Strander S, Kodali S, et al. Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcome. Stroke. 2019;50:1797–1804.

This study recapitulates what should be a well-known phenomenon in the vascular neurology community: Decreases in blood pressure (BP) in patients undergoing endovascular thrombectomy (EVT) tend to result in poorer outcomes compared to outcomes of patients with sustained, stable blood pressure throughout diagnosis and EVT.

In this retrospective, observational study, the authors identified consecutive acute ischemic stroke patients with large vessel occlusion undergoing EVT at Yale-New Haven Hospital and University of Iowas and Clinics between 2014 and 2018. BP data was collected on admission and throughout EVT via anesthesia records. Decreases in BP were calculated between admission mean arterial pressure (MAP) and the single lowest MAP before recanalization during EVT. Sustained relative hypotension was measured as the area between baseline admission MAP and continuous measurements of intraprocedural MAP from procedure start to vessel recanalization. Primary imaging outcome was infarct volume assessed via admission computed tomography and at 24 hours post EVT via magnetic resonance imaging. Primary functional outcome was assessed via patient’s modified Rankin scale (mRS) at discharge and at 90 days post discharge.