American Heart Association

Monthly Archives: August 2019

More Thrombectomies Might Mean Less Hemicraniectomies

Raffaele Ornello, MD

Rumalla K, Ottenhausen M, Kan P, Burkhardt J-K. Recent Nationwide Impact of Mechanical Thrombectomy on Decompressive Hemicraniectomy for Acute Ischemic Stroke. Stroke. 2019;50:2133–2139

Decompressive hemicraniectomy (DHC) is performed to treat malignant cerebral edema (MCE), a potentially devastating consequence of ischemic stroke. It has been hypothesized that mechanical thrombectomy (MT) procedure might prevent the need of MCE in patients with the most severe forms of ischemic stroke by restoring the blood flow in the ischemic penumbra.

To verify that hypothesis, the authors of the present study reviewed the National Inpatient Sample, a large United States dataset of hospitalized patients, to assess the trends of DHC and MT from 2012 to 2016, the years in which there was a massive implementation of MT. The study showed that the increase of MT procedure was paralleled by a sharp decrease in the number of DHCs, that was more evident after 2015, when the MT guidelines were published. Data also showed that patients undergoing MT were less likely to undergo DHC.

By |August 13th, 2019|clinical|0 Comments

Blood Pressure Lowering During Endovascular Thrombectomy Associated With Poor Radiological and Clinical Outcome

Piyush Ojha, MBBS, MD, DM

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

Recent studies have shown that acute ischemic stroke patients with large vessel occlusion (LVO) have good clinical outcome following endovascular thrombectomy (EVT), which is now a new standard of care. However, only 46% of patients undergoing EVT were functionally independent (mRS 0-2) at 90 days, and only 10% were neurologically normal in the meta-analysis of EVT trials [Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials (HERMES)].1 Several factors could potentially contribute to this observation. Both clinical and imaging variables have been shown to correlate with poor outcome, especially age, stroke severity, lack of effective reperfusion and infarct volume.  

Management of blood pressure is hotly debated in the stroke literature. There are theoretical concerns and benefits of acute blood pressure lowering in acute ischemic stroke. Blood pressure fluctuations during EVT could lead to inadequate cerebral perfusion causing poor final radiological (infarct progression) and clinical outcomes (functional status) in patients with LVO. Hypotension prior to reperfusion may compromise collateral flow, which may be further worsened by the exhaustion of compensatory vasodilatory capacity distal to the occluded vessel and the loss of intrinsic autoregulatory function in the ischemic tissue leading to a poor clinical and radiological outcome. 

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

To Bridge or Not to Bridge

Jennifer Harris, MD
@JenHarrisMD

Altavilla R, Caso V, Bandini F, Agnelli G, Tsivgoulis G, Yaghi S, et al. Anticoagulation After Stroke in Patients With Atrial Fibrillation: To Bridge or Not With Low-Molecular-Weight Heparin? Stroke. 2019; 50:2093–2100

Despite evidence that it might be harmful, some clinicians still use bridging therapy with low-molecular-weight heparin (LWMH) to prevent early recurrent stroke in patient with acute stroke and history of atrial fibrillation. In the August issue of Stroke, Altavilla et al. report the results of pooled observational data from RAF (Early Recurrence and Cerebral Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation) and RAF NOAC (Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non–Vitamin K Oral Anticoagulants) to shed some light on the clinical characteristics and differences in outcomes of patients who received or did not receive bridging therapy.

The primary outcome was a composite of ischemic stroke, TIA, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after acute ischemic stroke.

By |August 6th, 2019|clinical|0 Comments

Reconsidering Role of Immune System in Neuropathophysiology After Stroke

Lin Kooi Ong, PhD
@DrLinOng

Perego C, Fumagalli S, Miteva K, Kallikourdis M, De Simoni M-G. Combined Genetic Deletion of IL (Interleukin)-4, IL-5, IL-9, and IL-13 Does Not Affect Ischemic Brain Injury in Mice. Stroke. 2019;50:2207–2215

Primary brain injury occurs immediately after the onset of stroke, and triggers a cascade of immune responses including glial activation, recruitment of peripheral immune cells and release of cytokines and chemokines. These inflammation responses may aggravate brain injury by enhancing oxidative stress, production of neurotoxic proteins and disruption of neurovascular unit. On the other hand, inflammation may also participate in waste clearance, production of neurotropic factors and support the survivor of neurons. The recognition of the crucial role of inflammation after stroke has motivated stroke researchers to investigate novel interventions to target brain inflammation processes, leading to improve neurological outcome.

Article Commentary: “Timing and Relevance of Clinical Improvement After Mechanical Thrombectomy in Patients With Acute Ischemic Stroke”

Muhammad Taimoor Khan, MD

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

Mechanical thrombectomy can prevent functional dependence in about half of the patients with acute ischemic stroke from proximal vessel occlusion. Dr. Rudilosso and his colleagues studied the relevance of the timing of clinical improvement in the prediction of long-term outcome in patients treated with mechanical thrombectomy. Patients who presented substantial clinical improvement SCI at the earliest assessment after MT had the highest odds for functional recovery at 3 months and an improvement >30% in National Institutes of Health Stroke Scale score NIHSS at the end of MT represents a reliable prognostic marker.

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