American Heart Association

Yearly Archives: 2020

Fire and Forget, or Treat to Target?

Vera Sharashidze, MD

Endres M, Kernan WN. LDL (Low-Density Lipoprotein) Cholesterol Below 70: Good to Go! Stroke. 2020;51:2276–2278.

The current guidelines of the American Heart Association/American Stroke Association (AHA/ASA) recommend high-intensity statin therapy initiation or continuation with the aim of achieving a 50% or greater reduction in low-density lipoprotein cholesterol (LDL-C) levels in patients with stroke who are 75 years of age or younger. In patients who are unable to tolerate high-intensity therapy, moderate intensity statins should be started with the goal of achieving a 30% to 49% reduction in LDL-C levels.

The first evidence that stroke patients could benefit from statins came out from the Heart Protection Study that was a double-blind, randomized, placebo-controlled study in which patients received either placebo or simvastatin 40 mg daily. This study showed that in patients with high risk for cardiovascular disease, cholesterol lowering with simvastatin was associated with reduction in all-cause mortality and major vascular event risk.

Malaysia Stroke Virtual Conference 2020: “Stroke Strikes Fast, ResQ Faster!”

Malaysia Stroke Virtual Conference 2020
August 14 – 16, 2020
Contents available online from August 14 to September 14, 2020 at:

Lin Kooi Ong, PhD

Wan Asyraf Wan Zaidi, MMed*

As a consequence of the COVID-19 pandemic, the Malaysia Stroke Council, in collaboration with Angels Initiative, organized the first-ever Malaysia Stroke Virtual Conference 2020. This virtual conference had an excellent scientific program which covered hyperacute stroke, stroke emergency, stroke rehab, basic/translational stroke research, and many more topics ( The program included live plenary lectures, symposia, e-posters, a virtual expo, and a Game of Stroke tournament. In addition to talks by leading Malaysian clinicians and researchers, this virtual conference also featured experts around the world, including Professor Sheila Martins (Brazilian Stroke Network), Professor Valery Feigin (University of Auckland), and Dr Ramesh Sahathevan (Ballarat Health Service).

The Deputy Director General of Health Malaysia Datuk Dr Hj. Rohaizat Hj. Yon officiated the opening ceremony of the conference. He also presented the World Stroke Organisation Angels Awards to five Malaysian hospitals: Hospital Tuanku Jaafar in Seremban (Gold), Hospital Seberang Jaya (Gold), Sarawak General Hospital (Gold and Diamond), Regency Specialist Hospital (Gold), and Pantai Hospital Penang (Diamond), as recognition for outstanding stroke care.

The Malaysia Stroke Virtual Conference 2020 was declared open. (Left to right) Assoc. Prof. Dr. Hoo Fan Kee (Malaysia Stroke Council President), Datuk Dr Hj. Rohaizat Hj. Yon (Deputy Director General Ministry of Health Malaysia), Dr. Santhi Datuk Puvanarajah (Head of Neurology Service Ministry of Health Malaysia), Mrs. Sylvia Chong (National Stroke Association of Malaysia CEO), Prof. Dr. Hamidon Basri (Malaysia Stroke Council advisor), and Prof. Dr. Khairul Azmi Abdul Kadir (President of Malaysia Neurointerventional Society). Photo provided by Dr. Wan Asyraf Wan Zaidi, co-scientific chairperson of the Malaysia Stroke Conference 2020, with permission. 

The first live plenary session was by Dr. Law Wan Chung (Sarawak General Hospital), who spoke about “Data Monitoring: Why I Need This For My Stroke Centre?”. Dr. Law presented some exciting data related to thrombolysis outcome and stroke outcome from the Sarawak General Hospital. He highlighted that 1442 ischemic stroke patients were admitted to the hospital between June 2013 and August 2018, and the mean age was 60. The incidence of stroke in individuals under age 60 has risen at an alarming rate; in this case, approximately 13% were under 45 years.

Article Commentary: “Predicting Longitudinal Progression in Functional Mobility After Stroke”

Tamaya Van Criekinge, PT, PhD

Buvarp D, Rafsten L, Sunnerhagen KS. Predicting Longitudinal Progression in Functional Mobility After Stroke: A Prospective Cohort Study. Stroke. 2020;51:2179–2187.

Regaining the ability to walk is the primary therapy goal for the majority of stroke survivors. However, gait rehabilitation does not end when a patient is able to walk up and down the corridor for six meters. People living with stroke need to be able to walk independently, with or without aids, on stable and unstable surfaces, in crowded environments full of distractions, under time pressure of moving traffic, while performing dual tasks, and all this in an energy-efficient manner. To optimize the walking pattern of stroke survivors, we need to fully understand the underlying impairments and recovery process. The aim of this study was to investigate the longitudinal progression in functional mobility during the first year after stroke and determine the rate of change between different levels of stroke severity.

In total, 140 participants who are over 18 years of age, diagnosed with stroke according to the World Health Organization (WHO) criteria, living near the rehabilitation center (Sahlgrenska University Hospital, Sweden), The National Institutes of Health Stroke Scale (NIHSS) ≤16, Barthel Index (BI) ≥50, life expectance ≥1 year, were included in this study. The Timed up-and-Go test (TUG) was used to assess functional mobility after 5 days of onset, within 24 hours of discharge, 1 after discharge, 3 months and 1-year post-stroke. In addition, clinical and activity limitations were assessed with the NIHSS, Fugl-Meyer Assessment, Montreal Cognitive Assessment, modified Rankin Scale (mRS) and BI.

By |September 2nd, 2020|clinical|0 Comments

Navigating Major Bleeding and Embolic Strokes of Undetermined Source

Kevin O’Connor, MD

Mikulík R, Eckstein J, Pearce LA, Mundl H, Rudilosso S, Olavarría VV, Shoamanesh A, Chamorro Á, Martí-Fàbregas J, Veltkamp R, et al. Frequency and Predictors of Major Bleeding in Patients With Embolic Strokes of Undetermined Source: NAVIGATE-ESUS Trial. Stroke. 2020;51:2139-2147.

About a third of ischemic strokes are categorized as being cryptogenic. Embolic strokes of unknown source (ESUS) represent a subset of these cryptogenic strokes. Clinicians are often faced with choosing between an anticoagulant and a platelet antiaggregant as one component of secondary prevention in patients having an ESUS. The NAVIGATE-ESUS trial provides data on the frequency and predictors of major bleeding in ESUS patients based on antithrombotic therapy choice, which can help inform treatment decisions.

NAVIGATE-ESUS was an international, double-blind, phase III trial that included 7213 participants from 31 countries who were randomized to receive rivaroxaban 15 mg once daily or aspirin 100 mg once daily. Sites were in Europe, East Asia, North America, and Latin America. The primary outcome of this analysis was major bleeding. Clinically-relevant nonmajor bleeding (CRNMB) was excluded for several reasons: CRNMB determinations were not determined centrally, whereas there was centralized adjudication of major bleeding events; intracranial bleeding was not considered to be a CRNMB; and analysis of independent predictors of major bleeding and CRNMBs such as epistaxis requiring medical attention would have been potentially spurious. NAVIGATE-ESUS was terminated before targeted enrollment was completed after an interim analysis found increased bleeding among rivaroxaban-treated participants, but no reduction in recurrent stroke.

By |August 31st, 2020|clinical|0 Comments

A Collateral Dialogue: Addressing Neuroanatomy of Posterior Circulation in Basilar Artery Occlusion

Saurav Das, MD

Kwak HS, Park JS. Mechanical Thrombectomy in Basilar Artery Occlusion: Clinical Outcomes Related to Posterior Circulation Collateral Score. Stroke. 2020;51:2045–2050.

The successful endovascular treatment (EVT) trials for large vessel occlusion (LVO) strokes have excluded patients with basilar artery occlusion (BAO). Recently, the results of the Basilar Artery International Collaboration Study (BASICS) were presented at the European Stroke Organization (ESO-WSO) virtual platform. The results, even though underpowered to show significant benefits of EVT <6 hours of BAO, were effective in patients with moderate to severe deficits (NIHSS > 10). The trial results have shifted the spotlight to the distinction in the neuro-anatomy of posterior-circulation vessels and collateral circulation in this part of the brain, etio-pathological mechanisms involved in large vessel disease in the posterior circulation, as well as appropriate patient selection based on symptom severity and time window from symptom onset. In this blog, I will discuss a retrospective study from South Korea relevant to this topic that was published in the July issue of Stroke.

In this study, the authors present data from 81 patients with acute BAO treated with EVT using manual aspiration or stent retriever at their institute in South Korea over a period of eight years from 2012 to 2019. Posterior circulation collaterals were graded using the Basilar Artery on CT Angiogram (BATMAN) score and posterior circulation collateral score (PC-CS). Both these scoring systems have a maximum possible score of 10 points. 64% of these patients achieved TICI 2b or 3 recanalization within a median time of 5.5 hours from symptom onset, and 37% of patients had good functional outcomes defined by a 3-month modified Rankin scale ≤ 2. When compared to patients with poor outcomes, the ones with favorable outcomes had lower baseline NIHSS (15 vs 7.5, p<0.01), a greater proportion of distal BAO (20% vs 63%,  p<0.01), and better posterior circulation collateral scores (5 vs 6,  p<0.01). The authors also compared these groups on a timeline of < 3hrs, 3-6 hrs, 6-12 hrs, and >12 hrs from symptom onset. Interestingly, the time to recanalization from symptom onset was not significantly different between the groups. Receptor operating characteristic (ROC) curve analysis for collateral scores yielded the highest area under the curve with a cut-off score of 6 for both BATMAN and PC-CS. Using these cut-offs, multivariate analysis revealed that NIHSS score <15 (odds ratio 8.49, P=0.004), PC-CS ≥6 (odds ratio 3.79, P=0.042), and distal BAO (odds ratio 3.67, P=0.035) were independent predictors of good clinical outcomes.

Figure 1. Schematic illustration of collateral scores.

IV Thrombolysis for CRAO: Time is Vision?

Song J. Kim, MD

Mac Grory B, Nackenoff A, Poli S, Spitzer SM, Nedelmann M, Guillon B, Preterre C, Chen CS, Lee AW, Yaghi S, et al. Intravenous Fibrinolysis for Central Retinal Artery Occlusion: A Cohort Study and Updated Patient-Level Meta-Analysis. Stroke. 2020;51:2018–2025.

Patients presenting with complete retinal artery occlusion (CRAO), often first evaluated by ophthalmologists, are advised to seek emergent neurological evaluation. On the receiving end, even when the patient arrives within the typical thrombolysis window of <4.5 hours, some vascular neurologists may demur on offering reperfusion therapy owing to : 1) lack of robust evidence with regards to outcomes, and 2) absence of a comprehensive ophthalmological evaluation in excluding other non-ischemic differentials. 

To address the above, Mac Grory and co-authors developed a protocol for a rapid evaluation of CRAO including a dilated ophthalmologic evaluation and other work-up, ruling out mimics such as optic neuritis, giant cell arteritis, and retinal detachment. Barring any contraindications, patients received tPa if CRAO was deemed the most likely diagnosis, with visual acuity of less than 20/200 in the affected eye and presenting within 4.5 hours of symptom onset. Over a 10-year time span, 112 were diagnosed with acute CRAO. They were subsequently included in a retrospective observational analysis on post-tPa visual outcomes, as well as an updated subject-level meta-analysis expanding upon the authors’ 2015 study.

By |August 24th, 2020|clinical|0 Comments

Article Commentary: “Clot-Based Radiomics Predict a Mechanical Thrombectomy Strategy for Successful Recanalization in Acute Ischemic Stroke”

Aurora Semerano, MD

Hofmeister J, Bernava G, Rosi A, Vargas MI, Carrera E, Montet X, Burgermeister S, Poletti P-A, Platon A, Lovblad K-O, Machi P. Clot-Based Radiomics Predict a Mechanical Thrombectomy Strategy for Successful Recanalization in Acute Ischemic Stroke. Stroke. 2020;51:2488–2494.

Tools for predicting the success or the failure of reperfusion treatments in the acute setting of ischemic stroke are useful both to assist treatment decision-making and to guide the selection of the best device and reperfusion strategy. Multiple biomarkers and models, including clinical, biochemical, and radiological parameters, are currently under investigations with this purpose. Recently, multimodal analyses of the occlusive clot are receiving growing interest for the potential predictive value on reperfusion outcomes.

Hofmeister et al.(1) addressed this important issue in their recent article in Stroke. More specifically, the authors aimed at identifying the radiomic features of the occlusive clot on pre-treatment non-contrast CT scan, which may predict both first-attempt successful reperfusion with thromboaspiration (defined by modified Treatment in Cerebral Ischemia, mTICI 2b-3) and the number of maneuvers required to achieve successful reperfusion.

Ticagrelor: Is It Here to Stay?

Elena Zapata-Arriaza, MD

Johnston SC, Amarenco P, Denison H, Evans SR, Himmelmann A, James S, Knutsson M, Ladenvall P, Molina CA, Wang Y, for the THALES Investigators. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. N Engl J Med. 2020;383:207-217.

Without urgent treatment, the risk of major stroke in the week after a transient ischemic attack (TIA) or minor stroke can be as high as 10%. Some studies have shown that the combination of aspirin (ASA) plus Clopidogrel reduces the risk of stroke and other major ischemic events. Given the limitations in Clopidogrel due to hepatic conversion and the high resistance rates, Ticagrelor emerges as an interesting alternative, not dependent on metabolic activation.

With the aim of testing the effect of Ticagrelor and aspirin combination on stroke prevention, Johnston et al performed this randomized, placebo-controlled, double-blind trial involving patients who had had a mild-to-moderate acute noncardioembolic ischemic stroke, with a NIHSS≤5 or TIA, and who were not undergoing thrombolysis or thrombectomy. The patients were assigned within 24 hours after symptom onset, in a 1:1 ratio, to receive a 30-day regimen of either Ticagrelor (180-mg loading dose followed by 90 mg twice daily) plus aspirin (300 to 325 mg on the first day followed by 75 to 100 mg daily) or matching placebo plus aspirin. The primary outcome was a composite of stroke or death within 30 days. Secondary outcomes were first subsequent ischemic stroke and the incidence of disability within 30 days. The primary safety outcome was severe bleeding.

By |August 17th, 2020|clinical|0 Comments

The Future of Stroke in Europe: The Good and Bad News

Raffaele Ornello, MD

Wafa AH  Wolfe CDA, Emmett E, Roth GA, Johnson CO, and Wa Y. Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years. Stroke. 2020;51:2418–2427.

Making projections about the future of stroke is important, due to the high burden of the disease in the general population and especially among the elderly. However, it is hard to provide accurate estimates due to the high number of variables to take account of.

In the present study, which used data from the Global Burden of Diseases 2017, the authors considered two variables, namely time and GDP per capita, to estimate variations in stroke incidence, prevalence, mortality, and disability-adjusted life years (DALYs) lost from 2017 to 2047 in 28 European countries. The authors’ statistical model predicted a slight increase (+3%) in stroke incidence, a striking 27% increase in stroke prevalence, fewer deaths (-17%) and DALYs lost (-33%).

By |August 14th, 2020|clinical|0 Comments

Tackling a Long Overdue Problem: The Eyes Have It

Richard Jackson, MD

Mac Grory B, Nackenoff A, Poli S, Spitzer MS, Nedelmann M, Guillon B, Preterre C, Chen CS, Lee AW, Yaghi S, et al. Intravenous Fibrinolysis for Central Retinal Artery Occlusion: A Cohort Study and Updated Patient-Level Meta-Analysis. Stroke. 2020;51:2018–2025.

Mac Grory et al. have published data that all stroke neurologists on call have been waiting for. In hospital systems where there are ophthalmologists taking calls, usually the neurologist on call for stroke gets the stroke code page for acute onset loss of vision or the patient is referred to the ER for a diagnosis of CRAO for evaluation. There is an ensuing debate between the on-call neurologist and ER physician about what to do for this patient. As neurologists, we are taught that the eye is an extension of the brain, and infarcts to the eye are technically infarcts to the brain. However, there is no data on whether or not thrombolysis with alteplase is efficacious. The ophthalmologists cite a lack of efficacy in trials and only one randomized trial with a small sample of 25 that showed no benefit when treated with standard dose 0.9mg/kg IV-tPA but within 24 hours of onset. An even more difficult situation arises in the primary stroke centers that do not have ophthalmologists on call where the neurologist on call for stroke has to make a decision based on clinical judgement. Both of these scenarios usually end in poor visual acuity for the patient after medical treatment with monotherapy or dual therapy antiplatelet with or without permissive hypertension and statin treatment.

By |August 10th, 2020|clinical|0 Comments