American Heart Association

Monthly Archives: January 2020

Good Collaterals Despite Low ASPECTS: Expanding Thrombectomy Candidates

Elena Zapata-Arriaza, MD
@ELeNaZapS

Broocks G, Kniep H, Schramm P, Hanning U, Flottmann F, Faizy T, et al. Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization. J Neurointerv Surg. 2019.

The primary therapeutic target of mechanical thrombectomy defined by the salvageable tissue at risk is minimized in patients with low Alberta Stroke Program Early CT Score (ASPECTS). In contrast, the risk of developing malignant infarctions is maximized in patients with a large early ischemic core, which can lead to severe complications by progressive ischemic edema within the first days after stroke onset. Low ASPECTS (≤5) still represents a limitation for stroke thrombectomy performance. But what happens in those patients with low ASPECTS and good collaterals after endovascular treatment? Do these cases have the potential to achieve good functional results? Broocks and colleagues have employed these questions as the starting point in the present paper.

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

Meet the Blogger: Lina Palaiodimou, MD

Lina Palaiodimou

Name: Lina Palaiodimou, MD
Hometown: Athens, Greece
Current Position: Neurologist, Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

Q: What made you interested in a career in stroke?

A: Until the recent past, the following playful dogma prevailed: “Neurologists know everything, but do nothing.” Stroke and the recent therapeutic advances regarding acute treatment really changed that scenery. Rapid information processing, accurate critical thinking, effective cooperation, and, of course, the adrenaline rush constitute the core of acute stroke management and actually describe my dream job. So, when I first got involved with an acute stroke patient being thrombolyzed and getting dramatically better, I was determined that a stroke career would suit me. That has not changed a bit since then.   

Q: What has been your career path into this field?

A: I graduated from Medical School, Aristotle University of Thessaloniki, in Greece, and the Military Medical Academy in Thessaloniki, Greece. In late 2019, I completed the neurology residence in Attikon University General Hospital of Athens. Currently, I am a PhD student in Medical School, National and Kapodistrian University of Athens, and my thesis is focused on stroke management and prognosis. I am also working with a team of dedicated stroke neurologists in the Division of Cerebrovascular Diseases of Attikon University General Hospital of Athens, where more than 600 stroke patients are being evaluated per year, in an inpatient and outpatient setting.

By |January 28th, 2020|clinical|0 Comments

PICASSO Trial: The Shades of Anti-Platelets

Rachel Forman, MD

Kim BJ, Kwon SU, Park J-H, Kim Y-J, Hong K-S, Wong LKS, et al. Cilostazol Versus Aspirin in Ischemic Stroke Patients With High-Risk Cerebral Hemorrhage: Subgroup Analysis of the PICASSO Trial. Stroke. 2019.

One of the most common discussions on any given stroke service involves the balance of preventing ischemic strokes (IS) and preventing intracranial hemorrhage (ICH). Whether it is about resuming anticoagulation in a hemorrhage patient or resuming aspirin in a patient with cerebral amyloid angiopathy there is always much debate on timing and decisions.  The decision to resume aspirin in a patient with an MRI full of cerebral microbleeds (CMBs) is often difficult. This paper looks into an alternative agent, cilostazol, for reducing hemorrhage risk in patients who warrant anti-platelet therapy. The background of the study is that cilostazol has shown to have less hemorrhagic events than aspirin among patients with ischemic stroke. 

The PICASSO trial (Prevention of Cardiovascular Events in Asian Ischemic Stroke Patients with High Risk of Cerebral Hemorrhage) was an Asian trial that aimed to determine which antiplatelet agent is more effective and safe in patients with prior hemorrhagic stroke or multiple CMBs. Cilostazol is an antiplatelet agent with additional vasodilatory effects. The trial, published in 2018, showed that cilostazol was noninferior to aspirin in preventing a composite of major vascular events; however, it failed to reduce ICH. This paper reviews the subgroup analysis to identify patients who would show greater benefit with cilostazol. 

Meet the Blogger: Piyush Ojha, MBBS, MD, DM

Dr. Piyush Ojha

Name: Dr. Piyush Ojha, MBBS, MD, DM
Hometown: Neemuch, Madhya Pradesh, India
Current Position: Stroke Neurologist, Jabalpur, Madhya Pradesh, India

Q: What made you interested in a career in stroke?

A: During my neurology residency, I attended the World Stroke Congress held in Hyderabad, India, where I presented two papers. I also got a chance to meet some of the best brains working in the field of stroke. Looking at the recent developments in the area of stroke over the last five years, I was inclined towards making stroke my future career.

Q: What has been your career path into this field?

A: After finishing my neurology residency, I worked at a hospital at Jabalpur, India, where I tried to create stroke awareness by conducting many talks and public awareness programs. Then, I was lucky enough to be selected as a stroke fellow with the prestigious Calgary Stroke Program, where I got an opportunity to work with an excellent team of dedicated stroke neurologists and fellows.

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

Meet the Blogger: Melissa Trotman-Lucas, PhD

Name: Dr. Melissa Trotman-Lucas, PhD
Hometown: Nottingham, England, UK
Current Position: Research Fellow, University of Nottingham, UK

Q: What made you interested in a career in stroke?

A: As an undergraduate at the University of Leicester, I studied biological sciences. A significant part of this course involved an in-depth look at brain function and, conversely, its dysfunction. I enjoyed thinking about cellular physiology and how functioning is impacted following the smallest of changes. When [there was] a PhD opportunity to study the role of excitotoxicity in the pathological damage that occurs following ischemic stroke, I was excited to investigate this and better understand it. A close family member of mine had suffered multiple strokes, so I knew the impact this debilitating disease could have on an individual, but also to the surrounding family. So, for me, to work even in the smallest way towards improving treatment and recovery for stroke sufferers was of a keen interest for me.

By |January 22nd, 2020|clinical|0 Comments

Article Commentary: “Effect of Heart Rate on Stroke Recurrence and Mortality in Acute Ischemic Stroke With Atrial Fibrillation”

Alan C. Cameron, BSc (Hons), MB ChB, PhD, MRCP

Lee K-J, Kim BJ, Han M-K, Kim J-T, Choi K-H, Shin D-I, et al. Effect of Heart Rate on Stroke Recurrence and Mortality in Acute Ischemic Stroke With Atrial Fibrillation. Stroke. 2020;51:162–169.

Atrial fibrillation (AF) is a common comorbidity in patients with acute ischaemic stroke and a dilemma frequently encountered in clinical practice is whether we should aim for stringent or lenient rate control in patients with AF. Lee and colleagues sought to address this question by assessing associations between mean heart rate, heart rate variability and clinical outcomes in more than 2,000 patients with acute ischaemic stroke and AF included in a prospective, multi-centre, Korean-based stroke registry. The authors demonstrate a J-shaped association between heart rate and mortality, with heart rates in the region of 80 beats per minute associated with lowest risk of mortality at 24 hours or 3 to 7 days after stroke onset and heart rates above or below this sweet-spot associated with increased mortality. Similar results were observed for a composite endpoint of stroke recurrence, myocardial infarction and all-cause mortality, although no effect was observed on stroke recurrence alone, nor from heart rate variability on mortality, stroke recurrence or the composite endpoint. 

By |January 21st, 2020|clinical|0 Comments

Meet the Blogger: Burton J. Tabaac, MD

Burton J. Tabaac

Name: Burton J. Tabaac, MD
Hometown: Philadelphia, PA
Current Position: Comprehensive Stroke Director, Renown Health, and Clinical Assistant Professor of Neurology at the University of Nevada Reno

Q: What made you interested in a career in stroke?

A: The acuity and pace of emergent stroke care is unmatched in the field of medicine. In staying current with clinical trials, and by following updates to AHA/ASA guidelines, vascular and interventional neurologists can deliver the most forefront and up-to-date evidence-based medicine as it pertains to management, treatment, prevention, and rehabilitation. I share in the passion and dedication to this field, supported by a vast, dedicated, and engaged community of providers.

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

The Acute Ischemic Stroke Patient with Cerebral Microbleeds — When is IV Thrombolysis Beneficial?

Bahar M. Beaver, MD

Schlemm L, Endres M, Werring DJ, Nolte CH. Benefit of Intravenous Thrombolysis in Acute Ischemic Stroke Patients With High Cerebral Microbleed Burden. Stroke. 2020;51:232–239.

Cerebral microbleeds (CMB) have long presented a clinical challenge in the treatment of acute ischemic stroke. Patients with a high burden of CBMs are at a higher risk of intraparenchymal hemorrhage; however, thoroughly evaluating this burden in each treatment-eligible patient is time-intensive and can delay otherwise life-saving therapy. The authors in this article, led by Dr. Ludwig Schlemm, MD, of Berlin, dove into this dilemma and evaluated risk/benefit profiles of treatment with intravenous thrombolysis (IVT) in patients with both high (> 10) and low (<10) CMB burden presenting with acute ischemic stroke. Their attention was mainly on outcomes in these patients. 

The authors used existing data from recent meta-analyses and prospective cohort studies in their statistical analysis. In total, they used data from seven studies. The primary outcome measure was the effect of IVT in patients with high CMB burden and low CMB burden. This was measured using a weighted modified Rankin Score (mRS). In a complicated, yet thorough, 13-step algorithm, results were divided into multiple categories and compared against several pathways. This breakdown is nicely depicted in Figure 1 of the article. Briefly, the authors used estimated 90-day mRS of patients with acute ischemic stroke and presumed average CMB burden who did not receive IVT and those who did. They also included treatment delay as a factor in this model. Then, they analyzed the mRS outcomes of patients who received IVT with high CMB burden and low CMB burden. They further compared the outcomes of patients with both high and low CMB burden who did not receive IVT.

Schematic diagram of the algorithm.

Figure 1. Schematic diagram of the algorithm.
By |January 15th, 2020|clinical|0 Comments

Article Commentary: “Non–Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Asians With Atrial Fibrillation”

Anusha Boyanpally, MD

Xue Z, Zhang H. Non–Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Asians With Atrial Fibrillation: Meta-Analysis of Randomized Trials and Real-World Studies. Stroke. 2019;50:2819–2828.

The authors have evaluated randomized control trials (RCT) and meta-analysis of observational studies (real-world studies) to compare the effects of non-vitamin K antagonist oral anticoagulation (NOACs) with warfarin in atrial fibrillation (AF) in the Asian population. The incidence of AF and complications associated with it are higher in the Asian population. Four worldwide RCT studies (1-4) compared NOACs with warfarin. NOACs demonstrated noninferiority in efficacy and reasonable safety. Specifically, in the Asian population, Wang et al. (5) have demonstrated that standard NOACs are safer and more effective in Asians. When a lower dose of NOACs was used in the Asian population, it still showed similar efficacy and safety. However, the Asian Pacific Heart Rhythm Society still recommends a standard dose of NOACs for the Asian population. Nevertheless, real-world efficacy and safety of NOACs in the Asian population is still unclear.

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

Author Interview: Dr. Christopher D. Anderson, MD, MMSC, on “Genetics of Cerebral Small Vessel Disease”

Christopher D. Anderson
Dr. Christopher D. Anderson

A conversation with Christopher D. Anderson, MD, MMSC, Assistant Professor of Neurology, Harvard Medical School, Director or Acute Stroke Services at Massachusetts General Hospital, Faculty in the Center for Genomic Medicine and Associate Member at the Broad Institute. 

Interviewed by Rachel Forman, MD, vascular neurology fellow, Massachusetts General Hospital.

They will be discussing the article “Genetics of Cerebral Small Vessel Disease,” published in the January 2020 issue of Stroke.

Dr. Forman: First of all, thank you for taking the time to sit down with me and discuss this important topic. How did this article come to fruition?

Dr. Anderson: This feature is part of a larger set of articles on cerebral small vessel disease (SVD) that was submitted as a group, and the genetics of SVD is a specific consideration that sheds a lot of light on the pathogenesis of the disease. I think it merited its own exploration as part of this issue. 

Dr. Forman: Can you expand on the categorization of SVD into arteriosclerosis and amyloidosis?

Dr. Anderson: As it stands, these days SVD is subcategorized into amyloid-related and hypertensive or SVD-related. You can think of SVD as an arteriolar process that arises from the perforating arteries of the deep structures and is categorized by lipohyalinosis and sometimes perivascular necrosis. This is really pathologically distinct from the amyloid-related disease, which tends to be on the other side of the brain out in the cortical surface and the sub-cortical structures and is characterized by the classic apple green birefringent amyloid-related disease that results in this arteriopathy. This can co-exist often with SVD and certainly seems to be accelerated by the concurrent presence of SVD, but genetically at least, has a relatively distinct set of risk factors. 

By |January 13th, 2020|clinical|0 Comments