Greater than 50% of patients with successful recanalization
are unable to regain functional independence at 3 months. There are several
factors that contribute to the functional outcomes of patients who undergo mechanical
thrombectomy; however, blood pressure is a prognostic factor that can be
modulated (or managed). This article
addresses blood pressure management as a critical prognostic factor for outcome
in acute ischemic stroke treated with mechanical thrombectomy.
A systematic review of peri-procedural blood pressure values
during mechanical thrombectomy was performed. A total of 9 studies out of 576
were eligible for systematic review after 2012. The 9 studies were comprised of
1 multicenter trial, 4 prospective trials, and 5 retrospective trials for a
total of > 1000 patients. The systematic review revealed differences in how
patient hemodynamics are being measured, as well as managed.
Name: Rohan Arora, MD, FAHA Hometown: New Delhi, India Current Position: Director of Stroke Program at LIJ Forest Hills, New York; Program Director, Vascular Neurology Fellowship, Zucker School of Medicine at Hofstra, Northwell, NY
Q: What made you interested in a
career in stroke?
A: Finding myself in a position
where my knowledge and expertise can save an individual from having permanent
disability due to stroke is my constant motivation to practice this field. It
could be a quick phone call/a telemedicine consult or long hours of ICU care;
Q: What has been your career path
into this field?
A: My focus is providing cutting
edge clinical care, especially to young stroke patients, and enrolling patients
in NIH-funded clinical studies and clinical trials. I am interested in finding
novel methods to encourage people for a low-stress healthy lifestyle; that is
one of the most commonly encountered risk factors for stroke and cerebrovascular
A conversation with Dr. Eric Jouvent,
MD, PhD, Professor of Neurology at Paris University. He is involved in acute
stroke care in the stroke unit in Lariboisière Hospital in Paris. He holds a
PhD in image processing.
Interviewed by Dr.Stephanie
Lyden, MD, BS, a vascular neurology fellow at the University of Utah.
First of all, thank you for taking the time to discuss this important topic.
What led you to become interested in studying CADASIL?
Dr. Jouvent: It was not really
a choice at first. Residency in France is different than in the United States,
where we first choose a city and then we move from department to department in
that city. At the end of that time period, you hope to match in a department or
with a team. At the end of my cycle, I matched with a team headed by Dr. Bousser,
who identified the first family with CADASIL, in part because I was not only
interested in stroke, but also in cognitive and behavioral alterations and in
advanced MRI techniques, which are key aspects in small vessel diseases. This
was how I started to become involved in CADASIL research.
An interview with Dr. Marco Pasi, MD,
Stroke Clinical Fellow at Université de Lille, CHU Lille, Inserm U1172,
France, on his article “Clinical Relevance of Cerebral Small Vessel Diseases.” The article, co-authored by Prof. Charlotte Cordonnier,
was published in the January 2020 issue of Stroke as part of a Focused
Updates in Cerebrovascular Disease series of articles on topics related to cerebral
small vessel diseases.
Interviewed by Dr. Parneet Grewal, MD,
Vascular Neurology Fellow at Rush University Medical Center, Chicago, Illinois.
Dr. Grewal: First, I would
like to thank Dr. Pasi and Pr. Cordonnier for agreeing to do this interview.
This is an interesting paper which discusses in detail the main manifestations
of cerebral small vessel disease (SVD) along with their impact. Can you please
summarize the key findings of your paper and their application to clinical practice?
Dr. Pasi: Cerebral small vessel diseases (SVD)
have gained increased interest in the last decades as they play a crucial role
in a large variety of conditions, such as aging, stroke, cognitive impairment,
and other age-related disabilities. The term SVDis used with various meanings according to the context, but from a
neuropathological perspective, SVD describes a group of pathologies that affect
the perforating arteries and arterioles located in the brain parenchyma or in
the leptomeningeal vessels. Sporadic SVD is characterized by two main forms
that mainly differ for their localization within the brain. The first one is arteriolosclerosis,
also known as hypertensive-SVD, which has a predilection for the deep
lenticulostriate arteries that are vulnerable to poorly controlled and long-standing
hypertension or diabetes. The second most common form is cerebral amyloid
angiopathy that is a pathological process characterized by the progressive
accumulation of ß-amyloid protein in the wall of small cortical and
leptomeningeal arterioles and arteries. It is clinically relevant to
distinguish these two forms of SVD because they differ in terms of hemorrhagic
risk with important consequences when antithrombotic decisions need to be taken.
In our review, we aimed to provide a comprehensive overview of the main
clinical manifestations of SVD that could help stroke physicians in their daily
Given the association among successful reperfusion and good
functional outcomes, it is rational to look for tools that allow us to achieve
the best TICI in patients undergoing mechanical thrombectomy. Within the ways
to improve recanalization, we find the employment of safe and reliable devices
with the ability to navigate more and more distally or the use of
intra-arterial medication at the occlusion site. To determine the safety and
efficacy of intra-arterial urokinase after failed or incomplete reperfusion in
stroke mechanical thrombectomy(MT), Kaesmacher et al. performed an observational
cohort study, with data collected from a prospective registry in a tertiary
care stroke center from 2010-2017.
Primary safety outcome was the occurrence of symptomatic
intracranial hemorrhage (sICH), and secondary endpoints included 90-day mortality
and 90-day functional independence (defined as modified Rankin Scale score of
2). Efficacy was evaluated angiographically, applying the Thrombolysis in
Cerebral Infarction (TICI) scale. Patients who were treated with intra-arterial
urokinase (with or without intravenous tPA) only and patients presenting with
posterior circulation large-vessel occlusion or distal anterior circulation
vessel occlusions were excluded. Endovascular treatment was performed with
second generation devices only, mostly stent retrievers. Urokinase was injected
manually before or next to and distal to the thrombus, usually via the same
microcatheter used to introduce the MT device. Final TICI grades were assessed
by an independent researcher. When intra-arterial urokinase was administered
after failed or incomplete MT, TICI grade was assessed before and after the
intra-arterial urokinase administration. If no change occurred in TICI after
urokinase administration, the rater had to assess whether any kind of
angiographic improvement occurred compared with before administration of
Spontaneous intracerebral hemorrhage (ICH) remains a major
cause of morbidity and mortality worldwide. Hematoma expansion affects 30-40%
of patients with acute ICH within the first few hours of onset; hence, its
prevention is an important treatment target in acute ICH care to prevent
neurological worsening and poor long-term outcome, thus necessitating more
close neurological monitoring. Although the presence of spot sign in Computed
Tomography (CT) angiography predicts hematoma expansion, only a minority of ICH
patients receives contrast injection during the initial imaging. Since non-contrast
CT (NCCT) is widely available and used, NCCT markers represent an important
alternative for prediction of hematoma expansion.
NCCT signs can be divided into density markers (swirl sign,
blend sign, black hole sign, hypodensity and fluid level) and shape markers
(irregular shape, island sign and satellite sign).
Various observational studies, RCT populations and
meta-analyses have suggested that NCCT signs markers might be reliable
predictors of hematoma expansion and poor outcome in ICH, but with different
effect size and strength of association.
Oudeman et al. have published a paper on non-focal TIA’s
which have been called transient neurological attacks (TNAs). As neurologists,
we are always trained to localize first, but anyone who has taken stroke calls
from the ER knows that not all the presentations and calls are localizable,
such as those mentioned in this paper and described as “bilateral weakness,
unsteadiness, or confusion.” In the introduction, the authors mention that
these were historically thought to be secondary to hypoperfusion, but recent
imaging have shown them to be associated with ischemia. Underlying risk factors
are common to traditional TIA’s, such as smoking and hypertension, but not
atherosclerotic disease or atrial fibrillation, which led to the current
investigation for an association between small vessel disease and TNAs.
International Stroke Conference February 19–21, 2020
Kat Dakay, DO
Use of the
transradial technique as an alternative to traditional femoral access in
neuroendovascular procedures has increased substantially over the last few
years after studies have demonstrated its advantages and lower risk of access
However, there is
a learning curve that one must traverse when adopting the transradial approach.
This year, the International Stroke Conference dedicated a symposium to a
multifaceted discussion about the benefits, challenges, and potential
complications unique to transradial access.
The session was moderated by Dr. Tudor Jovin and Dr. Nathan Manning, and speakers included Dr. Michael Levitt, Dr. Eric Peterson, Dr. Marios Psychogios, and Dr. Brian Snelling. Some major topics discussed:
1. Why go radial?
There are several reasons to consider utilizing the transradial approach. Dr. Peterson discussed one major reason, patient preference — with a transradial approach, there is no need for patients to lay flat postoperatively, which can make even small tasks like using the restroom awkward and cumbersome. Increased awareness of the transradial method by the general public has led to increasing patient requests to use this approach. Anecdotally, as a fellow explaining and obtaining consent for diagnostic angiograms, many patients have said to me, “I really hope you can use my hand instead of the leg.” As the popularity of transradial access in both cardiology and neuroendovascular procedures grows, this is likely to become more common. Objectively, one study demonstrated that 24/25 patients who underwent prior transfemoral cerebral angiography and subsequently underwent transradial angiography preferred the radial method. Another reason Dr. Peterson discussed is that in patients with obesity or significant arch tortuosity, transfemoral access can prove challenging and the radial approach may be easier in selected cases. Lastly, and probably the most compelling and important reason, which both Dr. Peterson and Dr. Levitt discussed, is that it is safer. Multiple cardiology trials have demonstrated that transradial procedures are safer than transfemoral procedures with an overall lower risk of major complications and mortality.[1, 3]
The relationship between normal-appearing white matter
(NAWM) integrity and specific brain functions has been reported during aging
and in patients with cerebral small vessel disease, suggesting that it might be
a relevant area of cerebral plasticity. In this study, the authors wanted to
evaluate the predictive value of NAWM integrity on different domains of
Through the Brain Before Stroke study undertaken by
the Bordeaux University Hospital, eligible patients (>18 years, ischemic
supratentorial stroke diagnoses within 24 to 72 hours after symptom onset,
NIHSS between 1-25, in the absence of pre-stroke dementia and pre-stroke
disability (mRS ≥1)) were prospectively and consecutively recruited between
June 2012 and February 2015.
International Stroke Conference
February 19–21, 2020
Session: “Screening for Cognition and Factors Related
to Brain Health,” Thursday, February 20, 2020
Moderators: Dr. Ronald M. Lazar, Birmingham, AL; and
Dr. Rebecca F. Gottesman, Baltimore, MD
Abstract: It is increasingly recognized that vascular
risk factors promote cognitive decline, both independently and interactively
with neurodegenerative disease. Because these risk factors are modifiable,
evaluation in the setting of primary care represents a unique opportunity for
early detection and treatment.
The session had four presentations. Dr. Walter N. Kernan Jr. from New Haven, CT, led the first talk on “Evaluating cognition in elderly at primary care.” He explained why primary care is important in recognizing cognitive issues. He went on to explain the spectrum of cognitive impairment, which ranges from subjective, mild cognitive impairment (annual risk of progression?), dementia (annual risk of progression 7%). He then laid out a simple flow chart of evaluating cognition in the primary setting: identifying the 1) signal, 2) case finding, 3) Classification and management. The signal could be in the form of reporting by patient or family, the observation by a physician, or casual inquiry. Case finding refers to using assessment tools such as Memory Impairment screen, MMSE, MOCA, etc., to screen for cognition. The final step is to confirm the diagnosis, identify any treatable causes, identify functional impairment, classify etiology, and further neuropsychiatric assessment.
Dr. Virginia J. Howard from Birmingham, AL, gave the second
presentation on “Considerations in cognitive assessment in disparate
populations.” Her talk focused on disparities related to sex, age, disability, socioeconomic
status, and geographic locations. She identified barriers to recruitment and
retention at different levels, i.e., individual to research institutions. She
suggested engaging community leaders in the research process and using
community outreach programs, and that preparing a realistic budget would
greatly help achieve the goal. Changes are also required in the study design, i.e.,
in-home evaluations, and identifying all levels of influences and barriers at
the institution and community would help with more recruitment and higher retention.