American Heart Association

Monthly Archives: October 2020

Every Life Matters! What We Learned From This Pandemic

Nurose Karim, MD

Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke. 2020;51:3433–3439.*

This article aims to address the role of social determinants of health (SDOH) on stroke disparities in order to understand the impact of SDOH on stroke outcome.

SDOH are non-clinical and non-biological social factors that impact health and include fundamental causes of disease such as racism and discrimination; unequal distribution of power, income, wealth, and education; and societal values. This is supported by the statistic provided in the article, for instance; in New York City, Black and Latinx Americans have about two times higher mortality from the Coronavirus Disease 2019 (COVID-19) pandemic than non-Hispanic White Americans. Similarly, in Michigan, Black people had 35% morbidity and 40% mortality rate from COVID-19 despite being 14% of the Michigan population.

By |October 30th, 2020|clinical|0 Comments

World Stroke Day: The Long Journey of Revascularization Treatments for Ischemic Stroke: From Strict Patient Selection to Extending Time Windows

Raffaele Ornello, MD

Until the early 1990s, stroke was regarded as a disabling event with no cure. The NINDS trial of intravenous thrombolysis, published in 1995, changed the minds of stroke physicians and marked the rise of revascularization treatments for acute ischemic stroke. The initial criteria for patient selection were very strict. After that, more and more refined protocols were established, allowing the progressive extension of the therapeutic window and the loosening of selection criteria.

The last decade saw the rise of endovascular treatments. After the first unsuccessful trials, adequate protocols for the selection of patients with salvageable brain ischemic tissue led to success in recanalization treatments. Better use of brain neuroimaging led to refinements in patient selection, allowing the extension of time windows for treatments in eligible patients. Over the years, revascularization treatments for ischemic stroke spread over most hospitals in the world, allowing widespread access to treatments.

World Stroke Day: Interview with Dr. Anna Bersano on the Impact of the COVID-19 Pandemic on Stroke Care in Italy

Dr. Anna Bersano
Dr. Anna Bersano

An interview with Dr. Anna Bersano, MD, PhD, at the Cerebrovascular Unit of Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy, about the impact of the COVID-19 pandemic on stroke care in Italy.

Interviewed by Francesca Tinelli, MCs, rare cerebrovascular disease fellow at Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

Dr. Tinelli: First of all, I present you Dr. Anna Bersano, the neurologist I work with, and I would like to thank Anna for agreeing to do this interview. 

Anna is a stroke neurologist with long-term expertise in cerebrovascular diseases, particularly in genetics of monogenic and complex stroke diseases, combining research with an active practice as a vascular care neurologist. She coordinated several studies on genetics of stroke, such as the Lombardia GENS study on stroke monogenic disease and the SVE-LA study on genetics of small vessel disease and lacunar stroke. Recently, she implemented an Italian network for the study of Moyamoya disease named GE-NO-MA (Genetics of Moyamoya Disease) and an Italian network for the study of Cerebral Amyloid Angiopathy (SENECA project). 

Dr. Bersano: Thank you for discussing this relevant and critical topic in the current situation.

Dr. Tinelli: What is the correlation between SARS-CoV2 and cerebrovascular diseases?

Dr. Bersano: It is well known that SARS-CoV2 invades human respiratory epithelial cells through its S-protein and ACE2 receptor on human cell surface. Then, the virus can spread from the respiratory tract to the central nervous system, causing possible neurological complications. A recent study on 214 Chinese COVID-19 patients reported acute cerebrovascular events in 5.7% of COVID-19 patients. However, the exact relationship between SARS-CoV2 and stroke is unclear. Patients affected by COVID-19 have been observed to have a higher risk of cerebrovascular events, probably due to the activation of coagulation and inflammatory pathways, which lead to cardiovascular and thrombotic complications, or to cardioembolic causes.

World Stroke Day: #DontStayAtHome: Stroke Symptoms Awareness Among Young Adults — Education is Key

Victor J. Del Brutto, MD

Mszar R, Mahajan S, Valero-Elizondo J, Yahya T, Sharma R, Grandhi GR, Khera R, Virani SS, Lichtman J, Khan Su, et al. Association Between Sociodemographic Determinants and Disparities in Stroke Symptom Awareness Among US Young Adults. Stroke. 2020.

Stroke is a devastating disease with potentially catastrophic consequences to its victims and their families. In the acute setting, immediate specialized evaluation and rapid delivery of time-sensitive therapies are crucial to improve the chances of a meaningful neurological recovery. Stroke systems of care across the world work daily in maximizing their treatment times in order to save neurons. However, time from symptoms onset to hospital arrival mainly depends on community awareness of stroke warning signs and the emergent response to stroke-like symptoms when they are perceived.

The World Stroke Day observed annually on October 29 was launched in 2006 with the main goal of raising awareness of the prevention and treatment of stroke. Mszar and colleagues bring us a timely analysis on the association between sociodemographic characteristics and disparities in awareness of stroke symptoms among U.S. young adults, a population group that has shown increasing trends in stroke incidence and stroke-related hospitalizations during the last few decades.

Stroke Plays Neither Fair, Nor Equal

Isabella Canavero, MD

Kamin Mukaz D, Zakai NA, Cruz-Flores S, McCullough LD, Cushman M. Identifying Genetic and Biological Determinants of Race-Ethnic Disparities in Stroke in the United States. Stroke. 2020;51:3417–3424.*

The hypothetical “democracy” of diseases potentially affecting everyone has to be retracted when analyzing real-world data. We must acknowledge that, actually, nothing is fair about diseases. Access to medical care, nutrition, socioeconomic status, and education are relevant factors in determining course and outcome of many diseases, especially in the vascular area. Stroke follows this rule: As compared to White people, other underrepresented racial-ethnic populations are featured by a disproportionately higher prevalence of traditional vascular risk factors (hypertension, diabetes, obesity above all).

Besides socioeconomic and cultural determinants of lifestyle resulting in vascular risk factors, Kamin Mukaz et al. explored genetic and biological factors partly accounting for the racial disparity of stroke by reviewing current evidence from large cohorts.

Author Interview: Dr. Bruce Ovbiagele on “HEADS-UP: Understanding and Problem-Solving: Seeking Hands-Down Solutions to Major Inequities in Stroke”

A conversation with Dr. Bruce Ovbiagele, MD, MSc, MAS, MBA, Professor of Neurology, University of California, San Francisco.

Interviewed by Dr. Saurav Das, MD, Fellow in Vascular Neurology, Washington University School of Medicine, St. Louis.

They will be discussing the article “HEADS-UP: Understanding and Problem-Solving: Seeking Hands-Down Solutions to Major Inequities in Stroke,” published in November 2020 issue of Stroke. The article is part of a Focused Updates series of articles on topics related to health equity.

Dr. Das: Dr. Ovbiagele, at the outset, I want to thank you on behalf of the Blogging Stroke team for organizing this timely and reflective series of articles. I read with enthusiasm your introduction to the series. Thanks for finding time for this interview.

Dr. Ovbiagele, COVID-19 and the killings of unarmed Black individuals by police recently have brought to the forefront discussions about pre-existing racial disparities in stroke care. However, the idea of HEADS-UP was envisaged even before these extenuating circumstances. Please throw some light on the origins of the idea.

Dr. Ovbiagele: My co-chair, Dr. Amy Towfighi, and I have been involved in stroke disparities research for a while (Amy doing work with the Latinx population in Los Angeles, and I doing work with people of African ancestry in South Carolina and Sub-Saharan Africa), and had lamented about both the lack of successful interventions and a clear pipeline of next generation stroke disparities researchers. We observed that with changing U.S. demographics and anticipated worsening of stroke inequities, stroke disparities research and publications seemed to mostly focus on repeatedly pointing out the existence and magnitude of racial/ethnic disparities, that the stroke disparities community was not routinely connected or integrated in a sustainable way, and that early career individuals interested in stroke disparities did not appear to have an established avenue through which to nurture that interest into a successful independent academic career. We thought that if we could bring key stakeholders together in a forum that routinely informs and inspires established and budding stroke disparities researchers to better solutions and greater heights, we might be able to accelerate the pace of discoverers and discoveries. We approached the American Stroke Association, National Institute of Neurological Disorders and Stroke, and several of our esteemed research colleagues about the idea, and then collectively planned and implemented the inaugural Symposium.

Pictured, from left to right, at the International Stroke Conference 2020, are Dr. Amy Towfighi, Dr. Bruce Ovbiagele, Dr. Ralph Sacco, and Ms. Adrienne Kenton, daughter of Dr. Edgar Kenton III, after whom the Kenton Award is named.
Pictured, from left to right, at the International Stroke Conference 2020, are Dr. Amy Towfighi, Dr. Bruce Ovbiagele, Dr. Ralph Sacco, and Ms. Adrienne Kenton, daughter of Dr. Edgar Kenton III, after whom the Kenton Award is named. Photo provided, with permission, by Dr. Ovbiagele.

Dr. Das: Dr. Ovbiagele, you have summarized in your introduction a series of key papers from the 2020 HEADS-UP symposium in Los Angeles, California. These papers explore biological and social determinants of disparities and explore multi-level interventions. However, neither of these categories have explored “racism,” individual or systemic, as a study variable in stroke research. What are your thoughts, and will this be addressed in the HEADS-UP symposium in 2021?

Author Interview: Prof. Marc Ribo on “Deep Learning Based Software to Identify Large Vessel Occlusion on Noncontrast Computed Tomography”

Prof. Marc Ribo
Prof. Marc Ribo

An interview with Prof. Marc Ribo, MD, PhD, Assistant Professor at the Stroke Unit/Department of Neurology at the Hospital Vall d’Hebron, Barcelona, Spain.

Interviewed by Dr. Vera Sharashidze, MD, Vascular Neurology Fellow, University of Miami.

They will be discussing the article “Deep Learning Based Software to Identify Large Vessel Occlusion on Noncontrast Computed Tomography,” published in the October 2020 issue of Stroke.

Dr. Sharashidze: First of all, thank you for taking time to discuss this very interesting article. What led you to become interested in this topic?

Prof. Ribo: My first interest in AI analysis of acute stroke imaging began when I met by coincidence with an expert engineer who wanted to use his skills to help stroke patients.

Author Interview: Dr. Mayank Goyal on “Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging”

Dr. Mayank Goyal and Dr. Saurav Das
Dr. Mayank Goyal, left, and Dr. Saurav Das

A conversation with Mayank Goyal, MD, PhD, Professor of Radiology and Clinical Neurosciences, University of Calgary.

Interviewed by Saurav Das, MD, Fellow in Vascular Neurology, Washington University School of Medicine, St. Louis.

They will be discussing the topical review “Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging,” published in October 2020 issue of Stroke

Dr. Das: Dr. Goyal, the Blogging Stroke team is happy to have you for an author interview today. Thanks for this provocative paper, which disrupts several currently accepted ideas that guide decision-making in stroke patients to make way for new innovation.

Let’s start by discussing the context in which this paper was conceptualized. The paper has a line-up of great authors, many considered visionaries in vascular neurology, across countries. Please tell us more about how this collaboration came into being.

Dr. Goyal: I have been thinking about the problem of defining ischemic core on baseline imaging for a long time. I noticed patients with a really bad-looking baseline CT, patients in which you would be inclined to call the whole MCA territory “core.” But when these patients went on to endovascular treatment and we managed to re-open the occluded vessel quickly, many of those did well, and their follow-up MRI scans showed that much of the parenchyma thought to be “core” was not actually damaged. More importantly, many of these patients did well clinically, resulting in a clinical-imaging mismatch. In addition, I was quite convinced that the so called “core” on CT perfusion was quite an exaggeration of the truth. In some ways, when many of the trials were being designed, they came in the aftermath of the Interventional Management of Stroke (IMS) 3 trial, and hence, people were over-conservative in their selection criteria. I then started talking to several of my collaborators and friends from all over the world, to see whether they felt the same way. This is when this collaboration was formed.

Does Gender Play a Role in TIA/Stroke Diagnosis?

Shashank Shekhar, MD, MS

Gocan S, Fitzpatrick T, Wang CQ, Taljaard M, Cheng W, Bourgoin A, Dowlatshahi D, Stotts G, Shamy M. Diagnosis of Transient Ischemic Attack: Sex-Specific Differences From a Retrospective Cohort Study. Stroke. 2020.

Sex differences might play a role in TIA/stroke diagnosis. Men and women could have variable TIA/stroke symptom characteristics. Women especially have been reported to have non-specific and atypical symptoms, which can result in a wrong diagnosis or no diagnosis. However, stroke in women tends to have a more severe and complicated course. The recent study by Gocan et al., published in Stroke, attempts to determine the relationship between clinical variables associated with a neurologist’s final diagnosis of TIA/stroke and the patient’s sex difference.

The authors conducted a retrospective analysis of the patient cohort from the Ottawa Hospital Stroke prevention clinic in 2015. The study identified 23 character variables for TIA/stroke diagnosis. Out of that, 15 variables were used, and the remaining eight were excluded due to the low frequency of occurrences.

Is CT Perfusion Blocking the Route to Endovascular Thrombectomy?

Ammad Mahmood, MBChB, BMedSci

Lopez-Rivera V, Abdelkhaleq R, Yamal J-M, Singh N, Savitz SI, Czap AL, Alderazi Y, Chen PR, Grotta JC, Blackburn S, et al. Impact of Initial Imaging Protocol on Likelihood of Endovascular Stroke Therapy. Stroke. 2020;51:3055–3063.

The optimum imaging to evaluate patients presenting with acute ischemic stroke and determine suitability for endovascular thrombectomy (EVT) remains contentious. Non-contrast CT brain (NCCT) is universal, and CT angiogram (CTA) is necessary if EVT is planned. The added value of CT perfusion (CTP) is the subject of ongoing research and debate.

Lopez-Rivera et al. conducted a retrospective analysis of data collected in a study of implementation of EVT in the Houston area. They compared data from one center where CTP was carried out in all patients without contraindications (CTP-H – high usage) and three centers where CTP was carried out optionally at the discretion of the clinical team (CTP-L – low usage). Baseline populations differed significantly with CTP-H sites having higher proportions of patients with history of AF (24% vs 16%), diabetes (34% vs 21%), hypertension (77% vs 49%), hyperlipidaemia (45% vs 23%) and higher median NIHSS (14 vs 11), but better baseline modified Rankin scale (mRS) score (78% mRS 0-2 vs 66%). CTP-H sites also had proportionately fewer direct presentations but more early time window (0-6 hours) presentations and more patients treated with IV thrombolysis. The proportion of patients undergoing EVT in both CTP-H and CTP-L centers showed no significant difference, including amongst patients who had undergone CTP (47% vs 51%) and those who had not (41% vs 49%); those with large (>50ml) predicted ischemic core (53% vs 37%); and those with ASPECTS score <6 (32% vs 23%).

By |October 20th, 2020|clinical|0 Comments