Monthly Archives: January 2021

Parneet Grewal, MD
@parneetgrewal6

Akyea RK, Vinogradova Y, Qureshi N, Patel RS, Kontopantelis E, Ntaios G, Asselbergs FW, Kai J, Weng SF. Sex, Age, and Socioeconomic Differences in Nonfatal Stroke Incidence and Subsequent Major Adverse Outcomes. Stroke. 2021;52:396–405.

Stroke is a leading cause of disability worldwide, and despite advances in management, mortality and disability rates remain high. This prospective population-based cohort study explores demographic variations in incidence of first ever non-fatal stroke and incidence of major adverse outcomes (composite major adverse cardiovascular events (MACE), recurrent stroke, cardiovascular (CVD)-related and all-cause mortality) after it. The data source of the study is UK Clinical Practice Research Datalink (CPRD), which collects de-identified patient data from data quality-assured GP practices across the UK. The cohort included patients aged 18 years and over who had first record of non-fatal stroke between January 1, 1998 and December 31, 2018. The patients were followed until they developed a major adverse outcome or left the original cohort for a mean follow up time of 1.81 years (SD: 2.78).

Ammad Mahmood, MBChB
@AMahmoodNeuro

Howard VJ, Algra A, Howard G, Bonati LH, de Borst GJ, Bulbulia R, Calvet D, Eckstein H-H, Fraedrich G, Greving JP, et al. Absence of Consistent Sex Differences in Outcomes From Symptomatic Carotid Endarterectomy and Stenting Randomized Trials. Stroke. 2021;52:416–423.

Management of carotid artery stenosis has been approached differently in women and men since the 1990s following the NASCET criteria.¹ More recently, trials comparing carotid artery stenting with endarterectomy have shown the modification of treatment effect by sex to be variable. The Carotid Revascularisation Endarterectomy vs Stenting Trial (CREST)² suggested women receiving stenting were at higher periprocedural risk of stroke, myocardial infarction or death compared to men, though there was no difference in the primary endpoint (periprocedural risks above or ipsilateral stroke within 4 years). Conversely, the International Carotid Stenting Study (ICSS)³ suggested a borderline higher periprocedural risk for men undergoing stenting. 

This meta-analysis pooled data from four trials of carotid artery stenting vs endarterectomy — CREST, ICSS, Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S)⁴ and Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE).⁵ A total of 4754 patients, 1437 women (30%), were included. The majority of events were periprocedural (335/433). Combining periprocedural risk and risk of ipsilateral stroke thereafter, the risk for women of stenting versus endarterectomy was found to be significantly lower in EVA-3S, non-significantly lower in ICSS and non-significantly higher in both SPACE and CREST. Overall, they found heterogeneity and inconsistency between trials, making the pooling of data inappropriate to draw conclusions from. Pooled data showed a trend to higher risk of stenting which did not reach significance in women but did in men, with no significant difference between women and men. Similar results were seen when considering periprocedural risk alone.

Yasmin Aziz, MD

Rothstein A, Oldridge O, Schwennesen H, Do D, Cucchiara BL. Acute Cerebrovascular Events in Hospitalized COVID-19 Patients. Stroke. 2020;51:e219-e222.

The search for the association between coronavirus and stroke began months ago in China. Since that time, various studies from around the world have sought to identify the incidence of vascular complications from the virus. 

In this study from The University of Pennsylvania, the authors performed a retrospective observational study across three hospitals between March 15 and May 3 to evaluate the incidence and mechanism of stroke in patients with COVID-19. The authors first looked for hospital-admitted patients who tested positive for SARS-CoV2 and then filtered by patients who received head imaging (either CT or MRI). Mechanism was then determined by a stroke neurologist using TOAST classification criteria.

Tolga D. Dittrich, MD

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.

Endovascular therapies (EVT) are a cornerstone of acute ischemic stroke therapy. CT- based perfusion imaging (CT-P), in addition to native CT and CT angiography, has become established in many clinics for the identification of patients with large vessel occlusions (LVO) who are eligible for EVT. But how does the choice of initial imaging protocol affect the probability of conducting EVT in patients with LVO?

A recent retrospective cohort study with four stroke centers has addressed this question. All four centers routinely performed native CT and CT angiography as part of the initial radiological assessment. The capacity to perform CT-P and EVT was present at all centers at all times. One participating center routinely performed additional CT-P with a high rate of usage (CTP-H), whereas the other three centers performed CT-P at a lower rate of usage (CTP-L) only at clinical discretion.

Setareh Salehi Omran, MD

Flint AC, Avins AL, Eaton A, Uong S, Cullen SP, Hsu DP, Edwards NJ, Reddy PA, Klingman JG, Rao VA, et al. Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment. Stroke. 2020;51:2697-2704.

Intravenous tissue-type plasminogen activator (IV tPA) and endovascular stroke treatment (EST) are considered standard-of-care for acute ischemic stroke. However, it is unclear whether there is a benefit to administrating IV tPA before EST in patients with large vessel occlusion who are eligible for both treatments. The need for IV tPA prior to EST has been further questioned by the results of the randomized DIRECT-MT trial, where EST alone was shown to be noninferior to IV tPA followed by EST.

Although IV tPA may improve early recanalization and reperfusion, there is concern for distal thrombus migration prior to EST, which may make the thrombus less accessible for endovascular retrieval. Data is scarce on how often this occurs. To address this issue, Flint et al performed a retrospective chart review of stroke cases in Kaiser Permanente Northern California’s Stroke EXPRESS program and examined the impact of IV tPA before EST on the rate of distal embolization, recanalization, and outcomes. The healthcare system comprises of 21 hospitals, two of which are comprehensive stroke centers, and is managed by a telemedicine program. All patients treated fully within the Kaiser Permanente Northern California system for both IV tPA and EST were included. Primary outcome was distal embolization, and secondary outcomes were angiographic (complete recanalization) and short- and long-term clinical improvements. Multivariable logistic regression was used to determine whether IV tPA with EST was associated with an increased risk of distal embolization compared to EST alone.