American Heart Association

Monthly Archives: February 2021

Antithrombotic Therapy Associated With Mild Severity of Ischemic Stroke in Patients With Atrial Fibrillation

Ying Gue, PhD
@DrYXGue

Jung YH, Kim YD, Kim J, Han SW, Oh MS, Lee JS, Lee K-Y. Initial Stroke Severity in Patients With Atrial Fibrillation According to Antithrombotic Therapy Before Ischemic Stroke. Stroke. 2020;51:2733–2741.

The use of oral anticoagulants (OAC) has been shown to reduce the incidence of stroke in patients with atrial fibrillation (AF). Apart from a study in 2006,1 there has not been any contemporary data exploring the association of OAC and stroke severity.

This study explores 10 years’ worth of data from a multicenter stroke registry in Korea investigating severity of acute ischemic stroke (AIS) and its relation to antithrombotic use (divided into none vs. antiplatelets vs. OAC) in patients with a history of AF. Out of a total of 77579 patients in the database, 6786 had a diagnosis of AF prior to their presentation with AIS. 2304 were not on antithrombotics, 2701 were on antiplatelets, and 1781 were on OAC.

By |February 16th, 2021|clinical|0 Comments

Article Commentary: “Association of Enlarged Perivascular Spaces and Anticoagulant-Related Intracranial Hemorrhage”

Song J. Kim, MD

Best JG, Barbato C, Ambler G, Du H, Banerjee G, Wilson D, Shakeshaft C, Cohen H, Yousry TA, Al-Shahi Salman R, et al. Association of enlarged perivascular spaces and anticoagulant-related intracranial hemorrhage. Neurology. 2020;95:e2192-e2199.

The clinical significance of cortical superficial siderosis, cortical microbleeds, and cortical subarachnoid hemorrhages — imaging markers of cerebral amyloid angiopathy (CAA) — has become clearer over the years as representing future and recurrent risk of symptomatic intracranial hemorrhages (sICH), especially lobar bleeds. Recently, enlarged perivascular spaces (EPVS) in the basal ganglia (BG-EPVS) and the centrum semiovale (CS-EPVS) have also come to the attention of researchers as possibly linked to hypertensive arteriopathy and CAA, respectively. Given this, could EPVS carry a risk of symptomatic intracranial hemorrhage (sICH) in patients starting anticoagulation? 

To answer this question, Best et al. conducted a post-hoc analysis of the CROMIS-2 (AF) study, a multicenter prospective cohort study examining the relationship between cerebral microbleeds and anticoagulant-related sICH over a 2-year follow-up period. Using baseline MRI imaging pre-anticoagulation, the number of BG-EPVS and CS-EPVS were enumerated and dichotomized (greater than 10 or less than 10). The association of EPVS with symptomatic intracranial hemorrhage was then investigated using Cox Regression analysis, which also incorporated other variables such as cortical microbleeds and lacunes.

COVID-19 Pandemic Disrupts Acute Stroke Care

Tyler Owens, DO

Montaner J, Barragán-Prieto A, Pérez-Sánchez S, Escudero-Martínez I, Moniche F, Sánchez-Miura JA, Ruiz-Bayo L, González A. Break in the Stroke Chain of Survival due to COVID-19. Stroke. 2020;51:2307–2314.

How has the COVID-19 pandemic affected our modern systems of acute stroke care? Montaner et al. performed a descriptive analysis before and during the current COVID-19 era, giving a glimpse into how the pandemic can negatively affect acute stroke care. The study was done in a southern region of Spain. Key metrics in the study were taken from pre-hospital and hospital acute care.

Data was collected from a region comprised of 2 stroke units and 2 large hospitals. One of the hospitals served as a thrombectomy referral center and the other as a tele-stroke referral center for several community hospitals. Data for the study was collected from an ongoing stroke registry. The study samples included 41 thrombectomies, 32 tele-stroke consults, and 51 patients treated with thrombolysis therapy. The bulk of the analyses focused on data 15 days prior to the outbreak to 15 days after (March 31, 2020).

Article Commentary: “Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease”

Lauren A. Peruski, DO

Kashyap VS, Schneider PA, Foteh M, Motaganahalli R, Shah R, Eckstein HH, Henao S, LaMuraglia G, Stoner MC, Melton J, et al. Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease. Stroke. 2020;51:2620–2629.

The ROADSTER 2 Trial discusses an innovative procedure (transcarotid artery revascularization – TCAR) aimed at treating patients with extracranial internal carotid artery (ICA) disease who are high-risk for current carotid revascularization options, through an assessment of early outcomes. Both symptomatic and asymptomatic patients were selected; symptomatic stenosis was defined as ≥ 50%, while asymptomatic stenosis was defined as ≥ 80%. The procedure uses the ENROUTE transcarotid stent and neuroprotection system, which clamps the proximal ICA and reverses blood flow through an extracorporeal arterial-venous shunt to the femoral vein, as a means of protecting the cerebral circulation from distal embolization during the procedure.

The patients chosen for the trial would otherwise be deemed too high-risk to undergo traditional carotid endarterectomy (CEA), whether due to unfavorable anatomy or significant medical co-morbidities. The 692 patients that comprised the study were a majority (67.8%) male, with comorbid hypertension, hyperlipidemia, and a history of tobacco use. 

By |February 10th, 2021|clinical|0 Comments

Article Commentary: “Vascular Endothelial Growth Factor 165-Binding Heparan Sulfate Promotes Functional Recovery From Cerebral Ischemia”

Francesca Tinelli, MS

Chan SJ, Esposito E, Hayakawa K, Mandaville E, Smith RAA, Guo S, Niu W, Wong PT-H, Cool SM, Lo EH, Nurcombe V. Vascular Endothelial Growth Factor 165-Binding Heparan Sulfate Promotes Functional Recovery From Cerebral Ischemia. Stroke. 2020;51:2844–2853.

Vascular endothelial growth factor-165 (VEGF165) is a member of the VEGF family that potently sustains angiogenesis and neurogenesis by stimulating proliferation and migration of endothelial and neural progenitor cells (NPC). Both processes are critical for the post-stroke recovery because they should restore the correct blood flow and supply oxygen and nutrients, enhancing brain functionality. Conversely, VEGF165 also regulates vascular permeability and increases blood-brain barrier (BBB) permeability, thus amplifying brain edema and neuroinflammation. Because of its powerful therapeutic potential, VEGF165 has been proposed as a treatment for improving stroke recovery.

Heparan sulfate (HS) proteoglycans are glycoproteins involved in several processes, such as cell adhesion and motility, signaling, transport, endocytosis, lysosomal degradation, cytoskeletal organization and basement membrane organization. They play an important role in angiogenesis, regulating VEGF receptor (VEGF-R) activation rates. The HS7 variant, thanks to the high affinity for VEGF165, stabilizes it in the extracellular matrix and thus safely enhances the effects of locally produced VEGF after stroke.

Does Admission Blood Pressure Influence the Outcomes of Endovascular Treatment for Ischemic Stroke?

Wern Yew Ding, MBChB

van den Berg SA, Uniken Venema SM, Mulder MJHL, Treurniet KM, Samuels N, Lingsma HF, Goldhoorn R-JB, Jansen IGH, Coutinho JM, Roozenbeek B, et al. Admission Blood Pressure in Relation to Clinical Outcomes and Successful Reperfusion After Endovascular Stroke Treatment. Stroke. 2020;51:3205–3214.

Endovascular treatment for early recanalization of an occluded artery has broadly been recognized to be an important aspect in the management of acute ischemic stroke. Yet, despite improvements in functional outcomes offered by this strategy, a significant proportion of patients have severe disability at follow-up. Therefore, additional targets for treatment need to be identified.

In a recent post-hoc analysis of the MR CLEAN Registry, Berg and colleagues assessed the relationship between admission blood pressure and short-term outcomes of ischemic stroke in patients treated with endovascular treatment. In brief, the MR CLEAN Registry was a prospective, observational cohort study of consecutive patients with ischemic stroke who were treated with endovascular treatment in the Netherlands. For the purposes of this analysis, the authors focused on adult patients who had a groin puncture within 6.5 hours after stroke onset and had intracranial proximal arterial occlusion in the anterior circulation, as demonstrated by computed tomography angiography.

By |February 8th, 2021|clinical|0 Comments

Article Commentary: “Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic”

Andy Lim, MBA, FACEM, GAICD
@ALim0211

Nguyen-Huynh MN, Tang XN, Vinson DR, Flint AC, Alexander JG, Meighan M, Burnett M, Sidney S, Klingman JG. Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic. Stroke. 2020;51:2918–2924.

There is an increasing evidence base for dramatic shifts in patient presentation patterns in response to the COVID-19 pandemic, and this article presents the Northern Californian experience in the stroke alert population subgroup. Presented is a before-and-after cohort analysis of presentation volumes, demographics, and short-term outcomes.

Data from 21 medical centers serving a population of 4.4 million were aggregated — 19 primary stroke centers and 2 comprehensive stroke centers. All participated in the ‘Stopping Stroke’ program, which involved rapid CT angiography, telestroke assessment, and expedited treatment for large vessel occlusion. The breakpoint chosen was the institution of ‘Shelter-in-place (SIP)’ orders, the period of lockdown during the pandemic, with the date cutoff of March 15, 2020.

By |February 5th, 2021|clinical|0 Comments

TCAR — Evidence is Accumulating. Is It Here to Stay?

Sara Hassani, MD, MHS

Kashyap VS, Schneider PA, Foteh M, Motaganahalli R, Shah R, Eckstein HH, Henao S, LaMuraglia G, Stoner MC, Melton J, et al. Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease. Stroke. 2020;51:2620–2629.

The ROADSTER II article, which follows its predecessor, the ROADSTER I study from 2015,1 recently published results in the September 2020 issue of Stroke. The article demonstrates some promising outcomes with regard to peri-procedural stroke rates when performing TransCarotid artery revascularization (TCAR).

TCAR represents a novel technique different from the established methods of carotid revascularization — namely, transfemoral stenting or carotid endarterectomy (CEA). With TCAR, the emphasis is on a transcarotid approach to stenting, and, additionally, there is a protection mechanism deployed to prevent cerebral embolization. The major Achilles heel of traditional transfemoral carotid artery stenting (tfCAS), known from prior studies (CREST,2 SPACE3), is the higher peri-procedural risk of stroke in comparison with CEA, and, unfortunately, distal filter placement during tfCAS has failed in the past to demonstrate convincing efficacy at lowering rates of peri-procedural stroke. TCAR differs importantly from tfCAS in that the operator avoids navigating the aortic arch, a known key source of embolization and subsequent stroke, particularly in elderly patients. The mechanism of neuroprotection with TCAR is with the use of an extracorporeal reversal flow system, and also clamping of the carotid artery below the sheath insertion, which leads to obligate reversal flow in the carotid system during the case. The protection groundwork is laid before any intervention is done; before a wire even crosses the lesion, reversal flow is achieved so that debris is trapped and removed via the system, and the blood is given back in the femoral vein.       

By |February 4th, 2021|clinical|0 Comments

Shell Shock Treatment Causes Brain Shock? To Treat or Not to Treat

Nurose Karim, MD

Gaffey AE, Rosman L, Burg MM, Haskell SG, Brandt CA, Skanderson M, Dziura J, Sico JJ. Posttraumatic Stress Disorder, Antidepressant Use, and Hemorrhagic Stroke in Young Men and Women: A 13-Year Cohort Study. Stroke. 2021;52:121–129.

Posttraumatic stress disorder (PTSD) is a commonly encountered mental disorder, especially among veterans. It has an association with ischemic stroke among younger adults, but it may also be associated with early-onset hemorrhagic stroke by modulating inflammatory and atherosclerotic pathways.

The authors in this article assessed an independent and combined risk for incident hemorrhagic stroke, which represents up to 50% of incident stroke cases, and the association with PTSD and the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) medication in a nationwide sample of 1.1 million young and middle-aged U.S. veterans who served in support of the Iraq and Afghanistan conflicts.

By |February 3rd, 2021|clinical|0 Comments

Gender Differences in Stroke Incidence

Ying Gue, PhD
@DrYXGue

Vyas MV, Silver FL, Austin PC, Yu AYX, Pequeno P, Fang J, Laupacis A, Kapral MK. Stroke Incidence by Sex Across the Lifespan. Stroke. 2021;52:447–451.

Vyas et al. followed a cohort of 9.2 million adults in Ontario, Canada, over a median period of 15 years in order to identify the incidence of stroke or transient ischemic attack (TIA), identified through health records of hospitalization and emergency department visits. The authors identified an interesting relationship between age, gender and stroke incidence whereby young women were at a much higher risk of stroke when compared to men (HR 1.26, 95% CI 1.10 – 1.45). This risk reverses (men higher risk than women) as age increases (HR 0.69 at age 50 – 59) and equalizes at ages above 80 years. This was mostly true within the ischemic subtypes (ischemic stroke or TIA) but reverses with subarachnoid hemorrhage, with middle-aged women at higher risk than men (HR 1.38, 95% CI 1.29 – 1.48).

The authors postulated that the differences could be due to the changing risk in women across their lifespan, with younger women more likely to be on oral contraceptive pills (OCP) and postmenopausal women losing the protective effect from endogenous oestrogen, therefore being more at risk of thrombotic events. This could also reflect that younger men are less likely to seek medical attention for presumed “mild” symptoms and could partly explain the much higher HR (2.02) within TIA.

By |February 2nd, 2021|clinical|0 Comments