Monthly Archives: February 2021

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. 

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.

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.       

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.