American Heart Association

Monthly Archives: March 2021

Local Anesthesia or Conscious Sedation in Mechanical Thrombectomy

Melanie R. F. Greenway, MD

Benvegnù F, Richard S, Marnat G, Bourcier R, Labreuche J, Anadani M, Sibon I, Dargazanli C, Arquizan C, Anxionnat R, et. al. Local Anesthesia Without Sedation During Thrombectomy for Anterior Circulation Stroke is Associated with Worse Outcome. Stroke. 2020;51:2951-2959.

As mechanical reperfusion therapy continues to advance, questions regarding procedural methods of anesthesia continue to arise.  This article compares functional outcomes in patients who received local anesthesia or conscious sedation for mechanical thrombectomy in acute ischemic stroke.

Utilizing the Endovascular Treatment in Ischemic Stroke Registry (ETIS) in France, the authors evaluated  1034 patients with large vessel occlusion admitted for mechanical thrombectomy from January to December 2018 at 4 centers. Three centers used a protocol with conscious sedation as the first-line treatment approach for mechanical thrombectomy, while one center used local anesthesia as the first-line treatment approach. After excluding patients because of missing information, absence of large vessel occlusion, or other exclusion criteria, 636 patients from the conscious sedation centers and 238 from the local anesthesia center were included in the intention-to-treat analysis. From there, 577 patients in the conscious sedation group and 185 patients from the local anesthesia group were included in the per-protocol analysis, as additional patients were excluded because of a change to their anesthesia management after enrollment. 

The Rhythm of Training in Stroke Medicine

Aurora Semerano, MD
@semerano_aurora

Lloret-Villas MI, Butt A, Khan K, Shuaib A. Days and Nights of a Stroke Fellow at a Comprehensive Stroke Center: Program Structure and Patients Encountered. Stroke. 2020;51:e301–e304.

With the growing advances and complexity in the current “new era” of stroke care history, there is an increasing need for professional figures with strong and specific training in stroke medicine, which includes the development of robust skills in resource organization, clinical decision-making, research insight and network building.

Stroke fellowship is a valuable gym for neurologists that want to become experts in stroke. It consists of a 1- or 2-year training program focused on cerebrovascular diseases, with large exposure to stroke cases within a stimulating educational environment. Stroke fellowships are now offered in many countries, evolve over time mirroring the progressive clinical advances, and can have different characteristics reflecting the territorial organization of stroke care.

By |March 29th, 2021|clinical|0 Comments

Cerebral Microbleeds, Atrial Fibrillation, and Anticoagulation

Kevin O’Connor, MD

Choi KH, Kim JH, Lee C, Kim JM, Kang KW, Kim JT, Choi SM, Park MS, Cho KH. Microbleeds and Outcome in Patients With Acute Ischemic Stroke and Atrial Fibrillation Taking Anticoagulants. Stroke. 2020;51:3514–3522.

Oral anticoagulation is indicated for atrial fibrillation (AF) following cardioembolic stroke. When cerebral microbleeds (CMBs) are present, anticoagulated patients may have an increased risk of intracerebral hemorrhage (ICH). Choi et al. explored the impact of CMBs on the risk of major adverse cerebrovascular and cardiovascular events (MACCE) in ischemic stroke patients with AF on oral anticoagulation. They also examined the impact of choice of oral anticoagulant (OAC), whether vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC).

By |March 26th, 2021|clinical|0 Comments

ISC 2021 Session: Treatment of Acute Stroke in Childhood and Young Adults (Debate)

Sishir Mannava, MD
@sishmannMD

International Stroke Conference 2021
March 17–19, 2021
Session: Treatment of Acute Stroke in Childhood and Young Adults (Debate) (179, On Demand)

This session began with Dr. Lisa Sun from Johns Hopkins School of Medicine presenting on brain attacks in teenagers, and that “we can best care for adolescents with stroke by organizing existing adult stroke centers to be able to treat teenagers.” Dr. Sun discussed how adult stroke centers and dedicated stroke units have better outcomes with organized stroke teams and stroke protocols. This leads to faster stroke recognition and treatment times. Dr. Sun presented data from time to imaging/diagnosis in major pediatric stroke centers after stroke protocol initiation, and, at best, the times appear to be between 1.3-1.6 hours, which is slower than the DTN times median of about 1 hour in adult stroke programs. Although primary pediatric stroke center development has been proven by the TIPS trial, Dr. Sun argued that it may not be feasible or resourceful to develop the needed amount of pediatric stroke centers to provide adequate coverage to all pediatric stroke populations.

“Endovascular therapy can be more safely and effectively administered to adolescents at an adult stroke center.” Dr. Sun discussed how thrombectomy in adolescents is technically like adult thrombectomy, and that by 5 years of age, head and neck arteries approach adult size. The common femoral artery (FA) sheaths used in adults can even be used in smaller adolescents as long as the ratio of FA size to catheter size is maintained, to avoid vasospasm. Adult stroke centers also have greater procedural experience, larger stock of devices, and higher volume of thrombectomies than pediatric thrombectomy centers. Data from the TRACK registry showed a significant difference in mRS ≥ 2 and final mTICI ≥2c-3 amongst higher volume centers as opposed to lower volume centers.

Carotid Stent Occlusion in Tandem Lesion: Another Stone on the Road

Elena Zapata-Arriaza, MD
@ElenaZaps

Renú A, Blasco J, Laredo C, Llull L, Urra X, Obach V, López-Rueda A, Rudilosso S, Zarco F, González E, et al. Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance. Atherosclerosis. 2020;313:8-13.

Balancing ischemic and hemorrhagic risk in tandem lesions in acute stroke represents a therapeutic challenge that we face on a daily basis. Maintaining the patency of a carotid in this context associates better long-term clinical results, but for this purpose we must use an antiplatelet protocol that guarantees us to reduce the risk of intra-stent reocclusion without exceeding the possibility of a hemorrhagic transformation.

With the aim of knowing the incidence, predictors and clinical relevance of early extracranial carotid stent occlusion following endovascular therapy (EVT), Renú et al. performed a single center retrospective analysis of consecutive patients with acute ICA occlusions, with or without intracranial large vessel occlusion treated with ICA stent placement between 2010-2018. A bolus of heparin was administered at the beginning of the procedure, and a single IV load of ASA 900 mg immediately before the stent placement, and a single dose of Clopidogrel 300 mg (p.o.) at the end of the procedure were given to the patient. All patients underwent cervical and transcranial Doppler sonography within 24 hours after stent placement.

By |March 25th, 2021|clinical|0 Comments

ISC 2021 Session: Stroke in Pregnancy: What To Expect When They’re Expecting

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Stroke in Pregnancy: What To Expect When They’re Expecting (150, On Demand)

Eliza C. Miller, MD, MS: In this session, Dr. Miller pointed out three important topics: epidemiology, mechanism and prevention. The trend in maternal mortality in pregnancy in the United States increased from 1987 until 2016. And so is the rate of maternal stroke. The incidence is 30/100,00 deliveries. Half are hemorrhagic with a mortality of 10-16%, which is different than stroke in the general population, where 85% of strokes are ischemic. Hypertension is the leading cause, and there is some racial disparity among the prevalence. The risk is higher in the non-White population (African American, Asian and Hispanic). Migraine is another stroke risk factor, which increases the risk of hypertension and preeclampsia, which ultimately are risk factors for stroke.

The diagnostic criteria for Pre-eclampsia per ACOG and ISSHP is new onset hypertension at the gestational age greater than 20 with proteinuria or without proteinuria with a new onset headache unresponsive to the treatment or new onset focal neurological deficit. 

The take-home message from this talk was, headache and hypertension in pregnancy are red flags and should be taken seriously.

Predicting Early Decline in Stroke Patients Treated Endovascularly

Lauren Peruski, DO
@LaurenPeruski

Girot J-B, Richard S, Gariel F, Sibon I, Labreuche J, Kyheng M, Gory B, Dargazanli C, Maier B, Consoli A, et al. Predictors of Unexplained Early Neurological Deterioration After Endovascular Treatment for Acute Ischemic Stroke. Stroke. 2020;51:2943-2950.

Endovascular thrombectomy (EVT) has become part of the standard of care for select patients with acute ischemic stroke. Studies regarding optimizing patient selection and improvement in short- and long-term outcomes are an area of research interest. A subset that has been examined includes patients that have experienced “early neurological deterioration.” In most papers, early neurological deterioration is defined as an increase of four or more points on the NIH Stroke Scale (NIHSS) within one day of endovascular treatment. In some cases, the etiology of this clinical worsening is obvious, for example, reperfusion failure, peri-procedural complications, hemorrhagic transformation, or malignant edema. However, a significant proportion of these patients experience a neurologic worsening that is not explained by a known entity. 

By |March 23rd, 2021|clinical|0 Comments

Location, Location, Location: Article Commentary on “Plaque Distribution Correlates With Morphology of Lenticulostriate Arteries in Single Subcortical Infarctions”

Richard Jackson, MD

Jiang S, Yan Y, Yang T, Zhu Q, Wang C, Bai X, Hao Z, Zhang S, Yang Q, Fan Z, et al. Plaque Distribution Correlates With Morphology of Lenticulostriate Arteries in Single Subcortical Infarctions. Stroke. 2020;51:2801–2809.

My father, also a neurologist, used to say that if he learned one new topic at a conference, it was worth going. I love reading articles that open my eyes to a new topic or change the way I view a previous topic. I have been interested in vessel wall imaging (VWI) and its applications since I learned about eccentric and concentric plaques being higher or lower risk for ischemic stroke. This article by Jiang et al. expands on the previous work by Yoon et al. in assessing the location of MCA wall plaque location and its relation to single subcortical infarcts (SSI) as proximal or distal to lenticulostriate perforators and located superiorly or inferiorly. Jian et al. used VWI to visualize the plaque location, perforator origin and branches, and length of perforator in relation to risk for SSI and have expanded on the knowledge of an old C. Miller-Fisher concept of branch atheromatous disease (BAD) which I have really only previously thought of as a consequence of diabetes. 

The group prospectively enrolled 40 patients between July 2017 and December 2019 with SSI and no MRA evidence of large vessel disease excluding patients with other possible etiologies or prior infarcts. 3-T MRI was used, and two neuroradiologists evaluated the images.

By |March 23rd, 2021|clinical|0 Comments

ISC 2021 Session: Tenecteplase Is Ready for Clinical Practice (Debate)

Saurav Das, MD
@sauravmed

International Stroke Conference 2021
March 17–19, 2021
Session: Tenecteplase Is Ready for Clinical Practice (Debate) (183)

Whether tenecteplase (TNK) is ready for clinical practice is certainly one of the crucial questions faced by the stroke community today, especially in the changing landscape with emerging evidence for non-inferiority of direct thrombectomy compared to bridging recanalization treatment, the success of mobile stroke units (MSU), and our ability for pre-hospital treatment of patients within the golden hour of last known well. TNK is not a new drug. It is successfully used in treatment of myocardial infarction, and we have evidence from five randomized controlled trials (alluded to several times in the following debate) for non-inferiority compared to alteplase (tPA) in treatment of stroke. The nay-sayers do point to inherent issues with these trials and argue that we need more data. But the question is, how much longer is this wait going to be?

This debate was in 5 segments. In the first segment, Dr. Jeffrey Saver from the University of California, Los Angeles (UCLA) argued in favor of the motion. In the second segment, Dr. Patrick Lyden from Keck School of Medicine, University of South California, argued against the motion. In the third segment, both the speakers had an opportunity for rebuttal. In the fourth segment, Dr. Shelagh Coutts from the University of Calgary provided her balancing view. And in the final segment, Dr. Steven Warach from Dell School of Medicine, UT Austin, shared his practical experience with use of TNK for the past 15 months. The session was moderated by Dr. E. Clarke Haley Jr. from the University of Virginia, Charlottesville.

ISC 2021 Session: Imposter Syndrome – Our Stories

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Imposter Syndrome – Our Stories

“Perfectionism is a sick mindset.”
— Darshan H Mehta

There is no formal definition of imposter syndrome, but it is defined vaguely as to doubt your abilities and capabilities. It is a feeling of discomfort, second-guessing, and mild anxiety in the workplace, especially for women.

The term gets its origin in 1978 when two psychologists, Pauline Rose Clance and Suzanne Imes, used the concept of “imposter phenomena” while studying high-achieving women. They found that despite stellar academic and professional achievements, women who experience the imposter phenomenon kept on believing that they are really not bright enough, and they question themselves if they are deserving of accolades.

This session put up a healthy discussion among women pointing out when they first recognized that they are suffering from imposter syndrome. It also discussed why imposter syndrome exists in the first place and what role workplace systems play in fostering and exacerbating it in women. Leaders must create a culture for women and people of color that addresses systemic bias and racism. By doing so, we can reduce the experiences that culminate in so-called imposter syndrome among employees from marginalized communities — or, at the very least, help those employees channel healthy self-doubt into positive motivation, which is best fostered within a supportive work culture.