American Heart Association

Monthly Archives: March 2021

ISC 2021: Framework for a Pediatric Thrombectomy Center

Kevin O’Connor, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P589

Lauzier DC, Galardi MM, Guilliams KP, Goyal MS, Amlie-Lefond C, Hallam DK, Kansagra AP. Pediatric Thrombectomy: Design and Workflow Lessons From Two Experienced Centers. Stroke. 2021.

The lack of evidence-based guidelines for endovascular thrombectomy (EVT) in children with acute ischemic stroke has forced institutions to develop their own policies and procedures based on trials in adults and limited pediatric studies. Lauzier et al. describe the framework of their pediatric EVT-capable practices in Seattle and St. Louis. Their joint ventures include co-located (connected structures; St. Louis) or nearby (Seattle) pediatric hospitals and adult comprehensive stroke centers that are guided by interdisciplinary teams comprising pediatric neurologists, radiologists, neurointerventionalists, anesthesiologists, and pediatric intensivists, among others.

Strong collaboration among the multidisciplinary group and advocacy for pediatric stroke patients are integral components of the programs. Their efforts led to formalized and streamlined workflows, including initial triaging of a pediatric stroke case, rapidly acquiring and reviewing imaging studies with MRI/MRA protocols prioritizing DWI and time-of-flight sequences, initiating acute interventions as needed (including intravenous alteplase), and consulting a neurointerventionalist using a pre-specified script. Candidates for pediatric EVT are selected based on consensus inclusion and exclusion criteria developed by the group.

ISC 2021: Daily Step Count in Stroke Rehabilitation: A Useful Tool That Predicts Future Physical Activity

Csilla Manoczki, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P198

Handlery R, Regan EW, Stewart JC, Pellegrini C, Monroe C, Hainline G, Handlery K, Fritz SL. Predictors of Daily Steps at 1-Year Poststroke: A Secondary Analysis of a Randomized Controlled Trial. Stroke. 2021.

With wearable technologies becoming widely available, daily step count can be easily measured and utilized to track the patient’s physical activity in the home environment. Understanding which factors contribute to achieving a higher daily step count can help with tailoring interventions in the individual’s rehabilitation process.

A previous study showed that achieving a step count of at least 6000 steps a day decreases the risk of future cardiovascular events in patients after stroke; hence, the authors selected 6000 steps as target at 1 year post stroke with the potential of improved long-term health outcomes.

ISC 2021: Ischemic Stroke is Not Only a Rankin Scale: Endovascular Treatment and Quality of Life

Raffaele Ornello, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P521

Joundi RA, Rebchuk AD, Field TS, Smith EE, Goyal M, Demchuk A, Dowlatshahi D, Poppe AY, Williams DJ, Mandzia JL, et al. Health-Related Quality of Life Among Patients With Acute Ischemic Stroke and Large Vessel Occlusion in the ESCAPE Trial. Stroke. 2021.

Measuring modified Rankin scale (mRS) scores 90 days after endovascular treatment (EVT) has become the mainstay of any trial on the acute phase of ischemic stroke. mRS is easy to assess and gives a clear idea of post-stroke dependency; however, it does not encompass all the dimensions of quality of life.

To fill in the gap of knowledge about health-related quality of life after EVT for ischemic stroke, the ESCAPE trial investigators randomized 315 patients to EVT or no EVT. Outcomes assessed at 90 days included mRS scores and the EuroQol-5D (EQ-5D) for quality of life. Compared with patients not receiving EVT, those receiving EVT had better mRS and EQ-5D scores at 90 days from stroke onset. In detail, the improvement was related to self-care, usual activities, mobility — only for those aged 60-79 years — and pain/discomfort — for women — while there was no association with anxiety/depression.

Is Dural Arteriovenous Fistulae a Common Complication of Cerebral Venous Thrombosis?

Setareh Salehi Omran, MD

Ferro JM, Coutinho JM, Jansen O, Bendszus M, Dentali F, Kobayashi A, van der Veen B, Miede C, Caria J, Huisman H, et al. Dural Arteriovenous Fistulae After Cerebral Venous Thrombosis. Stroke. 2020;51:3344–3347.

Intracranial dural arteriovenous fistulas (dAVF) are abnormal communications between the meningeal arteries and the dural venous sinuses or cerebral veins. dAVFs account for nearly 15% of intracranial vascular lesions and cause variable clinical symptoms depending on the location of the fistula and any associated edema resulting from venous congestion. Several risk factors have been associated with the development of dAVFs, including prior craniotomy, head trauma, thrombophilias, and cerebral venous thrombosis (CVT). Although the exact pathophysiology is unknown, progressive stenosis or occlusion of the dural venous sinuses may contribute to the development of dAVFs. Data is lacking on the frequency of dAVF formation after CVT.

Ferro et al. examined the frequency of dAVF development after CVT as part of a predefined substudy of the clinical trial RE-SPECT CVT. The trial was a prospective, randomized, multicenter, exploratory study of patients with acute CVT that were allocated to dabigatran 150mg twice daily or dose-adjusted warfarin for 24 weeks. All patients underwent MRI imaging at the end of treatment. Ferro et al. reviewed end-of-treatment MRIs (6 months after the acute CVT) for the presence of dAVF. If dAVF was found, the baseline images were evaluated to confirm whether this was a newly detected dAVF. Of the 112 patients included in this analysis, 57 were allocated to dabigatran and 55 to warfarin for treatment of their CVT. The mean age was 45.2 (SD 13.8 years), and more than half the patients were women (55%). The majority of patients had a dural venous sinus thrombosis. Three of the 112 patients had insufficient quality of follow-up imaging, which prevented meaningful evaluation for a dAVF. Among the remaining patients, there were no cases of dAVF 6 months following after CVT. Only one patient had an asymptomatic dAVF on their end-of-treatment imaging, and the dAVF was already present on baseline imaging.

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

Renal Dysfunction in Intracerebral Hemorrhage

Kevin O’Connor, MD

Qureshi AI, Huang W, Lobanova I, Hanley DF, Hsu CY, Malhotra K, Steiner T, Suarez JI, Toyoda K, Yamamoto H, et al. Antihypertensive Treatment of Cerebral Hemorrhage 2 Trial Investigators. Systolic Blood Pressure Reduction and Acute Kidney Injury in Intracerebral Hemorrhage. Stroke. 2020;51:3030-3038.

The ATACH-2 trial compared the effect of intensive systolic blood pressure (SBP) management (110-139 mmHg) to standard reduction (140-179 mm-Hg) on the incidence of death or severe disability following intracerebral hemorrhage (ICH).1 Although the study was stopped because of futility (no significant difference in primary outcome between treatment groups), the authors have since performed several post hoc analyses. The current report assesses the rates and predictors of acute kidney injury (AKI) and renal adverse events (AEs) and their effect on death within 90 days and death or disability at 90 days in 1000 participants from ATACH-2.

AKI and renal adverse events were present in 14.9% and 6.5% of ATACH-2 participants, respectively. In a multiple regression analysis, there was no difference in the frequency of AKI between standard and intensive treatment groups (relative risk 1.0 [95% CI, 1.0-1.0] versus relative risk 1.1 [95% CI, 0.8-1.5]; p=0.4241). There was, however, a higher risk of renal adverse events in the intensive treatment group (relative risk 2.3 [95% CI, 1.3–3.8] versus standard relative risk 1.0 [95% CI, 1.0-1.0], p=0.0013). Only AKI was associated with death within 90-days (odds ratio 2.9 [95% CI, 1.6–5.5]) and death or disability at 90 days (odds ratio 2.7 [95% CI, 1.7–4.1]).

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

Article Commentary: “The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis”

Ericka Samantha Teleg, MD

Yu WM, Abdul-Rahim AH, Cameron AC, Kõrv J, Sevcik P, Toni D, Lees KR. The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis: Results From SITS Registry. Stroke. 2020;51:2705–2714.

Early Neurological Deterioration after thrombolysis, or END, is defined in many ways, and as the authors have emphasized currently, this term is controversial. This is so because researchers have not been consistent in applying the definitions. This is attributed to the many factors that contribute to its variability as they have enumerated, including heterogeneity and difference in the temporal timing of assessments after stroke and the existing definitions of the different mechanisms of ischemic stroke.

Therefore, this paper aims to describe the END rate in patients with ischemic stroke post-thrombolysis and its relation to potential clinical predictors. It uses the Safe Implementation of treatments in Stroke International Stroke Thrombolysis Registry (SITS-ISTR), which is a multinational open registry of patients with acute ischemic stroke after IV rtPA treatment.

By |March 15th, 2021|clinical|0 Comments

Intravenous Tirofiban: When the Administration Route Matters

Elena Zapata-Arriaza, MD

Yang J, Wu Y, Gao X, Bivard A, Levi CR, Parsons MW, Lin L. Intraarterial Versus Intravenous Tirofiban as an Adjunct to Endovascular Thrombectomy for Acute Ischemic Stroke. Stroke. 2020;51:2925–2933.

Intracranial large vessel re-occlusion can happen during endovascular treatment (EVT) of acute ischemic stroke (AIS), either by endothelial damage triggered by the thrombectomy device itself or by the presence of intracranial atherosclerosis. Intra- or periprocedural antiplatelet therapy with tirofiban could be a solution that needs growing scientific evidence to back it up. Based on their own previous studies, Yang et al. aimed to evaluate the treatment effect of intraarterial (IA) vs intravenous (iv) tirofiban during EVT in AIS.

Authors from Chinese centers performed a retrospective study from 2017-19 of patients with acute ischemic stroke with large vessel occlusion who received endovascular thrombectomy within 24 hours of stroke onset. Before EVT, the thrombolysis treatment of intravenous tPA was administered to eligible patients. After EVT, antiplatelet treatment with 100 mg aspirin or 75 mg clopidogrel was administered within 24 hours if no intracranial hemorrhage was shown on follow-up noncontrast computed tomography and intravenous tPA was not used before the procedure. If intravenous tPA was used before the EVT procedure, antiplatelet treatment was initiated after 24 hours. Patient selection for tirofiban treatment was at the discretion of the interventionalists. For either IA or IV tirofiban, the routine practice was injection of a bolus dose of 10 µg/kg, followed by an intravenous infusion of tirofiban at a rate of 0.15 µg/(kg·min) for 12 to 24 hours. Patients were divided into 3 groups: no tirofiban, intraarterial tirofiban, and intravenous tirofiban. The 3 groups were compared in terms of recanalization rate, symptomatic intracerebral hemorrhage, in-hospital death rate, 3-month death, and 3-month outcomes measured by modified Rankin Scale score (good clinical outcome of 0–2, poor outcome of 5–6).

By |March 15th, 2021|clinical|0 Comments

Another Prehospital Model Favoring Liberal Transport to Thrombectomy Center, But Clinical Trials Still Elusive

Walter Valesky, MD

Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke. 2020;51:3310–3319.

With the increasing importance of endovascular therapy in acute ischemic stroke care, triage and emergency transport strategies have taken on renewed importance. Current recommendations advise preferential transport to a comprehensive stroke center (CSC) if a large vessel occlusion (LVO) is suspected based on prehospital screening and when the total transport time is less than 30 minutes. The study summarized here evaluated alternative triage strategies in comparison with the current American Heart Association (AHA) recommendations.

A previously utilized decision-tree model referred to in a prior study2 was used to map outcomes of a suspected LVO to either a primary stroke center (PSC) and then transferred for thrombectomy or directly to an intervention center. A base scenario was applied to the model in which emergency medical services (EMS) was activated for a hypothetical patient with a suspected stroke within 4.5 hours of symptom onset with several time assumptions corresponding to “Get With the Guidelines” recommendations. LVO prevalence was estimated at 20% among suspected stroke patients based on prior studies,2-3 and prehospital assessment applied the rapid arterial occlusion evaluation (RACE) with an assumed sensitivity of 84% and specificity of 60% at a cutoff of 5 points. 

Article Commentary: “Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage”

Ying Gue, PhD

Zhou E, Lord A, Boehme A, Henninger N, de Havenon A, Vahidy F, Ishida K, Torres J, Mistry EA, Mac Grory B, et al. Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage. Stroke. 2020;51:3592–3599.

Zhou et al. reported a retrospective study using the California State Inpatient Database to compare the risk of ischemic stroke in patients with atrial fibrillation (AF) after extracranial hemorrhage (ECH). Extracting data from 2005 to 2011, they identified a total of 764,257 patients with AF in which 98,647 (13.3%) had an admission with extracranial hemorrhage. The primary outcome of interest, which was re-hospitalization with an acute ischemic stroke after index admission for ECH and after first hospitalization for control patients, occurred in 22,748 (3.4%) patients.

Kaplan-Meier analysis indicated that patients with ECH had lower stroke-free survival probability when compared to patients without ECH (hazard ratio [HR] 1.15, 95% CI 1.11 – 1.19 in the unadjusted model). This difference persisted even with adjustments of potential confounders (age, gender, medical history and CHA2DS2-VASc score). 

By |March 12th, 2021|clinical|0 Comments

The Malignant Stroke Dilemma: Could Infarct Volume Before Hemicraniectomy Predict Catastrophic Outcome in Large Middle Cerebral Artery Infarcts?

Alejandro Rodríguez-Vázquez, MD

Casolla B, Kuchcinski G, Kyheng M, Hanafi R, Lejeune J-P, Leys D, Cordonnier C, Hénon H. Infarct Volume Before Hemicraniectomy in Large Middle Cerebral Artery Infarcts Poorly Predicts Catastrophic Outcome. Stroke. 2020; 51:2404-2410.

Malignant stroke is a devastating condition that often leads to death or severe impairment. In large middle cerebral artery (MCA) infarcts, decompressive hemicraniectomy (DH) practiced within the first 48 hours of symptom onset improves both survival rates and functional outcomes to a moderate but remarkable extent. Infarct volume is one of the most important elements that define a stroke as malignant and, therefore, is often used as a main landmark in making clinical decisions. However, there are controversies around the infarct volume threshold that would allow to make the best prognosis estimation.

In this study, Casolla et al. tried to determine optimal infarct volume using magnetic resonance imaging (MRI) to predict a catastrophic outcome 1 year after DH, defined as a modified Rankin scale (mRS) score 5 or death. They studied 173 patients who underwent DH using b1000 diffusion-weighted image (DWI) and apparent diffusion coefficient (ADC) maps on MRI performed in admission, 24-36 hours after treatment or earlier in case of clinical worsening. In patients who received 2 or more MRI before DH, the closest imaging to intervention was analyzed. Of those 173 patients, 42 had a catastrophic outcome (34 died, and 8 mRS 5) in a year. The optimal threshold of infarct volume to predict this outcome was 211 mL in b1000 DWI, with a sensitivity of 59.5% (955 CI, 43.3-74.4) and a specificity of 61.8% (95% CI, 52.9-70.2). On ADC maps, the optimal threshold was 181 mL, with a sensitivity of 57.1% (95% CI, 41.0-72.3) and a specificity of 62.5% (95%, 53.5-70.9). The area under the curve for both sequences’ optimal volumes as predictors for catastrophic outcome was 0.64. An infarct volume of 274 mL ob b1000 DWI and 244 mL in ADC maps had a specificity of 90% for death or mRS 5, but there was not a volume able to predict a catastrophic outcome with a specificity higher than 90%.

By |March 11th, 2021|clinical|0 Comments