American Heart Association

Monthly Archives: March 2021

Arteriovenous Malformation Recurrence After Resection: A Unique Risk for Children

Jeffrey Russ, MD, PhD

Copelan A, Drocton G, Caton MT, Smith ER, Cooke DL, Nelson J, Abla AA, Fox C, Amans MR, Dowd CF, et al. Brain Arteriovenous Malformation Recurrence After Apparent Microsurgical Cure: Increased Risk in Children Who Present With Arteriovenous Malformation Rupture. Stroke. 2020;51:2990–2996.

Traditionally, arteriovenous malformations (AVMs) were thought of as isolated, static anomalies of vascular development, and complete surgical resection was, therefore, considered curative. A commonly employed treatment approach was for patients to undergo microsurgical resection of their AVM followed shortly thereafter by post-operative digital subtraction angiogram (DSA), which could provide gold-standard confirmation of a complete resection. Because DSA-proven resection is typically presumed to be curative, subsequent surveillance imaging has not been undertaken across institutions in any systematic way, if it is even performed at all.1 While AVM recurrence remains rare, accumulating evidence suggests that AVMs do recur in a subset of patients, the vast majority of which are pediatric patients.1

Copelan et al. present a thorough analysis to specifically address AVM recurrence risk in the pediatric population. The authors review retrospective data from a cohort of 115 children and young adults, from ages 3 to 25, who underwent microsurgical resection of an AVM at a single institution. Based on institution-specific guidelines, patients with no evidence of residual nidus on post-operative DSA then underwent surveillance angiography 6 months later only if residual arteriovenous shunting had been identified; otherwise, repeat DSA was performed at 5 years.

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

What is the Role of Antiphospholipid Antibodies in Recurrent Ischemic Stroke?

María Gutierrez Sanchez de la Fuente, MD

Kim Y, Kim SY. Antiphospholipid Antibody and Recurrent Ischemic Stroke: A Systematic Review and Meta-Analysis. Stroke. 2020;51:3728–3732.

Antiphospholipid syndrome (APS) is an autoimmune multisystem disorder characterized by arterial or venous thromboembolic events in the presence of persistent antiphospholipid antibodies (aPL).

aPL are a heterogeneous group of antibodies directed against phospholipid-binding proteins. The aPL detection tests included in APS classification criteria are anticardiolipin (aCL) antibody (immunoglobulin G [IgG] or IgM), anti-beta2-glycoprotein (GP) I antibody (IgG or IgM), and lupus anticoagulant (LA). Based on the International Consensus Criteria for APF, clinically significant aPL profile is defined as the presence of one or more of the following aPLs on two or more occasions at least 12 weeks apart: A positive LA test; aCL IgG or IgM, with a titer >40 units; or/and anti-beta2-GP I IgG or IgM, with a titer >40 units.

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

Does CKD Promote a Certain Subtype of Cerebrovascular Ischemia?

Lukas Mayer, MD

Kelly DM, Li L, Rothwell PM, and on behalf of the Oxford Vascular Study. Etiological Subtypes of Transient Ischemic Attack and Ischemic Stroke in Chronic Kidney Disease: Population-Based Study. Stroke. 2020;51:2786–2794.

The increased cardiovascular risk of patients with chronic kidney disease (CKD) has been acknowledged for quite some time. Consequently, incidence of cerebrovascular events in CKD cohorts has routinely been assessed. Interestingly however, studies focusing on the incidence of CKD in ischemic stroke cohorts or the possible relationship between CKD and ischemic stroke etiology are scarce.

Through their analysis of patients with cerebral ischemia within the population-based OXVASC study, Kelly and co-authors present a detailed look into stroke etiology in subjects with CKD. The ongoing OXVASC study currently envelopes more than 90,000 individuals, of which 3,178 suffered ischemic stroke/TIA (N=2.696) or intracerebral hemorrhage (N=209). Kelly et al. used the TOAST classification, which denotes five subtypes of cerebral ischemia (cardioembolism, large artery disease, small vessel disease, unknown, other etiology), and tried to establish a possible linkage of specific stroke subtypes and chronic kidney disease, which the study team defined as eGFR ≤60mL/min/1.73m2 being evident 3 months or longer.

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

A Novel Use of EEG in Stroke

Mei Ngun, MBBS

Erani F, Zolotova N, Vanderschelden B, Khoshab N, Sarian H, Nazarzai L, Wu J, Chakravarthy B, Hoonpongsimanont W, Yu W, et al. Electroencephalography Might Improve Diagnosis of Acute Stroke and Large Vessel Occlusion. Stroke. 2020;51:3361–3365.

The search for tools to improve the diagnosis of acute stroke is ongoing. Recently, Erani et al. explored the use of electroencephalography (EEG) in diagnosing stroke, especially in large vessel occlusion (LVO) or transient ischemic attack (TIA) in the emergency department (ED). To date, the practicalities of performing EEG have meant that there has been limited clinical use in the emergent stroke setting.

Patients with suspected/definite acute stroke were recruited from an ED of a single comprehensive stroke center. EEG was recorded using a dry-electrode system (Quick-20) with a local active amplifier and Faraday cage. At the bedside, eyes-open, resting state EEG was recorded for 3 minutes. EEG data was exported for offline analysis, filtering, and removal of noise to produce a bipolar montage of 27 bipolar lead-pairs.

Poor Socioeconomic Status as a Risk Factor of Incidental Stroke in Those Under 75? Analysis of the U.S. REGARDS Study

Csilla Manoczki, MD

Reshetnyak E, Ntamatungiro M, Pinheiro LC, Howard VJ, Carson AP, Martin KD, Safford MM. Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke. 2020;51:2445–2453.

Studies have suggested that stroke disparities may be explained by other risk factors, such as social determinants of health (SDOH), beyond the traditional Framingham Stroke Risk Profile. According to the WHO: “the social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries”. This study investigated the association between incident stroke and the increasing number of multiple SDOH in the individual.

Data was used from the REGARDS study, a population-based prospective cohort study designed to identify the mechanisms of higher stroke mortality observed in the southeastern United States and among the Black population. The analytic sample of this study included 27813 individuals. Mean age at baseline was 64.7 years; 55.4% were women; 40.4% were of Black race; and 83.4% of all participants were <75 years old. Those with reported history of stroke at baseline were excluded. The primary outcome of the study was incident stroke based on expert adjudication following review of medical records.

Prevention of Covert Brain Infarction — Mission Impossible?

Thomas Raphael Meinel, MD

Sharma M, Hart RG, Smith EE, Bosch J, Eikelboom JW, Connolly SJ, Dyal L, Reeh KW, Casanova A, Diaz R, et al. Rivaroxaban for Prevention of Covert Brain Infarcts and Cognitive Decline: The COMPASS MRI Substudy. Stroke. 2020;51:2901–2909.

Covert brain infarctions (CBI) are multiple times more frequent than manifest ischemic stroke.1 However, data on preventive strategies to reduce accrual of CBI is almost non-existent. Sharma et al. aimed to investigate whether the combination therapy of rivaroxaban (2.5mg twice daily) plus aspirin (100mg once daily) or rivaroxaban (5mg twice daily) was superior to aspirin (100mg once daily) in the prevention of CBI in patients with stable atherosclerotic vascular disease.

For this purpose, the authors conducted the COMPASS-MIND substudy of the COMPASS trial including patients with coronary artery disease, peripheral arterial disease, or both. The exclusion criteria were high bleeding risk; ischemic stroke within 1 month or any history of hemorrhagic or lacunar stroke; severe heart failure; advanced kidney disease; or the need for other antithrombotic regimens. Of note, only 6.4% of the trial population had prior manifest cerebrovascular disease.

DOAC on the rise, NIHSS falling?

Thomas Meinel, MD

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.

Direct oral anticoagulants (DOAC) have proven at least equally effective in the prevention of acute ischemic stroke in patients with atrial fibrillation as compared to the vitamin K antagonists (VKA). They are recommended in stroke prevention for DOAC-eligible atrial fibrillation patients (without moderate-to-severe mitral stenosis or mechanical heart valve) as the oral anticoagulation of choice since their net clinical benefit arises mainly from a reduced risk of intracranial hemorrhage.1,2 Despite a significant reduction of stroke risk,1 recurrent ischemic stroke in patients on DOACs still occurs with an estimated rate of 1-2% per year.3 The randomized controlled trials did not report exact data on the stroke severity in patients on DOACs. Real-world data are conflicting, limited by arbitrary dichotomization of stroke severity scores, and mostly did not look at laboratory assessment of DOAC activity or information on compliance.4–8

In the August 2020 issue of Stroke, Jung et al. used a prospective, multicenter, hospital-based national stroke registry in Korea to evaluate trends of antithrombotic medication use in 6786 stroke patients with atrial fibrillation recruited between 2008 and 2018. The study aim was to explore the association between preceding antithrombotic medication use and initial stroke severity. 4009 patients were candidates for anticoagulation defined by a CHA2DS2-VASc score ≥2 and ATRIA score ≤4 prior to the acute ischemic stroke event. Among those, the overall prevalence of anticoagulation use was 27% and increased from 25% in 2010 to 41% in 2018 (P<0.001). Whereas the percentage of patients on VKA decreased in the recent years, the fraction of patients suffering ischemic stroke on DOACs increased from 4% in 2015 to 25% in 2018. Authors also found that stroke severity was higher in patients who were not on antithrombotics compared to those on antiplatelets or anticoagulants (median NIHSS: 8 versus 7 versus 6, P<0.001). Anticoagulation was also independently associated with mild stroke severity defined as NIHSS ≤5 (adjusted odds ratio, 1.31 [95% CI, 1.15–1.50]). However, there was no difference between antiplatelet agents and anticoagulation in terms of stroke severity.