Monthly Archives: April 2021

Kevin O’Connor, MD

Boulouis G, Hak JF, Kerleroux B, Benichi S, Stricker S, Gariel F, Alias Q, Bourgeois M, Meyer P, Kossorotoff M, et al. Hemorrhage Expansion After Pediatric Intracerebral Hemorrhage. Stroke. 2021;52:588-594.

Intracerebral hemorrhage (ICH), similar to most aspects of pediatric stroke, is not as well-studied as it is in adults, in part due to its lower incidence in children. Boulouis et al. retrospectively assessed a cohort of pediatric ICH patients at a single center in Paris, France (2000-2019). Various exclusion criteria reduced their patient population from 243 to 52. Of these children, 18 had hemorrhage expansion (HE; 34.6%) and 8 of these had significant hemorrhage expansion (sHE; 15.4%). Children with sHE were more likely to have coagulation disorders (50.0% versus 2.3%; P=0.022) and tended to more frequently have focal deficits on presentation, although the difference was not significant (75.0% versus 43.2%; P=0.08). Underlying coagulation disorders were independently associated with any HE (adjusted OR, 14.4 [95% CI, 1.04–217]; P=0.048).

Outcomes were assessed using the King’s Outcome Scale for Childhood Head Injury (KOSCHI) score at 12 months. Scores <5 were poor, with scores of 2-3 reflecting severe disabilities, and score of 1 representing death. Just under half of the 52 children had a poor outcome (n=21, 40.4%) with 8 being severely disabled or dying (15.4%). Significant HE was associated with poor outcome in general (adjusted OR, 6.01 [95% CI, 0.91–39.82]; P=0.048) and with severe disability or death in particular (adjusted OR 21.71 [95% CI, 3.35–140.64]; P=0.001).

Walter Valesky, MD

Labovitz AJ, Rose DZ, Fradley MG, Meriwether J, Renati S, Martin R, Kasprowicz T, Murtagh R, Kip K, Beck T, et al. Early Apixaban Use Following Stroke in Patients With Atrial Fibrillation: Results of the AREST Trial. Stroke. 2021;52:1164-1171.

In the era of direct oral anticoagulant (DOAC) therapy, a paucity of clinical trials exist guiding anticoagulation for atrial fibrillation (AF) after acute ischemic stroke (AIS). European Heart Rhythm Association guidelines promoted (by expert panel) a 1-3-6-12 day approach with anticoagulation started after 1 day in patients with a transient ischemic attack (TIA), after 3 days in those with small strokes, after 6 days in those patients with moderate strokes and approximately 2 weeks in those with large arterial distribution strokes._­¹ Guidelines from the American Heart Association are extremely broad and recommend starting anticoagulation after 4-14 days in patients with ischemic stroke.² Additionally, these recommendations are based on data that do not adequately reflect the current management of AF using DOACs.³ Labovitz et al. attempt to give clarity to this topic with an open-label, randomized trial to evaluate the safety of early use of apixaban in patients with recent stroke compared to warfarin. 

In the AREST trial, the authors enrolled patients with onset of symptoms of AIS or TIA within 3-5 days or within 3 days, respectively. These patients also had a history of AF or newly diagnosed AF confirmed using usual methods by an electrophysiologist. Once randomized, patients in the apixaban group were started on day 0-3 for TIA, day 3-5 for small-sized AIS (<1.5cm in largest dimension), and day 7-9 for medium-sized AIS (>1.5cm but less than a full vascular territory). Patients randomized to receive warfarin were started at 1-week post-TIA or 2 weeks post-stroke. Patients with large-sized AIS (entire vascular territory) and brainstem strokes were excluded. In addition, patients with obvious contraindications to anticoagulation use such as intracranial hemorrhage (ICH), hemorrhagic transformation, as well as those with AIS believed to be from non-embolic etiologies were excluded.

Kevin O’Connor, MD

Lefeber GJ, Knol W, Souverein PC, Bouvy ML, de Boer A, Koek HL. Statins After Ischemic Stroke in the Oldest: A Cohort Study Using the Clinical Practice Research Datalink Database. Stroke. 2021;52:1244–1252.

Statins are a component of usual care following ischemic stroke, but evidence for their initiation in patients age >80-years is limited. Lefeber et al. conducted an observational cohort study to examine the effect of statin initiation on recurrence of cardiovascular events and mortality in those age >80-years following a first stroke. They performed the same analyses on patients aged 65-80 for comparison.

Patients ≥80 and 65-80 had reductions in cardiovascular events when prescribed statins for > 2 years (≥80 adjusted HR, 0.70 [95% CI, 0.52–0.92]; 65-80 adjusted HR, 0.67 [95% CI, 0.49–0.91]) compared to no statin use. There was no significant difference in event rates for either cohort when treated for 1-2 years compared to untreated patients (≥80 adjusted HR, 0.79 [95% CI, 0.59–1.07]; 65-80 adjusted HR, 1.00 [95% CI, 0.69–1.46]). Using a statin for less than one year was associated with reductions in both groups (≥80 adjusted HR, 0.43 [95% CI, 0.29–0.41]; 65-80 adjusted HR, 0.43 [95% CI, 0.34–0.54]). Compared to < 2 years of statin use (or no use), there was a nonsignificant trend toward lower risk for the ≥80 cohort (adjusted HR, 0.80 [95% CI, 0.62–1.02]) and a significant reduction in the 65-80 group (adjusted HR, 0.74 [95% CI, 0.57–0.96]) with use >2 years. Adjusted for mortality, the NNT to reduce cardiovascular events in the ≥80 group and the 65-80 group were 48.8 and 68, respectively.

Elena Zapata-Arriaza, MD
@ElenaZaps

Seners P, Ben Hassen W, Lapergue B, Arquizan C, Heldner, MR, Henon H, Perrin C, Strambo, D, Cottier J-P, Sablot D, et al; for the MINOR-STROKE Collaborators. Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone. JAMA Neurol. 2021;78:321-328.

The conjunction of minor stroke and large vessel occlusion (LVO) occurs in a considerable frequency of patients. The question in the acute phase is always the same: Should we perform mechanical thrombectomy when symptoms are presented? Should we use bridging therapy? We do not have valid clinical trials that answer this question, but Seners and colleagues have performed a multicenter retrospective analysis to identify incidence and predictors of early neurological deterioration due to ischemia (ENDi) and thus develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke (NIHSS ≤ 5) and LVO (ICA T/L, Tandem lesion, M1, M2 and Basilar arteries). ENDi was defined as 4 or more points’ deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause.