Monthly Archives: June 2021

Kevin O’Connor, MD

Oesch G, Perez FA, Wainwright MS, Shaw DWW, Amlie-Lefond C. Focal Cerebral Arteriopathy of Childhood: Clinical and Imaging Correlates. Stroke. 2021.

Focal cerebral arteriopathy (FCA) is the cause of up to a quarter of strokes in children. FCA involves a focal and unilateral stenosis or irregularity of the distal internal carotid artery and its proximal branches. The suspected underlying pathophysiology is arterial inflammation resulting in vessel narrowing and thrombus formation on damaged endothelium. Post-varicella FCA is a common etiology and may occur within a year of infection. Imaging mimics of FCA include dissection, moyamoya, and embolus. Children with FCA may have progression of symptoms over several days/weeks, and up to a quarter have another stroke within a year.

Oesch et al. identified 15 cases (8%) of FCA among 179 children with strokes at a single center between 2009-2019. The median age was 6.8 years (range 0.5-16.3 years) and 8 were boys. Common presenting symptoms included hemiparesis (n=14), headache (n=7), and a concomitant infectious process (n=6). Two of thirteen tested children (15%) were positive for VZV antibodies and VZV DNA. The lower incidence of FCA with recent VZV infection compared to prior studies may be related to increased VZV vaccination. Six children had stuttering symptoms over 1-4 days prior to stroke. Three children (20%) had progression of stroke symptoms after the initial event. All 15 children received antithrombotic therapy following the stroke and over the course of follow-up (at least one year in 14 of 15 children). Data on the safety and efficacy of steroid use in FCA is unclear.

Parneet Grewal, MD
@parneetgrewal6

Yu CY, Blaine T, Panagos PD, Kansagra AP. Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke. 2021.

The impact of time on treatment and clinical outcomes in stroke patients has been well studied. American Heart Association/American Stroke Association guidelines recommend treatment with intravenous alteplase (IV-tPA) within 4.5 hours of last known well in the majority of the cases and endovascular therapy within 24 hours of last known well. This highlights the time-sensitive nature of the acute reperfusion therapies for ischemic stroke patients. Stroke systems of care include certification of centers to optimize acute stroke treatment, patient triage by emergency medical services and patient transportation. There are multiple levels of stroke certifications, which include acute stroke ready hospitals, primary stroke center, thrombectomy-capable stroke centers and comprehensive stroke centers. Variable geographic distribution of certified stroke centers and geographical clustering of demographic groups have created potential disparities in acute stroke care with multiple studies trying to characterize the access to stroke care in the United States.

In this cross-sectional study, the authors try to meticulously quantify these relationships using national and statewide data in order to potentially impact and reduce the inequalities to access. The population data is obtained at census tract level from 2014-2018, and stroke hospital data is curated from both national and statewide data of stroke certification. Certified stroke centers were defined as the centers able to provide IV-tPA as of August 2020 in this study, and road distances from each census tract to the nearest stroke center in 48 states and the District of Columbia were estimated. The authors further classified each census tract by composition of age, race, ethnicity, and insurance status, median annual income, and population density along with additional classification as urban and non-urban.

Setareh Salehi Omran, MD

Mistry EA, Yeatts S, de Havenon A, Mehta T, Arora N, De Los Rios La Rosa F, Starosciak AK, Siegler III JE, Mistry AM, Yaghi S, Khatri P. Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change. Stroke. 2021.

Endovascular therapy (ET) is the recommended treatment for acute ischemic stroke due to a large vessel occlusion. Early neurological improvement and recovery, most commonly measured using the 24-hour National Institutes of Health Stroke Scale score (NIHSS), can occur in some patients undergoing thrombolysis or ET. Early measurements of NIHSS are associated with a favorable long-term functional outcome^1-4 and are frequently used as an outcome measure in ET trials. Despite its utility, there appears to be a lack of consensus on the definition of early neurological recovery. An absolute decrease in NIHSS score of 4,⁵ 8,⁶ or 10⁷ or binary NIHSS outcomes have all been used to reflect early neurological recovery in various trials. However, a change in NIHSS from baseline and an arbitrarily chosen dichotomous outcome both have limitations. A change in NIHSS (from baseline to 24-hour) does not account for the baseline NIHSS and its accompanying deficits. While dichotomization can simplify statistical analyses, it also comes with several major drawbacks. Dichotomization of continuous variables such as NIHSS may lead to the loss of critical clinical information and a reduction in statistical power, underestimation of the degree of variation in outcomes between groups, and a concealment of non-linearity between the variable and outcome. Given the lack of a standardized approach, it is important to identify the best early NIHSS-based outcome measure to predict the 90-day functional outcome in ischemic stroke patients.  

Burton J. Tabaac, MD
@burtontabaac

Chen M-H, Tsai S-J, Su T-P, Li C-T, Lin W-C, Chen T-J, Pan T-L, Bai Y-M. Increased Risk of Stroke in Patients With Obsessive-Compulsive Disorder: A Nationwide Longitudinal Study. Stroke. 2021.

The World Health Organization has categorized obsessive compulsive disorder (OCD) as one of the top ten disabling conditions worldwide, noting a lifetime prevalence of 1-3%. The authors of this comprehensive study cite mounting evidence supporting an association between OCD and stroke-related risk factors inclusive of obesity and diabetes. Using data collected between 2001 and 2010 by Taiwan’s National Health Insurance Research Database, it was demonstrated that patients with OCD have an elevated risk of suffering an acute ischemic stroke compared to non-OCD controls, with no difference in hazard ratio for hemorrhagic stroke.

Obsessive compulsive disorder secondary to cerebral infarction has been reported in the medical literature, yet the relationship between OCD and subsequent stroke has been minimally investigated. This study included patients aged 20 years and older diagnosed with OCD by psychiatrist expertise between January 2001 and December 2010, and who had no history of stroke prior to enrollment. In a follow up analysis (up to 11 years), the use of OCD medications was assessed, with study cohorts separated into subgroups: nonusers, short-term users (1 month to 1 year), and long-term users (more than 1 year). Medication use included SSRIs, SNRIs, and norepinephrine-dopamine reuptake inhibitors, e.g., bupropion.

Isabella Canavero, MD

Ziai WC, Cho S-M, Johansen MC, Ergin B, Bahouth MN. Transcranial Doppler in Acute COVID-19 Infection: Unexpected Associations. Stroke. 2021.

COVID-19 has been reported to increase the risk of ischemic stroke, especially from large vessel disease, probably due to a combination of hypercoagulability and vascular inflammation. To explore the pathophysiology of COVID-19–related neurological and especially cerebrovascular diseases, Ziai et al. analyzed TCD findings in patients with and without COVID-19 infection, some of which also suffered from acute ischemic stroke. Indeed, differently from other radiological techniques, specific practical advantages make TCD easy to perform in the critical care setting. In cerebrovascular patients, TCD allows the identification of useful information such as detection of circulating microemboli and the assessment of cerebral blood flow velocity (CBV).