American Heart Association

Monthly Archives: September 2021

FLAIR Imaging Serves as a Tissue Clock

Fransisca Indraswari, MD

Aoki J, Sakamoto Y, Suzuki K, Nishi Y, Kutsuna A, Takei Y, et al. Fluid-Attenuated Inversion Recovery May Serve As a Tissue Clock in Patients Treated With Endovascular Thrombectomy. Stroke. 2021;52:2232–2240.

This retrospective study by Aoki et al. investigated the role of fluid-attenuated inversion recovery (FLAIR) sequence in the magnetic resonance imaging (MRI) of the brain as a tool to predict outcome after an endovascular thrombectomy (EVT), regardless of the time of symptom onset. The notion of imaging-based prognostication of clinical outcome has been elucidated in previous trials, e.g., THAWS1 and WAKE UP.2 Similarly, the concept of extending therapeutic window of thrombectomy up to 24 hours based on imaging selection criteria in DAWN3 and DEFUSE3.4 They hypothesized that if the signal change on FLAIR was associated with the clinical outcome after EVT, FLAIR may be able to serve not only as a time clock, but also as a tissue clock.

Patients with acute ischemic stroke treated with EVT were recruited between September 2014 and December 2018. They were divided between FLAIR-positive and FLAIR-negative groups based on the parenchymal change on FLAIR sequence in their MRI brain. The clinical characteristics, imaging findings, EVT parameters, and the intracranial hemorrhage defined as Heidelberg Bleeding Classification ≥1c hemorrhage (parenchymal hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, and/or subdural hemorrhage) were compared between the 2 groups. Clinical outcome at 3 months was defined as modified Rankin Scale Score (mRS) with 0-1 being good outcome.

By |September 28th, 2021|clinical|0 Comments

PCSK9 Inhibitors Are Potential Alternatives to Statins in Patients with High Risk of Intracerebral Hemorrhage

Praveen Hariharan, MD

Sanz-Cuesta BE, Saver JL. Lipid-Lowering Therapy and Hemorrhagic Stroke Risk: Comparative Meta-Analysis of Statins and PCSK9 Inhibitors. Stroke. 2021.

Since the birth of statins in the late 20th century, statins have become an integral part of cardiovascular disease management. However, several studies showing increased risk of hemorrhagic stroke with statin use have raised concerns, and the risk is currently being evaluated with ongoing randomized clinical trials. PCSK9 (proprotein convertase subtilisin kexin 9) inhibitors are the most potent novel antihyperlipidemic medications and could serve as potential alternatives to statins.

In this study, Drs. Sanz-Cuesta and Saver investigated the hemorrhagic stroke rates of PCSK9 inhibitors by undertaking a meta-analysis of data available from randomized clinical trials (RCTs) comparing low or high dose statins with each other or controls, and low and high dose PCSK9 inhibitors with each other or controls. Assuming a gradient risk based on the history of ischemic or hemorrhagic stroke and medication dosing, RCTs were planned to be grouped into 4 subcategories: 1) all patients/any dose; 2) all patients/high dose; 3) history of ischemic stroke/any dose; and 4) history of hemorrhagic stroke/any dose.

By |September 27th, 2021|clinical, treatment|0 Comments

Direct Oral Anticoagulants Versus Warfarin in Cancer Patients with Atrial Fibrillation

Mona Al Banna, MB BCh, MSc

Chan YH, Chao TF, Lee HF, Chen SW, Li PR, Liu JR, et al. Clinical Outcomes in Atrial Fibrillation Patients With a History of Cancer Treated With Non-Vitamin K Antagonist Oral Anticoagulants: A Nationwide Cohort Study. Stroke. 2021.

Atrial fibrillation is a known risk factor for stroke, increasing stroke risk 5-fold and mortality 2-fold compared to patients without atrial fibrillation. Cancer causing a hypercoagulable state is another well-known risk factor for stroke. Current guidelines recommend direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation. In patients with cancer who develop atrial fibrillation, warfarin or low-molecular weight heparin have traditionally been preferred over the direct oral anticoagulants.

In this study, Chan et al. investigated the effectiveness and safety of the DOACs when compared to warfarin in this population. A nationwide retrospective cohort study was performed using the Taiwan National Health Insurance Research Database. They identified 85,641 patients diagnosed with atrial fibrillation and treated with an anticoagulation over a 5-year period. Of those AF patients with a diagnosis of cancer, 6274 were treated with DOACs and 1681 were treated with warfarin. The DOAC group had a lower risk of ischemic stroke, acute myocardial infarction, major adverse limb events and venous thrombosis compared to the warfarin group. DOAC use was associated with a lower risk of ICH and major bleeding when compared to warfarin. Subgroup analysis was also performed to determine how different DOACs or different dosages of DOACs compared to warfarin. In general, there was lower risk of thrombotic events and major bleeding for DOACs over warfarin irrespective of DOAC type and whether it was standard-dose or low-dose. In addition, this benefit of DOACs over warfarin was consistent across patients with different types of cancer and at different stages of disease activity.

By |September 24th, 2021|clinical, treatment|0 Comments

Article Commentary: “Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke”

Melissa Bailey, MD

Preston E, Ada L, Stanton R, Mahendran N, Dean CM. Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke. Stroke. 2021.

Being able to anticipate post-stroke prognosis is important in that it can allow patients to have a reasonable idea of what recovery they may have, can allow caregivers and patients to anticipate care needs, and can impact healthcare costs and patient placement after stroke. Recovery of walking after stroke can be especially important in returning to functional independence. A prior systematic review1 examined prognostic factors that would predict ability to walk 30 days after stroke regardless of if the patient was able to walk shortly after the stroke occurred, and factors such as age, leg strength, hemianopia, and size and location of stroke were found to be predictors. Preston and colleagues recently published a systematic review in which they examined prognostic factors for independent walking at 3, 6, and 12 months post-stroke in patients who were nonambulatory within one month after acute hemiplegic stroke.

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

Author Interview: Dr. Eva Mistry on “Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change”

Dr. Eva Mistry
Dr. Eva Mistry

A conversation with Dr. Eva Mistry, MBBS, MSCI, Assistant Professor of Clinical Neurology and Rehabilitation, University of Cincinnati, on predicting 90-day outcome following thrombectomy.

Interviewed by Dr. Yasmin N. Aziz, MD, T32 Stroke Fellow, University of Cincinnati.

They will be discussing the paper Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change,” published in the August 2021 issue of Stroke.

Dr. Aziz: How did the idea behind this paper come to fruition?

Dr. Mistry: To help emphasize the importance of choosing ideal surrogate markers and their correct definitions. When we are developing tools to identify most efficacious acute stroke therapies that improve patient outcomes, and the surrogate outcome measures that we use to predict these patient-centered outcomes are flawed, then all that follows will be flawed as well. Ultimately, there is a real need for solid surrogate markers in acute stroke studies. NIHSS-based surrogate outcome measures are widely used in acute stoke trials. However, they are defined heterogeneously. With the paper, we wanted to establish the pros and cons of using various definitions NIHSS-based surrogate markers, and especially to show how each of them predict the patient-centered outcomes of 90-day modified Rankin Scores.

ESOC 2021: Challenging Clinical Situations in Stroke Medicine (and Tips to Face Them)

Aurora Semerano, MD

European Stroke Organisation Conference
September 1–3, 2021

Session: “Acute Stroke Treatment in Difficult Clinical Situations: In-Hospital Strokes and Other Challenges,” September 2, 2021

Making decisions in stroke medicine is a difficult task and may turn to be really challenging in selected cases, which, however, are quite frequent in our clinical practice. These daily challenges were the focus of the discussion in the session chaired by Daniel Strbian (Finland) and Silke Walter (Germany). Also, some useful tips for more confident decisions were proposed.

When deciding about thrombolysis in patients with recent surgery, existing studies are mostly retrospective and heterogenous, thus evidence for the best practice is very low. Gordian J. Hubert (Germany) suggested a comprehensive approach, which includes the evaluation of the risk of bleeding in the surgical wound (in terms of size, time from surgery, vascularization of the tissue), the damage of a potential bleeding in that site, and the possibility of measures to efficiently stop the bleeding (i.e., compressibility, surgical intervention). Similarly, in patients with recent trauma, the evaluation of the bleeding risk at the trauma site can be crucial, whereas estimating the damage of a potential bleeding may be challenging since location of trauma is often unknown.

ESOC 2021: Thrombosis and Inflammation Team Up in Ischemic Stroke

Aurora Semerano, MD

European Stroke Organisation Conference
September 1–3, 2021

Session: “Inflammation, Thrombosis and Stroke Pathogenesis,” September 3, 2021

The complex interplay between inflammation and thrombosis in ischemic stroke was the subject of the interesting scientific session chaired by Mervyn D. Vergouwen (Netherlands) and Christoph Kleinschnitz (Germany). The five speakers dissected the topic by presenting the main players involved in pathophysiology of stroke-related thrombo-inflammation, and prospected potential interventions of immune modulation.

Bernhard Nieswandt (Germany) showed how platelets, besides their well-established functions, have a critical role in inflammation. They are involved not only in the process of thrombus formation, but also in the subsequent mechanisms of infarct growth. Identifying the optimal target to interfere with platelet activity is crucial, due to the possible risk of hemorrhagic transformation. Two promising axes are discussed, namely the immunomodulatory function of von Willebrand Factor through its receptor on platelets Glycoprotein Ib, and the interplay with the kallikrein system and Factor XII activation. The resulting infiltration of immune cells (including T cells) into the ischemic brain contributes to the damage. Importantly, he pointed out that thrombo-inflammation doesn’t start after recanalization, but it is still ongoing during the occlusion, sustained by the collateral blood flow. This is supported in humans by a recent elegant work,1 which reported for the first time that leukocytes strongly accumulate in cerebral vessels distal to the occlusion. Bearing this in mind is fundamental to designing the optimal treatment.

Article Commentary: “Risk of Fractures in Stroke Patients Treated With a Selective Serotonin Reuptake Inhibitor”

Karissa C. Arthur, MD

Jones JS, Kimata R, Almeida OP, Hankey GJ. Risk of Fractures in Stroke Patients Treated With a Selective Serotonin Reuptake Inhibitor: A Systematic Review and Meta-Analysis. Stroke. 2021;52:2802–2808.

Depression is common in patients after a stroke. While depression can be treated effectively with selective serotonin reuptake inhibitors (SSRIs), several recent randomized controlled trials (RCTs), as well as previous observational cohort studies, have reported an increased risk of falls and fractures in patients treated with SSRIs. This risk is especially important considering that stroke patients are already at a higher risk of falls and fractures. Jones and colleagues aimed to determine the risk of fractures in stroke patients treated with SSRIs via a systematic review and meta-analysis.

A study was eligible for inclusion if it met the following criteria: 1) RCT, 2) included adult patients with previous hemorrhagic or ischemic stroke, 3) compared an SSRI to either placebo or no intervention, and 4) included incident fractures as an outcome. The authors searched for studies using combinations of key terms and subject headings without language restrictions in several databases and clinical trial registers, as well as used the references of included studies to identify other studies for possible inclusion. The results were independently evaluated by two reviewers.

By |September 17th, 2021|clinical|0 Comments

Sex Differences in Stroke Treatment Narrow Between 2005 to 2018 in Sweden

Hannah Roeder, MD, MPH

Eriksson M, Åsberg S, Sunnerhagen KS, von Euler M, on behalf of the Riksstroke Collaboration. Sex Differences in Stroke Care and Outcome 2005–2018: Observations From the Swedish Stroke Register. Stroke. 2021.

In this article, Eriksson et al. investigate whether stroke incidence, care, outcome, and sex differences changed between the years 2005 and 2018 in Sweden. Using data from the Swedish Stroke Register, a national registry including all Swedish hospitals admitting acute stroke patients, the authors highlight improvements in stroke care and narrowing sex gaps.

Sweden had a decreasing incidence of stroke over the 14-year period despite an aging and growing population. The authors propose that primary prevention and behavioral changes, such as less tobacco use, in the population contributed.

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

Does Concurrent COVID-19 Infection Affect Functional Outcomes of Patients With Acute Ischemic Stroke?

Mona Al Banna, MB BCh, Msc(Res)

Martí-Fàbregas J, Guisado-Alonso D, Delgado-Mederos R, Martínez-Domeño A, Prats-Sánchez L, Guasch-Jiménez M, Cardona P, Núñez-Guillén A, Requena M, Rubiera M, et al. Impact of COVID-19 Infection on the Outcome of Patients With Ischemic Stroke. Stroke. 2021.

Various studies are showing that neurologic complications, including stroke, occur frequently in COVID-19 patients. In addition, the COVID-19 pandemic has compromised the delivery of well-established time-sensitive therapies and system delivery in stroke care. The authors of this study set out to determine whether patients with stroke and COVID-19 had worse functional outcomes compared to patients without COVID-19 and, if so, evaluate whether this was attributable to direct effects of the virus itself or due to logistical difficulties of providing care during a global pandemic.

The authors conduced a prospective multicentered cohort study of 19 hospitals in Catalonia, Spain, from mid-March to May 15, 2020. Patients were eligible if they had an acute ischemic stroke with a previous modified Rankin Scale (mRS) of 0-3. Patients were then classified according to their SARS-CoV-2 PCR status. The authors then collected various data variables, including demographic data, vascular risk factor profiles, pre-admission medications, NIHSS on admission and at 72 hours, imaging data, reperfusion therapies (and, if applicable, TICI scores), time metrics (e.g., door to needle, door to groin), stroke etiology and functional outcome at 3 months.