American Heart Association

Monthly Archives: December 2021

Symptomatic Intracranial Thrombus Characteristics, Collateral Blood Flow and Recanalization Rates With/Without Intravenous Alteplase in Mild Ischemic Stroke Patients

Andrew Micieli, MMI MD

Lau HL, Gardener H, Coutts SB, Saini V, Field TS, Dowlatshahi D, Smith EE, Hill DM, Romano JG, Demchuk AM, et al. Radiographic Characteristics of Mild Ischemic Stroke Patients With Visible Intracranial Occlusion: The INTERRSeCT Study. Stroke. 2021.

Vascular imaging of the head and neck in the hyperacute stroke setting has important diagnostic and prognostic implications, especially in patients with mild stroke. The presence of an intracranial large vessel occlusion is a strong predictor of early neurological and radiographic deterioration in patients with mild stroke. Recanalization is associated with improved functional outcomes; however, the safety in mild stroke patients is less clear.

The authors sought to analyze thrombus characteristics, collateral blood flow and recanalization rates with or without intravenous alteplase in patients with mild ischemic stroke (NIHSS ≤5) and compare these with patients with moderate/severe symptoms (NIHSS >5) from the previously published INTERRSeCT study.

By |December 27th, 2021|clinical|0 Comments

Metabolic Consequences of Obesity, But Not Obesity Itself, Are Associated With Increased First Ischemic Stroke Risk

Dixon Yang, MD

Horn JW, Feng T, Mørkedal B, Strand LB, Horn J, Mukamal K, Janzsky I. Obesity and Risk for First Ischemic Stroke Depends on Metabolic Syndrome: The HUNT Study. Stroke. 2021;52:3555–3561.

Obesity is thought to be an important modifiable risk factor for ischemic stroke, especially given its high prevalence in certain European countries and the United States. However, obesity relationship to ischemic stroke may be more complex as there is still uncertainty on whether obesity itself or metabolic consequences of obesity are drivers of stroke risk. Horn et al. sought to assess the long-term association of weight, metabolic health, and ischemic stroke risk in the HUNT study (Trøndelag Health Study), a large prospective population-based cohort investigation based in Norway.

The present analysis included 35105 participants from HUNT who were free of stroke at baseline and had complete information on demographics, metabolic risk factors, and relevant covariates. Body weight categories were determined by standard body-mass index (BMI) thresholds (normal weight: 18.5 to <25 kg/m2, overweight: 25 to 29.9 kg/m2, obese: ≥30 kg/m2). The authors used a modified definition of metabolic syndrome from the International Diabetes Federation. Metabolically unhealthy was defined as the presence of increased waist circumference (WC) (≥102 cm in men, ≥88 cm in women) and 2 or more of the following: increased non-fasting triglycerides (≥1.7 mmol/L), decreased high-density lipoprotein (<1.03 mmol/L in men, <1.29 mmol/L in women), increased blood pressure (≥130/85 mmHg) or use of blood pressure medication, increased non-fasting glucose (≥11.1 mmol/L), or diabetes diagnosis. Outcomes were stroke diagnosis based on ICD codes in administrative hospital system data.

By |December 22nd, 2021|clinical|0 Comments

Patent Foramen Ovale Closure Reduces Clinical but Not Silent Brain Infarcts

Mona Al Banna, MB BCh, Msc(Res)

Messé SR, Erus G, Bilello M, Davatzikos C, Andersen G, Iversen HK, Roine RO, Sjöstrand C, Rhodes JF, Søndergaard L, Kasner SE, and on behalf of the Gore REDUCE Study Investigators. Patent Foramen Ovale Closure Decreases the Incidence but Not the Size of New Brain Infarction on Magnetic Resonance Imaging: An Analysis of the REDUCE Trial. Stroke. 2021;52:3419–3426.

Patent foramen ovale (PFO) is found in one quarter of the population. However, in cryptogenic strokes, PFOs have been found in approximately one half of patients. (1) The association is even stronger in younger patients with a stroke, as a four-fold greater incidence of PFO has been detected compared to a stroke-free age- and sex-matched control group. (2) The pathophysiology of PFO-related stroke involves the paradoxical embolism of a clot from the venous circulation to the arterial circulation through a right-to-left shunt. Therefore, PFO closure to eradicate the right-to-left shunt has been proposed as an intervention to reduce PFO-related stroke. Percutaneous PFO closure devices have been in use for many years. However, up until recently, clinical trials did not show significantly lower rates of recurrent stroke with PFO closure compared to standard medical therapy alone. (3-5) A sub-group analysis of the RESPECT (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment) trial showed significant reduction of stroke recurrence in patients with larger sized PFOs and atrial septal aneurysm. (6) The latest randomized controlled trials investigating the benefit of PFO closure utilized stricter inclusion criteria, in which patients were only eligible for closure if they had PFOs with an associated large interatrial shunt or atrial septal aneurysm, cortical stroke, and were <60 years old. (7-9) These trials concluded that the rate of recurrent stroke was significantly lower with closure, with one stroke avoided at 2 years for every 24 treated patients. (7)However, due to feasibility, these trials used an open label design where the patients and the treating clinicals were aware of the treatment assignment, increasing the risk of bias.

Real-World Experience of Mechanical Thrombectomy in Patients With Pre-Stroke Disability

Ammad Mahmood, MBChB

Millán M, Ramos-Pachón A, Dorado L, Bustamante A, Hernández-Pérez M, Rodríg uez-Esparragoza L, Gomis M, Remollo S, Castaño C, Werner M, et al., and on behalf of the Cat-SCR Consortium. Predictors of Functional Outcome After Thrombectomy in Patients With Prestroke Disability in Clinical Practice. Stroke. 2021.

Major clinical trials generally exclude patients with pre-stroke disability, generally defined as pre-stroke modified Rankin scale (mRS) of ≥2 or 3. Accordingly, thrombectomy guidelines [1, 2] state the benefit of mechanical thrombectomy (MT) for patients with pre-stroke disability is less clear, particularly for those aged >80. Patients with pre-stroke disability are routinely considered for MT particularly when other clinical and radiological factors are favorable, such as early presentation or good ASPECTS score. In this registry-based study, patients with mRS of 2 or 3 who underwent MT in the Catalonia stroke network were examined to assess any association between pre-stroke disability and outcomes, as well as aiming to identify factors predictive of favorable outcome for patients with pre-stroke disability. A favorable outcome in this context was defined as a return to baseline mRS at 90 days.

The Relationship Between Cerebrovascular Disease Profiles and Neurodegenerative Disease

Mona Al Banna, MB BCh, Msc(Res)

Lamar M, Leurgans S, Kapasi A, Barnes LL, Boyle PA, Bennett DA, Arfanakis K, Schneider JA. Complex Profiles of Cerebrovascular Disease Pathologies in the Aging Brain and Their Relationship With Cognitive Decline. Stroke. 2021.

Neurodegenerative disease with concurrent cerebrovascular disease (CVD) is associated with poorer long-term outcomes and increased functional dependency. Studies suggest that the co-existence of neurodegenerative pathologies and cerebrovascular pathologies ranges from 33-75%. However, little is known about the most common frequencies of cerebrovascular disease pathology types and the combinations of cerebrovascular pathologies that are encountered with dementia. The authors of this study set out to identify CVD frequencies and combinations in neurodegenerative disease and their association with cognitive domains affected.

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

Article Commentary: “Smoking Cessation in Stroke Survivors in the United States”

Nurose Karim, MD

Parikh NS, Parasram M, White H, Merkler AE, Navi BB, Kamel H. Smoking Cessation in Stroke Survivors in the United States: A Nationwide Analysis. Stroke. 2021.

Smoking is one of the leading and preventable causes of stroke. After a primary stroke, there is an increased risk for future strokes, and recurrent strokes are usually more disabling. This article is highlighting two major topics: rate of smoking cessation in stroke survivors and comparing it with cancer survivors. The hypothesis is that smoker cessation rate is higher in cancer survivors as compared to stroke survivors.

This is a retrospective study of prospective data from 2013-2019 from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS), which includes patients above age 18. Pregnant patients and those with incomplete information regarding their stroke, cancer or smoking status were excluded. A total of 3,029,122 respondents were identified, and their information was validated. Smoking status was self-reported and was validated as well. Quit ratio is defined as the proportion of ever smokers who quit. “Ever smokers,” by definition, smoked at least 100 cigarettes in a person’s lifetime. Inverse of the quit ratio is the proportion of ever smokers who continue to smoke.

By |December 13th, 2021|clinical|0 Comments

A New Independent Risk Factor for Stroke? A Brief Review of “Cumulative Concussion and Odds of Stroke in Former National Football League Players”

Yasmin Aziz, MD

Brett BL, Kerr ZY, Aggarwal NT, Chandran A, Mannix R, Walton S, DeFreese JD, Echemendia RJ, Guskiewicz KM, McCrea MA, Meehan III WP. Cumulative Concussion and Odds of Stroke in Former National Football League Players. Stroke. 2021.

In the last 20 years, the discovery of chronic traumatic encephalopathy has captured the attention of both the scientific and athletic communities, sparking a renewed interest in sports safety and concussion protocols. Inspired by preclinical studies, the authors for this article sought to examine if another feared neurologic complication, stroke, is associated with lifetime concussion exposure. In this cross-sectional study, nearly 979 men 50 years or older with at least one year’s experience in the National Football League (NFL) were sent a questionnaire asking about demographics, current functioning, as well as medical, football, concussion, and stroke history. Concussion was specifically defined using standard definition (i.e., not restricted to only episodes of being “knocked out”), and stroke history was defined by a personal history of obtaining this diagnosis from a healthcare provider. Concussion number was subgrouped into 5 categories: 0, 1-2, 3-5, 6-9, and 10 or more events. Traditional demographic risk factors were collected and placed in a multivariate logistic model to estimate adjusted odds ratio (aOR) for stroke.

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

Ischemic Stroke in Hospitalized COVID-19 Patients: Incidence, Risk Factors, and Outcomes

Melissa Bailey, MD

Sluis WM, Linschoten M, Buijs JE, Biesbroek JM, den Hertog HM, Ribers T, Nieuwkamp DJ, van Houwelingen RC, Dias A, van Uden IWM, et al. Risk, Clinical Course, and Outcome of Ischemic Stroke in Patients Hospitalized With COVID-19: A Multicenter Cohort Study. Stroke. 2021;52:3978–3986.

Stroke occurrence in COVID-19 patients has been widely observed, but our understanding of the incidence and outcomes associated with stroke in those with COVID-19 is still under investigation. The association between COVID-19 and thromboembolic events has been well established, and studies have reported varying incidences of ischemic stroke associated with this disease. However, few studies have analyzed the association between ischemic stroke and other cardiovascular risk factors in those with COVID-19. Sluis and colleagues investigated the incidence, associated risk factors, and outcomes in hospitalized patients in order to add to the growing body of literature regarding stroke and COVID-19.

By |December 8th, 2021|clinical|0 Comments

Article Commentary: “Increased COVID-19 Mortality in People With Previous Cerebrovascular Disease”

Ericka Samantha Teleg, MD

Lazcano U, Cuadrado-Godia E, Grau M, Subirana I, Martinez-Carbonell E, Boher-Massaguer M, Rodríguez-Campello A, Giralt-Steinhauer E, Fernández-Pérez I, Jiménez-Conde J, et al. Increased COVID-19 Mortality in People With Previous Cerebrovascular Disease: A Population-Based Cohort Study. Stroke. 2021.

The COVID-19 pandemic has shaped and changed the diagnostic, treatment, and management landscape in stroke healthcare throughout the world. The authors of this study emphasized several important points in the beginning in defining their research question: Is previous stroke an independent risk factor for mortality after COVID-19?

At the start, COVID-19 had stroke specialists and other health care specialists analyze mortality and risk of cerebrovascular disease in a population-based cohort in a prospective methodology. This is the strength of this article; using a prospective methodology to answer a research question such as theirs is a challenge since the pandemic landscape is continuously evolving. Several other studies utilized hospital cohorts.

By |December 7th, 2021|clinical|0 Comments

World Stroke Congress: RAISE Session on New Frontiers in Neurocardiology in the 2020s

Sishir Mannava, MD

World Stroke Congress
October 28–29, 2021

Neurocardiology: The Neurologist’s Perspective – Dr. Edip Gurol

Dr. Gurol started by discussing the importance of the neurologist classifying stroke etiologies, and ultimately concern for cardioembolic infarct, and the importance of long-term cardiac monitoring in these patients as highlighted by the findings in the CRYSTAL-AF and REVEAL-AF studies. Another important role of neurologists in these patients is stratifying ICH risk if they require anticoagulation (AC). The FDA approved AC for stroke prevention, include warfarin, direct oral antiocoagulants (DOACs), and left atrial appendage closure (LAAC) with WATCHMAN/Amulet devices. Importantly, AC increased intracranial hemorrhage (ICH) risks, and outcomes of AC-associated ICH are extremely poor. High-risk categories include prior brain bleed (of many types), brain microbleeds on MRI (as highlighted in the CROMIS-2 study), white matter disease on MRI, and cognitive/gait problems. AC has been associated with between 5-7x the risk of ICH as compared to antiplatelets (AP). In a recent trial from the UK, which randomized patients to AC vs AP after spontaneous ICH, 8% (AC) as opposed to 4% (AP) had recurrent ICH. Mortality of AC-related ICH is very high, ~50%. Having a prior history of ICH related to hypertension < mixed-ICH < cerebral amyloid angiopathy ICH significantly increases recurrent ICH risk as well. This concept also applies to patients who have independent evidence of lobar microbleeds. Interestingly, Dr. Gurol highlighted a 2019 study from Neurology that showed moderate/severe white matter hyperintensities were associated with ~6% increased risk of ICH if given AC (Marti-Fabregas et al). Regarding LAAC in nonvalvular atrial fibrillation, the PRAGUE-17 trial showed that stroke prevention and bleeding risks were similar when comparing closure to DOACs. Dr. Gurol closed with discussion of patent foramen ovale (PFO) closure for stroke prevention, highlighting that hypercoagulable states and other causes should be evaluated prior to PFO closure. Ultimately, all decision-making regarding AC or device placement (LAAC, PFO) should be shared with the patient.