American Heart Association

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So far gkaur has created 9 entries.

Using MRI-based Techniques for Easier Recognition of Hemodynamic Failure in Chronic Cerebrovascular Steno-Occlusive Disease

Gurmeen Kaur, MBBS
@kaurgurmeen

Fierstra J, van Niftrik C, Warnock G, Wegener S, Piccirelli M, Pangalu A, et al. Staging Hemodynamic Failure With Blood Oxygen-Level–Dependent Functional Magnetic Resonance Imaging Cerebrovascular Reactivity: A Comparison Versus Gold Standard (15O-)H2O-Positron Emission Tomography. Stroke. 2018

A major challenge faced by vascular neurologists and neuro-radiologists is accurately identifying the subset of patients with chronic cerebrovascular steno-occlusive disease, predicting those that have a propensity to develop hemodynamic failure and, as a result, have an increased risk of stroke.

Over the past few years, with development of imaging technology, multiple CT and MRI-based techniques have been developed to assess the degree of hemodynamic failure. Cerebral blood flow measurement using 15O PET scan has been recognized as the gold standard. There is a baseline measurement followed by a second scan with acetazolamide (Diamox) challenge.

Post-Marketing Observations From the Use of Apixaban in the Real-World Setting

Gurmeen Kaur, MBBS
@kaurgurmeen

Proiette M, Romanazzi I, Romiti GF, Farcomeni A, Lip GYH. Real-World Use of Apixaban for Stroke Prevention in Atrial Fibrillation. Stroke. 2017

The approval of NOACs for stroke prevention in atrial fibrillation has revamped the way anticoagulation is managed. NOACS have practically replaced the use of warfarin for non valvular atrial fibrillation. Currently, 4 NOACs are approved: apixaban, dabigatran, rivaroxaban and edoxaban. Among those, apixaban is the most widely used NOAC in the United States at this time.

For this systematic analysis, all observational studies with use of apixaban, comparison with other NOACS or warfarin with at least 100 patients and 3 month follow up data were selected. The systematic review and meta-analysis were performed according to PRISMA recommendations. A literature search was performed using PubMed and Scopus databases up to 6 March, 2017.

By |March 26th, 2018|clinical|0 Comments

Is Neuroprotection the Next Revolutionary Step in Stroke Therapy?

Gurmeen Kaur, MBBS
@kaurgurmeen

Savitz SI, Baron J, Yenari MA, Sanossian N, Fisher M. Reconsidering Neuroprotection in the Reperfusion Era. Stroke. 2017

The past few years have seen radical changes in stroke care, development of mechanical thrombectomy as standard of care and, more recently, extension of the time limit to 24 hours in the setting of the DAWN trial. With these changes, exploration of neuroprotective agents is the need of the hour, with an aim to extend the potential window for thrombolytic therapy.

Neuroprotection trials, unfortunately, have a dismal history. Reasons attributed to that may be wrong timing or monotherapy trials. Additionally, designing these trials has been difficult because of difficulty with designing animal models that exactly replicate the stroke penumbra.

By |February 19th, 2018|clinical|0 Comments

Management of Symptomatic Post tPA Hemorrhage in Acute Ischemic Strokes: An Expert Consensus Guideline

Gurmeen Kaur, MBBS
@kaurgurmeen

Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2017

The American Heart Association/American Stroke Association recently published a consensus statement on treatment guidelines for management of symptomatic intracranial hemorrhage (sICH), chaired by Dr. Yaghi. After extensive review of the existing literature, the consensus committee devised this guideline based on the current available evidence.

Different authors and trials have used varying definitions of what is classified as symptomatic ICH. Based on the definitions, there was a 2.5-5-fold variation in the rates of ICH noted. The incidence of sICH after alteplase in the modern era at the standard dose of 0.9 mg/kg administered over 1 hour with a 10% bolus varies from 2% to 7% in clinical trials and prospective stroke registries.

To standardize and make the various trials comparable, the group suggested that stroke centers should classify the appearance of hemorrhagic transformation according to radiographic criteria as described in ECASS II (hemorrhagic infarction [HI] type 1, HI-2, parenchymal hematoma [PH] type 1, PH-2, or remote ICH), assess the degree of neurological worsening by National Institutes of Health Stroke Scale (NIHSS) point change, and provide an attribution of causality for the worsening. The natural history of patients with sICH, particularly the PH-2 radiological subtype, is very poor, approaching 50% mortality and significant morbidity with survival.

By |December 27th, 2017|clinical|0 Comments

Could Bypassing Primary Stroke Centers for Thrombectomy-Capable Centers Lead to Improved Outcomes?

Gurmeen Kaur, MBBS
@kaurgurmeen

Froehler MT, Saver JL, Zaidat OO, Jahan R, Aziz-Sultan MA, Klucznick RP, et al. Interhospital Transfer Prior to Thrombectomy is Associated with Delayed Treatment and Worse Outcome in the STRATIS Registry. Circulation. 2017

Since “Time is Brain” when it comes to ischemic strokes and large vessel occlusions (LVO), the authors designed the STRATIS trial, which is a multicenter, observational, single-world perspective on real-life issues faced during transfers of patients for tPA and mechanical thrombectomy.

1000 patients with anterior circulation LVOs were included over a 22-month period. About half of the patients were transferred to a comprehensive stroke center which is capable of mechanical thrombectomy, and the remaining half was transferred from an outside hospital to an endovascular-capable center. IV-tPA was administered to 628 patients; 329/539 (61.0%) of direct patients and 299/445 (67.2%) of transferred patients (p=0.044).

By |December 15th, 2017|clinical|0 Comments

Peri-Procedural Silent and Clinical Infarctions in Cardiovascular Procedures

Gurmeen Kaur, MBBS
@kaurgurmeen

Cho S-M, Deshpande A, Pasupuleti V, Hernandez AV, Uchino K. Radiographic and Clinical Brain Infarcts in Cardiac and Diagnostic Procedures: A Systematic Review and Meta-Analysis. Stroke. 2017

Cardiovascular procedures including Aortic Valve Replacement (AVR), coronary artery bypass grafting (CABG), and cardiac and cerebral catheterization have been associated with increased prevalence of peri-procedural acute ischemic brain lesions on magnetic resonance imaging (MRI).

In this systematic review, Cho et al compared the ratio of radiographic brain infarcts (RBI) to strokes and transient ischemic attacks across cardiac and vascular procedures. RBIs are common after invasive vascular procedures and are encountered a lot more frequently than clinical strokes or TIAs. Literature suggests that peri-procedural ischemic events might serve as a potential surrogate marker for optimizing invasive procedures, which is why an effort was made to compare the rates of RBIs to clinical events.

Reducing Recurrent Strokes with Secondary Risk-Factor Modification — Reflections from Temporal Trends in a Population-Based Study

Gurmeen Kaur, MBBS
@kaurgurmeen

Bergström L, Irewall AL, Söderström L, Ögren J, Laurell K, Mooe T. One-Year Incidence, Time Trends, and Predictors of Recurrent Ischemic Stroke in Sweden From 1998 to 2010: An Observational Study. Stroke. 2017

The risk of recurrent stroke has been on a decline as per estimates from different countries, including Italy, Taiwan and the “Western world.” Rikstroke is the Swedish Stroke Register where all Swedish hospital admissions because of stroke are recorded. The authors describe an excellent longitudinal study design where patients with ischemic strokes were followed up from 1998 to 2009. From the year 1998, all Swedish hospitals and rehab centers report their admissions to the Rikstroke registry, which had an astounding 85% coverage in the year 2009.

The recurrence of ischemic stroke events was calculated by amalgamating the Rikstroke registry with the Swedish National Inpatient Register (IPR), which contains data about diagnoses and dates of discharge from hospitalizations in Sweden.

Understanding Changing Temporal Trends in Dementia — Does Improving Vascular Health Have a Role?

Gurmeen Kaur, MBBS
@kaurgurmeen

Pase MP, Satizabal C, Seshadri S. Role of Improved Vascular Health in the Declining Incidence of Dementia. Stroke. 2017

It is projected that 13.8 million Americans will have dementia by the year 2050, making it a major public health epidemic. While the overall prevalence is on a rise, every individual’s chance of developing dementia per year is decreasing. The authors used the Framingham Heart Study (FHS) to demonstrate nearly a 20% decrease in developing dementia by a specific age over the past 30 years and have explored the temporal trends of this change.

Improved cardiovascular health and better management of stroke and vascular risk factors may be the reason for this observed decrease. Vascular risk factors have also been implicated in the pathophysiology of both vascular dementia and Alzheimer’s type dementia. A meta-analysis of 14,730 adults, including 862 with a history of stroke and 13,868 controls, demonstrated that a history of stroke increased the risk of AD dementia by 59%. Leukoariosis or increased burden of small vessel disease suggests silent ischemia. Many large databases show that the incidence of strokes is decreasing, which may be a contributing factor to decreased rates of dementia.

Stroke Risk Stratification in Non-Valvular Atrial Fibrillation — Validating CHA2DS2-VASc in an Asian Cohort

Gurmeen Kaur, MBBS
@kaurgurmeen

Kim T, Yang P, Uhm J, Kim J, Pak H, Lee M, et al. CHA2DS2-VASc Score (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65–74, Female) for Stroke in Asian Patients With Atrial Fibrillation: A Korean Nationwide Sample Cohort Study. Stroke. 2017

Non-valvular atrial fibrillation (AF) is a cause of at least 15-20% of strokes in the U.S., with a 5-times increased risk when compared to patients with no atrial fibrillation. The safety, efficacy and availability of oral anticoagulants, in addition to Vitamin K antagonists like warfarin, have made strokes secondary to atrial fibrillation virtually preventable. This has created a need for accurate Stroke Risk Assessment and Stratification.

Various stroke risk schemas over the years have included AFI/ SPAF (1994), CHADS2 (2001), Framingham (2003), NICE (2006) and the relatively recent CHA2DS2-VASc Score, also referred to as Birmingham 2009, that accounts for congestive heart failure, hypertension, 75 years of age and older (2 points), diabetes mellitus, previous stroke or transient ischemic attack (2 points), vascular disease, 65 to 74 years of age, female sex.

Kim et al study a total of 5855 oral anticoagulant (OAC) naïve patients with AF to determine whether the CHA2DS2-VASc score could be reliably used for the Asian population, because the validation studies were performed in an all-Caucasian cohort and various Asian studies have previously reported ethnic differences in the conventional stroke risk factors.

By |August 14th, 2017|clinical, prognosis|0 Comments