American Heart Association

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So far gkaur has created 12 entries.

Outcomes of Anticoagulation for Venous Thrombosis, a Meta-Analysis

Gurmeen Kaur, MBBS
@kaurgurmeen

Aguiar de Souza D, Neto LL, Canhão P, Ferro JM. Recanalization in Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis. Stroke. 2018

With the advent of the endovascular era for ischemic strokes, the role for endovascular therapy for cerebral venous thrombosis (CVT) has been approached with growing interest. However, anticoagulation continues to be the mainstay of treatment for CVT.

In this interesting meta-analysis, de Sousa et al reviewed recanalization rates, clinical outcomes and recurrence rates in patients with CVT.

A total of 468 studies were screened, of which 19 were identified after excluding those studies which had pediatric patients, in which >10% of individuals had endovascular treatment and in whom anticoagulation was not used as part of the post-operative treatment plan.

By |October 1st, 2018|clinical, prognosis|0 Comments

Use of DWI-FLAIR Mismatch for IV-tPA: Results from the WAKE UP Trial

Gurmeen Kaur, MBBS
@kaurgurmeen

Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. NEJM. 2018

Recently, the impressive results of the MRI-Guided Thrombolysis trial, popularly known as WAKE UP, were announced at the European Stroke Organization Conference 2018.

In an investigator initiated, multicenter, randomized, double blind, placebo controlled clinical trial, patients waking up with stroke or those with undetermined last known well because of aphasia and confusion were included between 18-80 years of age.

All patients included did not have contraindications to getting IV tPA, but did not qualify because of the unclear LKW. Previous studies have determined that at the 4.5-hour mark, roughly estimating, the DWI shows positivity but the FLAIR does not show parenchymal involvement. Hence, the mismatch between DWI and FLAIR was used to screen and select patients to be divided into 2 groups: one that received alteplase and the other group that received placebo. Interestingly, patients that qualified for mechanical thrombectomy were excluded from this trial.

By |July 30th, 2018|clinical|0 Comments

AHA Scientific Statement on Intracranial Endovascular Procedures and the Evidence Behind Them

Gurmeen Kaur, MBBS
@kaurgurmeen

Eskey CJ, Meyers PM, Nguyen TN, Ansari SA, Jayaraman M, McDougall CG, et al. Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association. Circulation. 2018

Endovascular intracranial procedures have seen significant advances over the past 3-4 years as reflected in all the recent stroke thrombectomy trials. Given that the last scientific review by the American Heart Association was in 2009, this Scientific Statement document updates the review of outcomes data for the efficacy and safety of these procedures and provides new recommendations for the use of these therapies.

A highly selected writing group did a computerized search of the National Library of Medicine database of literature (PubMed) from July 2007 to January 2016 to come up with these recommendations.

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.