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The Tale of High Cortisol Levels, Shrinking Brain and Cognitive Impairment Among Adults in Their 40s

Lin Kooi Ong, PhD

Echouffo-Tcheugui JB, Conner SC, Himali JJ, Maillard P, DeCarli CS, Beiser AS, et al. Circulating cortisol and cognitive and structural brain measures: The Framingham Heart Study. Neurology. 2018

Chronic stress has been shown to have detrimental effects on the brain structure and functions in pre-clinical studies. These negative effects are partially attributable to the hypothalamic-pituitary-adrenal axis dysregulation indexed by high cortisol levels. However, there are limited human studies in general population. In this study, Echouffo-Tcheugui et al. used data from the Framingham Heart Study, a large community-based study, to examine the association of early morning serum cortisol with cognitive performance including memory, abstract reasoning, visual perception, attention and executive function in a population of 2231 young and middle-aged adults (mean age 48.5 years) without dementia. Brain Magnetic Resonance Imaging (MRI) was performed on eligible 2018 individuals for volume of brain structures, and integrity of white matter and gray matter. Interestingly, the team observed higher levels of serum cortisol were significantly associated with lower total cerebral brain and occipital and frontal lobar gray matter volumes, as well as poorer cognitive performance in memory and visual perception, with the association being prominent in women. Further, the team identified that higher cortisol was associated with decreased integrity of the white matter tracts.

By |January 22nd, 2019|clinical|0 Comments

Early Reocclusion after Mechanical Thrombectomy: Prevalence, Predictors, and Impact on Long-Term Outcome

Sami Al Kasab, MD

Mosimann PJ, Kaesmacher J, Gautschi D, Bellwald S, Panos L, Piechowiak E, et al. Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients. Stroke. 2018

Mechanical thrombectomy (MT) is now the standard of care for patients presenting with anterior circulation LVO, who otherwise have small core infarct defined by ASPECTS score or perfusion scans admission. Rapid and complete revascularization have been shown to predict good functional outcome. Data on the rate of early revascularization are scares. In this article, Mosimann et al. evaluate the prevalence and predictors of early reocclusion following successful MT and its impact on long-term functional outcome.

A total of 711 patients were included in this study; all patients underwent MT and had revascularization score of TICI2b or 3 at the end of the procedure; intravenous thrombolysis was administered when indicated. Post-thrombectomy care was performed according to the standard institutional guidelines. Etiology for stroke was documented according to the TOAST classification system. Early reocclusion was defined as reocclusion seen on CTA or MRA during the first 48 hours following MT.

By |January 18th, 2019|clinical|0 Comments

Intracranial Carotid Artery Calcification and Effectiveness of Endovascular Thrombectomy and Functional Outcome in Acute Ischemic Stroke

Kara Jo Swafford, MD

Compagne KCJ, Clephas PRD, Majoie CBLM, Roos YBWEM, Berkhemer OA, van Oostenbrugge RJ, et al. Intracranial Carotid Artery Calcification and Effect of Endovascular Stroke Treatment: MR CLEAN Subgroup Analysis. Stroke. 2018

Endovascular thrombectomy (EVT) is an effective treatment for patients with acute ischemic stroke caused by a large vessel occlusion. The pattern and quantity of intracranial carotid artery calcification (ICAC) may influence the effectiveness of EVT and functional outcome. There are two recognized patterns of ICAC: intimal and medial calcification patterns. Compagne et al. performed a post hoc analysis of data from MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment of Acute ischemic stroke in the Netherlands) investigating the effect of ICAC volume and pattern on treatment success and functional outcome. Intervention and control groups were included.

There was no modification of the EVT treatment effect by ICAC volume, and no association between ICAC volume and functional outcome. There, however, was a treatment effect modification by ICAC pattern (P interaction=0.04). Patients with a medial ICAC pattern had larger infarct volumes and poorer outcomes in the control group, but tended to benefit more from EVT compared to patients with an intimal ICAC pattern. One explanation for a greater EVT treatment effect in patients with a medial calcification pattern is that this pattern can lead to arterial stiffening, causing impaired regulation of distal flow and development of microcollaterals. Another proposed explanation is that the thrombus is different in patients with intimal versus medial calcifications and EVT is not as effective in removing thrombus in those with an intimal calcification pattern.

By |January 16th, 2019|clinical|0 Comments

Hemoglobin A1C and Clinical Outcomes After Thrombectomy

Robert W. Regenhardt, MD, PhD

Choi K-H, Kim J-H, Kang K-W, Kim J-T, Choi S-M, Lee S-H, et al. HbA1c (Glycated Hemoglobin) Levels and Clinical Outcome Post-Mechanical Thrombectomy in Patients With Large Vessel Occlusion. Stroke. 2018

Mechanical thrombectomy has revolutionized the acute care of patients suffering from stroke secondary to large vessel occlusions. With its proven efficacy up to 24 hours after stroke onset, current research endeavors include broadening the inclusion criteria for this powerful therapy, preventing complications such as reperfusion injury, and increasing favorable outcomes after successful recanalization. Admission hyperglycemia is a known predictor of poor outcomes and increased mortality in patients suffering from acute stroke, including those treated with intravenous thrombolysis and mechanical thrombectomy.

This recent manuscript by Choi et al. published in Stroke analyzed relationships between hemoglobin A1C (HbA1C), a marker of average blood glucose during the preceding 3 months, and clinical outcomes after thrombectomy. The authors examined HbA1C in 534 patients with acute ischemic stroke from large vessel occlusions that underwent thrombectomy in a prospective cohort study. The primary outcome was disability (mRS) at 3 months. Secondary outcomes included 3-month mortality. In addition, several other outcomes were examined within the first 7 days: intracranial hemorrhage, early neurologic deterioration (worsening by ≥2 NIHSS points), and early clinical improvement (by ≥4 NIHSS points).

By |January 15th, 2019|clinical|0 Comments

A New Tool to Quantify Severity, Extent and Course of Focal Cerebral Arteriopathy of Childhood Could Be Used for Treatment Trials

Alejandro Fuerte, MD

Fullerton H, Stence N, Hills N, Jiang B, Amlie-Lefond C, Bernard T, et al. Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History. Stroke. 2018

Focal cerebral arteriopathy (FCA) of childhood is an acute disease causing unilateral stenosis of the cerebral arteries. It appears to be caused by an inflammatory process, and corticosteroids are used in its treatment in the absence of clinical trial data. Because it is one of the most common causes of arterial ischemic stroke (AIS) in healthy children and it increases the risk of recurrent stroke, a Delphi consensus identified this issue as the highest priority for a clinical trial in the field of childhood stroke.

The main goal of Fullerton et al. was to develop a severity score for this disease (Focal Arteriopathy Childhood Severity Score; FCASS). For this they used data from the VIPS study (Vascular Effects of Infection in Pediatric Stroke), a large, international, prospective cohort study that enrolled 355 children (29 days to 18 years of age) with AIS and collected clinical, imaging data and serum samples.

The ARISTOPHANES Study: Real-World Evidence About Oral Anticoagulants

Lina Palaiodimou, MD

Lip GYH, Keshishian A, Li X, Hamilton M, Masseria C, Gupta K, et al. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients: The ARISTOPHANES Study. Stroke. 2018

The ARISTOPHANES study is a large retrospective observational study with real-world data pooled from 5 data sources in the United States, in order to compare stroke/systemic embolism (SE) and major bleeding (MB) among nonvalvular atrial fibrillation patients treated with either non-vitamin K antagonist oral anticoagulants (NOACs) or warfarin.

The researchers of this study collected data about a total of 321182 patients with a diagnosis of AF, who had an active medical and pharmacy health plan enrollment and were prescribed treatment with either NOAC or warfarin according to pharmacy claims. Exclusion criteria were the following: evidence of valvular heart disease, venous thromboembolism, previous oral anticoagulant treatment, transient AF due to treatable causes (pericarditis, hyperthyroidism, thyrotoxicity), heart valve replacement or transplant, pregnancy and recent surgical operations. Demographic data, Charlson Comorbidity Index score, baseline bleeding and stroke/SE history, comorbidities, baseline comedication and dose of NOAC were recorded about all patients. In contrast, reason for lose-dose NOAC prescription, creatinine clearance, international normalized ratio (INR) measurements in warfarin-treatment group and patient adherence data were not available. The outcome measures were time to stroke (either ischemic or hemorrhagic) or systemic embolism and time to major bleeding, either gastrointestinal or intracranial or at other key sites (eyes, pericardium, urinary tract, joints). Identification of these events were based just on hospitalization incidence with stroke/SE or MB as the principal diagnosis according to International Classification of Diseases, Ninth Revision (ICD-9). Mortality due to all-causes was also evaluated, but just for the patients enlisted in only one out of five data sources. Patients were followed up each for a different period, according to drug discontinuation date, switch to another drug date, death, end of medical and pharmacy health plan enrollment, or end of study period, whichever occurred first. In the conducted sensitivity analysis, the follow-up period was restricted to 1 year, to better achieve balance between the cohorts.

TCD Evaluation of Autoregulation as a Predictor of Stroke Functional Outcome

Richard Jackson, MD

Chi N-F, Hu H-H, Wang C-Y, Chan L, Peng C-K, Novak V, et al. Dynamic Cerebral Autoregulation Is an Independent Functional Outcome Predictor of Mild Acute Ischemic Stroke. Stroke. 2018

Nai-Fang Chi et al. published a study on the evaluation of autoregulation in ischemic stroke.  The purpose of this study was to investigate whether dynamic cerebral autoregulation (dCA) indices constitute an independent functional outcome predictor of acute ischemic stroke.

Cerebral autoregulation (CA) regulates vascular tone to compensate hypoperfusion after during ischemia but no concrete guidelines for blood pressure targets are currently known. The impact of cerebral autoregulation is associated with infarct volume but outcome is currently confounded by other comorbid variables. Dynamic cerebral autoregulation (dCA) is a way to quantify CA by analyzing the relationship between transient changes in cerebral blood flow and blood pressure. This study attempted to assess whether resting state dCA was a functional predictor of outcome.

By |January 9th, 2019|clinical|0 Comments

Post-Thrombolysis Recanalization in Patients with Large Vessel Occlusions

Mohammad Anadani, MD

Seners P, Turc G, Naggara O, Henon H, Piotin M, Arquizan C, et al. Post-Thrombolysis Recanalization in Stroke Referrals for Thrombectomy: Incidence, Predictors, and Prediction Scores. Stroke. 2018

Since the publication of the pivotal trials in 2015, mechanical thrombectomy (MT) has become the standard of care for patients with large vessel occlusions. Intravenous thrombolysis (IVT) before MT (bridging therapy) remains the standard of care in eligible patients; however, there is an ongoing debate on the benefit of IVT prior to MT, especially that IVT administration can delay MT, which could be harmful.

In this study, PREDICT-RECANAL investigators conducted a retrospective multicenter study to: 1) determine the incidence and predictors of early recanalization (ER); and 2) develop and validate an ER prediction score.

The derivation cohort included patients from 4 MT-capable centers. Inclusion criteria were: 1) acute stroke due to large vessel occlusion (LVO) of the anterior circulation; 2) patients received IVT; and 3) ER evaluation before MT. The validation cohort consisted of 4 prospectively collected MT databases. MRI was used as first line imaging in this study, and CT/CT angiography was used as a second line in patients with contraindication to MRI. MRIs were reviewed to collect the following variables: 1) occlusion site; 2) length of the susceptibility vessel sign (SVS); and 3) DWI lesion extent using the DWI-ASPECTS. ER was evaluated <=3 hours after initiation of IVT. ER was defined as mTICI (modified Thrombolysis In Cerebral Infarction) 2b-3 for ICA T/L or M1 occlusion and Arterial Occlusive Lesion scale (AOL) 3 for the remaining occlusion sites.

By |January 8th, 2019|clinical|0 Comments

Early Reocclusion: A Predictable Enemy

Elena Zapata-Arriaza, MD

Mosimann PJ, Kaesmacher J, Gautschi D, Bellwald S, Panos L, Piechowiak E, et al. Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients. Stroke. 2018

Obtaining and maintaining TICI 2b-3 recanalization grade is one of the most important modifiable predictors related to a good functional outcome in stroke patients due to large vessel occlusion.

The authors performed a retrospective analysis obtained prospectively from the institutional Bernese Stroke Registry. All patients with acute ischemic stroke (n=972) treated by mechanical thrombectomy between January 2010 and July 2017 with a Solitaire stent retriever ± distal aspiration catheters were reviewed. The main goal of this paper was to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies. The originality of the paper is the possibility to know the reocclusion rate after a successful thrombectomy in a real-life prospective cohort. In addition, predictors of reocclusion and the relation with clinical outcomes entail an interesting point to predict some cases of futile recanalization. The authors included in the analysis all the patients with successful recanalization grade (TICI 2b-3 score) and magnetic resonance or computed tomography angiography images available at follow-up within 48 hours (N= 711).

By |January 7th, 2019|clinical|0 Comments

Endovascular Thrombectomy Appears to be Effective Treatment for Acute Ischemic Stroke Associated with Cervical Artery Dissection

Muhammad Zeeshan Memon, MD

Li S, Zi W, Chen J, Zhang S, Bai Y, Guo Y, et al. Feasibility of Thrombectomy in Treating Acute Ischemic Stroke Because of Cervical Artery Dissection. Stroke. 2018

Acute ischemic stroke associated with cervical artery dissection is traditionally treated with anticoagulants or antiplatelet agents. However, hyperacute stroke patients with large artery occlusion because of cervical artery dissection may not have good outcomes even if treated with intravenous thrombolysis. The feasibility of thrombectomy in treating acute ischemic stroke because of cervical artery dissection has not been probed well.

In this multicenter study from China, the investigators compared outcomes of 48 patients treated with endovascular treatment matched by propensity score to 48 historical control managed with medical treatment only. Patients were included in the study if they had a large artery occlusion (ICA,M1) which was attributed to cervical artery dissection. The diagnosis of cervical artery dissection was based on typical radiologic characteristics, on magnetic resonance angiography, CT angiography, or digital subtraction angiography. Only patients with thrombectomy performed within 6 hours with stent retrievers were included in the interventional arm. For single artery occlusion, a stent retriever was usually used first; for tandem artery occlusions, priority to treat the proximal or the distal occlusion was decided by the operator depending on the lesion profiles. The authors reported that the proportion of favorable outcome (modified Rankin Scale score of 0–2) was higher in patients with thrombectomy than in those without (66.7% versus 39.6%; P=0.008). There were no significance differences about the incidence of symptomatic intracranial hemorrhage (8.3% versus 4.2%; P=0.677) and the 90-day mortality (10.4% versus 6.3%; P=0.714) between matched patients with and without thrombectomy.

By |January 4th, 2019|clinical|0 Comments