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Tackling a Long Overdue Problem: The Eyes Have It

Richard Jackson, MD

Mac Grory B, Nackenoff A, Poli S, Spitzer MS, Nedelmann M, Guillon B, Preterre C, Chen CS, Lee AW, Yaghi S, et al. Intravenous Fibrinolysis for Central Retinal Artery Occlusion: A Cohort Study and Updated Patient-Level Meta-Analysis. Stroke. 2020;51:2018–2025.

Mac Grory et al. have published data that all stroke neurologists on call have been waiting for. In hospital systems where there are ophthalmologists taking calls, usually the neurologist on call for stroke gets the stroke code page for acute onset loss of vision or the patient is referred to the ER for a diagnosis of CRAO for evaluation. There is an ensuing debate between the on-call neurologist and ER physician about what to do for this patient. As neurologists, we are taught that the eye is an extension of the brain, and infarcts to the eye are technically infarcts to the brain. However, there is no data on whether or not thrombolysis with alteplase is efficacious. The ophthalmologists cite a lack of efficacy in trials and only one randomized trial with a small sample of 25 that showed no benefit when treated with standard dose 0.9mg/kg IV-tPA but within 24 hours of onset. An even more difficult situation arises in the primary stroke centers that do not have ophthalmologists on call where the neurologist on call for stroke has to make a decision based on clinical judgement. Both of these scenarios usually end in poor visual acuity for the patient after medical treatment with monotherapy or dual therapy antiplatelet with or without permissive hypertension and statin treatment.

By |August 10th, 2020|clinical|0 Comments

Infection as a Risk Factor for Stroke Recurrence

Elena Zapata-Arriaza, MD
@ElenaZaps

Xu J, Yalkun G, Wang M, Wang A, Wangqin R, Zhang X, Chen Z, Mo J, Meng X, Li H, et al. Impact of Infection on the Risk of Recurrent Stroke Among Patients With Acute Ischemic Stroke. Stroke. 2020;51:2395–2403.

The association of immune changes after stroke and infection appearance has been widely evidenced recently. Inflammatory cascade occurring during infection may promote platelet, endothelial and coagulation changes triggering subsequent cerebrovascular events. Xu J et al. aim to investigate whether infection increases the short- and long-term risk of recurrent stroke in patients hospitalized due to acute ischemic stroke (AIS).

For the purpose, data were derived from ischemic stroke patients in 2 stroke registries (CSCA study and CNSR III study) realized in China. These registries recorded the medical data during hospitalization and finished 1-year follow-up. Associations of infection (pneumonia or urinary tract infection) during hospitalization with recurrent stroke in the short (during hospitalization) and long term (since 30 days to 1 year after stroke onset) were analyzed. The primary outcome was recurrent stroke, and secondary outcomes included the recurrence of ischemic stroke, intracerebral hemorrhage, hemorrhagic transformation, myocardial infarction, combined vascular events (including recurrent stroke, myocardial infarction, and vascular death), and all cause death. In the CSCA, the authors conducted multivariate logistic regression models to investigate the association of infection with in-hospital outcomes. To keep consistency and confirm the finding in the CSCA, the association of infection with in-hospital outcomes in the CNSR-III was analyzed using logistic regression models.

By |August 5th, 2020|clinical|0 Comments

Impact of COVID-19 on Stroke Workflow: Assessment from Comprehensive Hospitals in Connecticut

Shashank Shekhar, MD, MS

Jasne AS, Chojecka P, Maran I, Mageid R, Eldokmak M, Zhang Q, Nystrom K, Vlieks K, Askenase M, Petersen N, et al. Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic. Stroke. 2020.

Stroke management requires quick and timely evaluation by medical personnel and transfer to a primary stroke center to provide appropriate medical care. The American Heart Association/American Stroke Association recently revised the stroke guidelines in 2019 to reflect the recent advancement in clinical research to clinical practice. However, after the COVID-19 pandemic started in the United States in January 2020, the whole medical system came under severe strain. Around 72% of United States adults were no longer going to public places, including hospitals, to avoid COVID-19 exposure.

This study estimates this decline in stroke volume in the Comprehensive Stroke Centers (CSC) in Connective and eventually aims to increase public awareness. The aims of the study were: compare the volume of stroke codes before and during the COVID-19 local spread; describe the demographics and clinical characteristics of patients presented with acute stroke-like symptoms during this pandemic; and find the association between the onset of the pandemic and acute stroke metrics and outcomes.

This study is a retrospective pre and during event cohort analysis and was approved by the Yale-New Haven Hospital (YNHH) Institutional Review Board with a waiver of informed consent. The date was including from pre-pandemic cohort and pandemic cohort from 2019 and corresponding months in 2020. The number of stroke codes at three hospitals was analyzed from January 1 to April 28, 2020, and compared from the previous year.

Illustrated Teaching Cases Review Topics Likely to be Encountered in Practice

Sophia Sundararajan, MD, PhD, and Shadi Yaghi, MD

Unlike many case presentations, the Illustrative Teaching Cases in Stroke are not designed to present zebras, but rather to review things typically seen in practice. The hope is that this series will create a body of work that presents common topics encountered in stroke patients with discussions that inform the management of similar conditions.

The primary audience for these discussions is residents and fellows. An actual case is presented and discussed, and bulleted teaching points are included at the end of the article. The case is presented succinctly, and the discussion is the bulk of the paper. The articles are short and easy to read, and they are a quick way to review clinical “pearls” in cerebrovascular disease.

The purpose of this series is not to focus on esoteric or unusual cases, but to review and stress points that trainees are likely to encounter during their training and beyond. The focus of each case varies. In some cases, the key feature is a review of neuroanatomy. Another may review types of testing for a specific condition or the differential diagnosis for a particular symptom. The focus should not be related to a technical advance or how to do a procedure.

Should We Surgically Revascularize Asymptomatic Carotid Stenosis?

Muhammad Rizwan Husain, MD
@RIZWANHUSAINMD

Keyhani S, Cheng EM, Hoggatt KJ, Austin PC, Madden E, Hebert PL, Halm EA, Naseri A, Johanning JM, Mowery D, et al. Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis. JAMA Neurol. 2020.

In this entry, I discuss a recent publication by Keyhani and colleagues regarding treatment of asymptomatic carotid stenosis. There is anecdotal evidence from randomized clinical trials (Veterans Affairs Cooperative Study Group: Efficacy of carotid endarterectomy for asymptomatic carotid stenosis NEJM 1993, Endarterectomy for asymptomatic carotid artery stenosis, JAMA 1995 and Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial (ACST), Lancet 2004) that carotid Endarterectomy (CEA) is beneficial in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis. However, these studies were done a long time ago, and since then, there have been great improvements in stroke prevention strategies like enhanced antiplatelet regimens, high potency statins, better diabetes and stricter blood pressure control. The authors planned to investigate that with new and improved primary stroke management strategies available in the current era, revascularization for asymptomatic carotid stenosis (by CEA or carotid stent) might not be beneficial anymore.

The authors had two hypotheses: 1) The clinical superiority seen with CEA in asymptomatic carotid stenosis has diminished and that medical management is now more favorable, and 2) In a select cohort of patients, CEA may still be the treatment of choice.

By |July 24th, 2020|clinical|1 Comment

Article Commentary: “Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites”

Grace Y. Kuo, MD, MS, BA

Sozener CB, Lisabeth LD, Shafie-Khorassani F, Kim S, Zahuranec DB, Brown DL, Skolarus LE, Burke JF, Kerber KA, Meurer WJ, et al. Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites. Stroke. 2020.

Stroke prevention, treatment and management have crossed many milestones in the last 20 years in developed countries, with studies showing that recurrent strokes have declined over the last 50 years. As medical options become more publicly available, health disparities between those who have benefit from secondary stroke prevention become more apparent. Epidemiological data breaking down trends in stroke recurrence will be critical to public health planning as we strive for more equity in stroke care. In this article from the Brain Attack Surveillance in Corpus Cristi (BASIC) project, we see a glimpse of hope in closing the disparity gap.

This study examines the trend in stroke recurrence in an urban population in Nueces County, Texas, of Mexican Americans (MAs) and Non-Hispanic Whites (NHWs) over 14 years. The MA population are predominantly non-immigrant, second and third generation U.S. citizens, with low incidence of return migration. Patients were eligible for database enrollment if they were at least 45 years old and resided in Nueces County at least six months per year. Mortality data was obtained from the Texas Department of State Health Services.

Article Commentary: “Impact of Multiple Social Determinants of Health on Incident Stroke”

Jennifer Harris, MD
@JenHarrisMD

Reshetnyak E, Ntamatungiro M, Pinheiro LC, Howard VJ, Carson AP, Martin KD, Safford MM. Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke. 2020.

Health disparities have emerged as one of the great challenges to our health care system and a critical concern for the health of our U.S. population. Among the most dramatic disparities are seen in cardiovascular disease (CVD). Disparities in stroke outcomes are also widely reported in the literature. Whereas stroke rates in the U.S. have declined over the last decades, stroke mortality rates in nonwhites (predominantly Non-Hispanic (NH) Blacks) have remained substantially higher than in NH Whites [1]. This disparity may be due to differences in stroke incidence, with relative risk=2.77 (95%CI 1.37-5.62) between NH blacks and NH whites among those <55 years of age and 2.23 (95%CI 1.66-3.00) in those >55 years of age [2]. Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study suggest that the prevalence of stroke risk factors, particularly hypertension and diabetes, while clearly higher among NH Blacks, account for only 40% of the Black-White disparities in stroke incidence. The reasons for the remaining 60% are elusive [3].

Various socioeconomic determinants of health have been shown to predispose patients to developing CVD and stroke. According to national health disparities data for cardiovascular disease outcomes, there are several social determinants of health (SDOH) that may help explain stroke disparities. SDOH are defined as economic and social conditions that influence individual and group differences in health status. SDOH include low education, low income, living in an impoverished area, social isolation, and lacking health insurance, among others. To further investigate the association between incident stroke and SDOH, Reshetnyak et al. analyzed data from the REGARDS study to determine the individual and cumulative effect of SDOH on incident stroke.

The Dark Side of Low NIHSS and LVO

Elena Zapata-Arriaza, MD, PhD
@ElenaZaps

Lee VH, Thakur G, Nimjee SM, Youssef PP, Lakhani S, Heaton S, Powers CJ. Early neurologic decline in acute ischemic stroke patients receiving thrombolysis with large vessel occlusion and mild deficits. J Neurointerv Surg. 2020.

Large vessel occlusion (LVO) with minor neurological deficit can occur in about 24% of patients with acute ischemic stroke (AIS). The lack of clinical trials addressing this type of patient generates different therapeutic approaches, which impact the natural history of the disease. Lee et al. aim to determine the likelihood of early neurologic deterioration (END) in patients with LVO and low NIHSS treated with rtPA.

The authors performed a retrospective analysis of AIS with low NIHSS (≤7) and LVO (M1, M2, terminal carotid artery -ICAT- and tandem lesions) treated with rtPA from 2014-2019 in a telestroke platform. Most of the included patients were transferred to a tertiary hospital with endovascular treatment availability, and they received CTA on arrival. END was defined as NIHSS worsening of ≥4 within 24 hrs of stroke onset that was not related to symptomatic hemorrhage.

Catching Stroke Research in the Net

Raffaele Ornello, MD

Broderick JP, Elm JJ, Janis LS, Zhao W, Moy CS, Dillon CR, Chimowitz MI, Sacco RL, Cramer SC, Wolf SL, et al. National Institutes of Health StrokeNet During the Time of COVID-19 and Beyond. Stroke. 2020.

The National Institutes of Health StrokeNet is a wide collaborative network promoting trials in the field of stroke. The project was established in 2013, and, to date, it involves about 500 centers throughout the United States. Over the years, StrokeNet has given a substantial contribution to stroke research, not only favoring the completion of previously funded trials such as the POINT and SHINE trials, but also autonomously funding trials such as DEFUSE 3, ARCADIA, and Telerehab. StrokeNet also has educational goals and a special interest in homogenizing stroke imaging across sites.

The recent COVID-19 pandemic represented a challenge for stroke research, as it caused the forced suspension of all ongoing trials at the end of March and imposed rapid changes in protocols and operating procedures due to logistic barriers and safety concerns. In this context, StrokeNet showed a great capability of analyzing the new and unprecedented situation and providing rapid adaptations of the ongoing protocols. Those adaptations include a substantial use of telemedicine and remote solutions, the use of online surveys, an increasing use of innovative designs such as exemption from informed consent (EFIC), and reconsideration of processes such as timing of enrollment and outcome assessment. StrokeNet promptly responded to the COVID-19 pandemic, providing guidance to the principal investigators of ongoing trials, in which they were invited to adhere to safety recommendations and encouraged to use telemedicine, and modifying some aspects of data collection and patient follow-up due to the pandemic emergency.

Article Commentary: “Palliative Care: A Core Competency for Stroke Neurologists”

Burton J. Tabaac, MD
@burtontabaac

Creutzfeldt CJ, Holloway RG, Curtis JR. Palliative Care: A Core Competency for Stroke Neurologists. Stroke. 2015;46:2714–2719.

As physicians and healthcare providers, we often focus on restorative care and efficacious treatments. It is paramount, and of high import, that we are competent and trained to provide high-quality end-of-life care as well. Essential in our role is the ability to offer comfort measures when consistent with a patient’s wishes, and to serve as a source of information and support for family members when loved ones are transitioning to comfort-guided care.

This article’s authors provide a contemporary review of the literature and offer recommendations on how providers may integrate palliative medicine into the care of their patients. Palliative care is an approach to medical care for patients with serious illness. It includes end-of-life and hospice care, but is much broader. Palliative care is not limited to those with a terminal prognosis, but rather is appropriate at any age and at any stage of a serious illness.(1) The article articulates, “Palliative care focuses on improving communication about goals of care and maximizing comfort and quality of life of patients and families through the identification, prevention, and relief of pain and suffering in body, mind, and spirit.”