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The Importance of Recognizing New Anxiety in Post-Stroke Care

Mark R. Etherton, MD, PhD

Chun H-Y Y, Whiteley WN, Dennis MS, Mead GE, Carson AJ. Anxiety After Stroke: The Importance of Subtyping. Stroke. 2018

In this entry, I discuss a recent publication by Ho-Yan Yvonne Chun and colleagues exploring the prevalence and types of anxiety after stroke and how it relates to functional status.

Anxiety following stroke or TIA is common, occurring in up to 1/3 of patients, and can negatively impact stroke recovery and quality of life. The authors set out to characterize the proportions of specific anxiety subtypes and impact on functional outcomes and quality of life.

By |April 20th, 2018|clinical|0 Comments

Does tPA Really Save Lives?

Kevin S. Attenhofer, MD

Muruet W, Rudd A, Wolfe C, and Douiri A. Long-Term Survival After Intravenous Thrombolysis for Ischemic Stoke: A Propensity Score-Matched Cohort with up to 10-Year Follow-Up. Stroke. 2018

Although tissue plasminogen activator (tPA) has been approved in the United States for treatment of acute ischemic stroke since the mid-90s, there persists a sharp divide between neurologists and the emergency medicine community regarding the safety and efficacy of tPA. Imbalances between the treatment and control groups in the NINDS tPA study, criticisms of the subjective nature of functional outcome scores, and allegations of conflicts of interest have all contributed to the lingering controversy surrounding tPA. I have personally encountered significant resistance and hostility to IV tPA from other providers over 20 years after its approval. In this article, Muruet et al. add to a growing volume of literature that should help the community neurologist assuage the concerns of fellow providers.

Large Core at Presentation Does Not Essentially Translate Into Poor Outcomes, May Be Amenable to Treatment in Select Patients

Kaustubh Limaye, MD

Gautheron V, Xie Y, Tisserand M, Raoult H, Soize S, Naggara O, et al. Outcome After Reperfusion Therapies in Patients With Large Baseline Diffusion-Weighted Imaging Stroke Lesions: A THRACE Trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke) Subgroup Analysis. Stroke. 2018

The treatment landscape of acute ischemic stroke secondary to large vessel occlusion changed significantly in 2015 with the publication of 5 clinical trials that compared intravenous alteplase (IV t-pA) with IV t-pA and intra-arterial therapy (IAT). These clinical trials showed unequivocal benefit in reducing morbidity with the ESCAPE trial even showing mortality benefit. A similar trial conducted at 26 centers in France, THRACE (mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke) randomized 414 acute stroke patients with large vessel occlusion in either arm (IV t-PA vs IV tPA + IAT). 42 % of patients (IV tPA alone) vs. 53% (IV tPA +IAT) achieved functional independence [OR-1.55,95%CI 1.05-2.30; p-0.028], supporting data from the previous clinical trials. As this study was designed before the results of the IMS-III were published, it included patients treated within 4 hours of symptom onset. Other inclusion criteria were age 18-80 years, NIHSS 10-25, both anterior and posterior circulation and initiation of IAT within 5 hours.

Seeing Your Dentist Regularly Might Save You From Having a Stroke: The Association Between Poor Dental Hygiene and Incident Ischemic Stroke

Abbas Kharal, MD, MPH, and Richa Sharma, MD, MPH

Sen S, Giamberardino LD, Moss K, Morelli T, Rosamond WD, Gottesman RF, et al. Periodontal Disease, Regular Dental Care Use, and Incident Ischemic Stroke. Stroke. 2018

This is a well-designed study exploring the relationship of dental disease, a prevalent and modifiable condition, and the incidence of ischemic stroke. The authors sought to investigate whether an association was present between the two conditions given significant prior retrospective studies suggesting a correlation.

The study population is the ARIC (Atherosclerosis Risk in Communities) cohort who also had a dental examination during the fourth visit, resulting in a total of 6,736 patients. Utilization of regular dental visits was assessed by self-report. The degree of periodontal disease was determined by classifying each patient by aggregating data on the tooth level involving 7 dental parameters. The diagnosis of ischemic stroke and stroke subtype from visit 4 onwards was documented as the outcome of interest. Covariates that were accounted for included demographic data and history of vascular risk factors. Education level was used as a proxy for economic status of the participants as data about income level and insuredness were not included. Hazard ratios were obtained to assess the risk of incident stroke based on degree of dental disease and usage of dental care. Compared to those with dental health, participants with any dental disease, as categorized by periodontal profile class, had a higher risk of incident ischemic stroke, both in unadjusted and adjusted regressions (see Figure below). There was a trend towards increase in stroke risk with each periodontal profile class severity increment, suggesting a possible dose response. Furthermore, the increased hazard of ischemic stroke was noted only in patients with cardioembolic and thrombotic strokes, not lacunar strokes. The authors have also implicated that this association may be biologically plausible since periodontal disease induces systemic inflammation, which may lead to atherosclerosis and atrial fibrillation. Another possibility is that these patients may be transiently bacteremic and the burden of endocarditis was not assessed.

Risk for incident ischemic stroke in the dental ARIC (Atherosclerosis Risk in Communities) cohort depicted as crude (A) and adjusted (B) hazard ratios (HRs) for the various classes of periodontal disease periodontal profile classes (PPC)-A or reference healthy group without periodontal disease, PPC-B or mild periodontal disease, PPC-C or high gingival index (GI) score, PPC-D or tooth loss, PPC-E or posterior disease, PPC-F or severe tooth loss, and PPC-G or severe periodontal disease.

Figure. Risk for incident ischemic stroke in the dental ARIC (Atherosclerosis Risk in Communities) cohort depicted as crude (A) and adjusted (B) hazard ratios (HRs) for the various classes of periodontal disease periodontal profile classes (PPC)-A or reference healthy group without periodontal disease, PPC-B or mild periodontal disease, PPC-C or high gingival index (GI) score, PPC-D or tooth loss, PPC-E or posterior disease, PPC-F or severe tooth loss, and PPC-G or severe periodontal disease.

By |April 11th, 2018|clinical|0 Comments

Literature Synopses: Dementia and Vascular Cognitive Impairment

Terry Quinn, MD

Keeping up to date with stroke research is tough. In Stroke, we offer a monthly Literature Synopses section where we summarize recent, important stroke research. Sharing stroke research should not be limited to stroke-ologists. For the last Clinical Synopses, I created a plain language version for Blogging Stroke that (hopefully) was accessible to a non-specialist audience. Feedback was positive, and so I am offering another Clinical Synopses summary. 

You can read the original Synopses article here: Quinn TJ. Stroke Literature Synopses: Clinical Science. Stroke. 2018

I am keen to hear feedback, good and bad, via Twitter @DrTerryQuinn

For this month’s Clinical Synopses, I selected three papers concerned with psychological problems and stroke. People who have experienced stroke often rate memory and thinking problems as their most distressing symptom. However, it has taken a while for the clinical stroke community to appreciate the importance of these symptoms. Psychological problems in stroke remain under-researched compared to ‘physical’ issues. Thankfully, things are changing. Various high-profile, international initiatives are working to tackle stroke-related psychological issues, and I hope that in future blog posts, I can tell you about new treatments for these problems. In the meantime, my chosen papers all have a diagnosis theme.

Atrial Thromboembolism: Looking Beyond Atrial Fibrillation

Andrea Morotti, MD

Kamel H, Bartz TM, Elkind MSV, Okin PM, Thacker EL, Patton KK, et al. Atrial Cardiopathy and the Risk of Ischemic Stroke in the CHS (Cardiovascular Health Study). Stroke. 2018

Many patients experiencing cryptogenic stroke with an embolic pattern lack a documented source of thromboembolism, even after an extensive diagnostic workup and prolonged follow-up. In particular, atrial fibrillation (AF) is detected in less than half of these patients. Increasing evidence suggested that atrial dysfunction may lead to thromboembolism independently of AF. In this large, multicenter prospective study, Dr. Kamel and colleagues explored the association between markers of atrial cardiopathy and the risk of incident ischemic stroke.

Cerebral Venous Thrombosis Across the Ages

Hatim Attar, MD

Zuurbier SM, Hiltunen S, Lindgren E, Silvis SM, Jood K, Devasagayam S, et al. Cerebral Venous Thrombosis in Older Patients. Stroke. 2018

Although uncommon, cerebral venous thrombosis (CVT) is an established cause of stroke and is often skipped on initial diagnostics. Understanding the patient profile and high-risk clinical features would definitely allow physicians to maintain a higher index of suspicion. Authors Zuurbier et al have sought to do that: define patient population characteristics and contrast them in old and young patients. This becomes increasingly relevant with the ever expanding geriatric population and the differences across the age groups identified by this study.

Patients were pooled into a registry supported by 5 major academic centers of consecutive CVTs, totaling 843 patients. Comparisons were drawn for demographics, clinical manifestations and outcomes. The uppermost quartile for age distribution was the older patients group, age > 55 (n= 222), while the lower three quartiles were clubbed together for the younger patients, age < 55 (n= 621). While most patients aged < 55 were women (71%), the gender disparity did not exist in the older patients.

Analyzing Clots – A New Direction?

Tapan Mehta, MBBS, MPH

Choi MH, Park GH, Lee JS, Lee SE, Lee S-J, Kim J-H, et al. Erythrocyte Fraction Within Retrieved Thrombi Contributes to Thrombolytic Response in Acute Ischemic Stroke. Stroke. 2018

Clots retrieved from mechanical thrombectomy have been analyzed/studied in the past decade by multiple investigators, and the interest is growing with improved clot retrieval devices. Choi et al. investigate response of intravenous thrombolytics on mechanically retrieved clots in a single-center retrospective study that was conducted over 2 years.

Patients with large vessel anterior circulation strokes receiving tPA within 4.5 hours with baseline mRS <= 2, NIHSS >=4, and ASPECT>=6 were included in the study. Patients also receive baseline MRI before the procedure specifically to evaluate clot burden and nature using the Gradient Echo sequence. The response to intravenous thrombolytic was determined using the Clot Burden Score comparing baseline CTA to conventional angiogram pre thrombectomy images. Additional assessment of intravenous thrombolytic effectiveness was also assessed using the Qureshi scale. Mechanical thrombectomies were performed using Solitaire and Trevo stent retriever device or Penumbra suction catheter. The thrombectomy approaches were not universal; the authors mention use of angioplasty and tirofiban infusion in cases with initial failed attempts. The clots (including all pieces) retrieved from thrombectomy were fixed in 10% neutral buffered formalin. Subsequently, paraffin wax embedded tissues were cut into 4-micro meter sections and stained with hematoxylin-eosin and Martius scarlet blue staining. The sections were digitally scanned and analyzed by blinded examiners. Subgroups based on RBC content with the lowest, middle and highest tertiles and Intravenous thrombolytic responsiveness were further examined.

Study flowchart.

Figure 1: Study flowchart.

Predicting Blood in the Real World

Kevin S. Attenhofer, MD

Hilkens NA, Li L, Rothwell PM, Algra A, Greving JP. External Validation of Risk Scores for Major Bleeding in a Population-Based Cohort of Transient Ischemic Attack and Ischemic Stroke Patients. Stroke. 2018

You can’t discuss stroke prevention without talking about antiplatelet drugs. Drugs like Aspirin and Clopidigrel are frequently used by stroke neurologists as the secondary prevention treatment of choice for patients with TIA and non-cardioembolic ischemic strokes. However, we must remember that bleeding is a clinically important and potentially life-threatening side effect of these agents. Reliably predicting who is most likely to bleed would dramatically inform the clinician’s decision-making process and likely result in improved patient outcomes.

To that end, the S2TOP-BLEED score was derived from patient data from six randomized trials (CAPRIE, ESPS-2, MATCH, CHARISMA, ESPRIT, and PRoFESS). It is a 28-point score that incorporates readily available patient characteristics: Sex, Smoking history, Type of antiplatelet, Outcome (mRS), Prior stroke, Blood pressure, Low BMI, Elderly, Ethnicity, Diabetes. It was validated in the PERFORM trial (Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin Terutroban in Patients with a History of Ischemic Stroke or Transient Ischemic Attack Study). In this paper, Hilkens et al. externally validate the S2TOP-BLEED score in observational data from a real-world setting.

Optical Coherence Tomography: New Insights into Cerebral Vasculature

Aristeidis H. Katsanos, MD

Chen CJ, Kumar JS, Chen SH, Ding D, Buell TJ, Sur S, et al. Optical Coherence Tomography: Future Applications in Cerebrovascular Imaging. Stroke. 2018

Optical coherence tomography (OCT) uses low-coherence interferometry to produce two-dimensional images of optical scattering with promising clinical and research applications in the evaluation of vasculature in different regions and settings. Despite an imaging depth of only a few millimeters, OCT can produce significantly higher resolution images than ultrasound due to the inherent properties of light waves to provide higher quality transverse imaging compared to sonic waves.