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Direct Oral Anticoagulants Versus Warfarin in Cancer Patients with Atrial Fibrillation

Mona Al Banna, MB BCh, MSc

Chan YH, Chao TF, Lee HF, Chen SW, Li PR, Liu JR, et al. Clinical Outcomes in Atrial Fibrillation Patients With a History of Cancer Treated With Non-Vitamin K Antagonist Oral Anticoagulants: A Nationwide Cohort Study. Stroke. 2021.

Atrial fibrillation is a known risk factor for stroke, increasing stroke risk 5-fold and mortality 2-fold compared to patients without atrial fibrillation. Cancer causing a hypercoagulable state is another well-known risk factor for stroke. Current guidelines recommend direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation. In patients with cancer who develop atrial fibrillation, warfarin or low-molecular weight heparin have traditionally been preferred over the direct oral anticoagulants.

In this study, Chan et al. investigated the effectiveness and safety of the DOACs when compared to warfarin in this population. A nationwide retrospective cohort study was performed using the Taiwan National Health Insurance Research Database. They identified 85,641 patients diagnosed with atrial fibrillation and treated with an anticoagulation over a 5-year period. Of those AF patients with a diagnosis of cancer, 6274 were treated with DOACs and 1681 were treated with warfarin. The DOAC group had a lower risk of ischemic stroke, acute myocardial infarction, major adverse limb events and venous thrombosis compared to the warfarin group. DOAC use was associated with a lower risk of ICH and major bleeding when compared to warfarin. Subgroup analysis was also performed to determine how different DOACs or different dosages of DOACs compared to warfarin. In general, there was lower risk of thrombotic events and major bleeding for DOACs over warfarin irrespective of DOAC type and whether it was standard-dose or low-dose. In addition, this benefit of DOACs over warfarin was consistent across patients with different types of cancer and at different stages of disease activity.

By |September 24th, 2021|clinical, treatment|0 Comments

Article Commentary: “Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke”

Melissa Bailey, MD

Preston E, Ada L, Stanton R, Mahendran N, Dean CM. Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke. Stroke. 2021.

Being able to anticipate post-stroke prognosis is important in that it can allow patients to have a reasonable idea of what recovery they may have, can allow caregivers and patients to anticipate care needs, and can impact healthcare costs and patient placement after stroke. Recovery of walking after stroke can be especially important in returning to functional independence. A prior systematic review1 examined prognostic factors that would predict ability to walk 30 days after stroke regardless of if the patient was able to walk shortly after the stroke occurred, and factors such as age, leg strength, hemianopia, and size and location of stroke were found to be predictors. Preston and colleagues recently published a systematic review in which they examined prognostic factors for independent walking at 3, 6, and 12 months post-stroke in patients who were nonambulatory within one month after acute hemiplegic stroke.

By |September 23rd, 2021|clinical|0 Comments

Author Interview: Dr. Eva Mistry on “Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change”

Dr. Eva Mistry
Dr. Eva Mistry

A conversation with Dr. Eva Mistry, MBBS, MSCI, Assistant Professor of Clinical Neurology and Rehabilitation, University of Cincinnati, on predicting 90-day outcome following thrombectomy.

Interviewed by Dr. Yasmin N. Aziz, MD, T32 Stroke Fellow, University of Cincinnati.

They will be discussing the paper Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change,” published in the August 2021 issue of Stroke.

Dr. Aziz: How did the idea behind this paper come to fruition?

Dr. Mistry: To help emphasize the importance of choosing ideal surrogate markers and their correct definitions. When we are developing tools to identify most efficacious acute stroke therapies that improve patient outcomes, and the surrogate outcome measures that we use to predict these patient-centered outcomes are flawed, then all that follows will be flawed as well. Ultimately, there is a real need for solid surrogate markers in acute stroke studies. NIHSS-based surrogate outcome measures are widely used in acute stoke trials. However, they are defined heterogeneously. With the paper, we wanted to establish the pros and cons of using various definitions NIHSS-based surrogate markers, and especially to show how each of them predict the patient-centered outcomes of 90-day modified Rankin Scores.

ESOC 2021: Challenging Clinical Situations in Stroke Medicine (and Tips to Face Them)

Aurora Semerano, MD

European Stroke Organisation Conference
September 1–3, 2021

Session: “Acute Stroke Treatment in Difficult Clinical Situations: In-Hospital Strokes and Other Challenges,” September 2, 2021

Making decisions in stroke medicine is a difficult task and may turn to be really challenging in selected cases, which, however, are quite frequent in our clinical practice. These daily challenges were the focus of the discussion in the session chaired by Daniel Strbian (Finland) and Silke Walter (Germany). Also, some useful tips for more confident decisions were proposed.

When deciding about thrombolysis in patients with recent surgery, existing studies are mostly retrospective and heterogenous, thus evidence for the best practice is very low. Gordian J. Hubert (Germany) suggested a comprehensive approach, which includes the evaluation of the risk of bleeding in the surgical wound (in terms of size, time from surgery, vascularization of the tissue), the damage of a potential bleeding in that site, and the possibility of measures to efficiently stop the bleeding (i.e., compressibility, surgical intervention). Similarly, in patients with recent trauma, the evaluation of the bleeding risk at the trauma site can be crucial, whereas estimating the damage of a potential bleeding may be challenging since location of trauma is often unknown.

ESOC 2021: Thrombosis and Inflammation Team Up in Ischemic Stroke

Aurora Semerano, MD

European Stroke Organisation Conference
September 1–3, 2021

Session: “Inflammation, Thrombosis and Stroke Pathogenesis,” September 3, 2021

The complex interplay between inflammation and thrombosis in ischemic stroke was the subject of the interesting scientific session chaired by Mervyn D. Vergouwen (Netherlands) and Christoph Kleinschnitz (Germany). The five speakers dissected the topic by presenting the main players involved in pathophysiology of stroke-related thrombo-inflammation, and prospected potential interventions of immune modulation.

Bernhard Nieswandt (Germany) showed how platelets, besides their well-established functions, have a critical role in inflammation. They are involved not only in the process of thrombus formation, but also in the subsequent mechanisms of infarct growth. Identifying the optimal target to interfere with platelet activity is crucial, due to the possible risk of hemorrhagic transformation. Two promising axes are discussed, namely the immunomodulatory function of von Willebrand Factor through its receptor on platelets Glycoprotein Ib, and the interplay with the kallikrein system and Factor XII activation. The resulting infiltration of immune cells (including T cells) into the ischemic brain contributes to the damage. Importantly, he pointed out that thrombo-inflammation doesn’t start after recanalization, but it is still ongoing during the occlusion, sustained by the collateral blood flow. This is supported in humans by a recent elegant work,1 which reported for the first time that leukocytes strongly accumulate in cerebral vessels distal to the occlusion. Bearing this in mind is fundamental to designing the optimal treatment.

Article Commentary: “Risk of Fractures in Stroke Patients Treated With a Selective Serotonin Reuptake Inhibitor”

Karissa C. Arthur, MD

Jones JS, Kimata R, Almeida OP, Hankey GJ. Risk of Fractures in Stroke Patients Treated With a Selective Serotonin Reuptake Inhibitor: A Systematic Review and Meta-Analysis. Stroke. 2021;52:2802–2808.

Depression is common in patients after a stroke. While depression can be treated effectively with selective serotonin reuptake inhibitors (SSRIs), several recent randomized controlled trials (RCTs), as well as previous observational cohort studies, have reported an increased risk of falls and fractures in patients treated with SSRIs. This risk is especially important considering that stroke patients are already at a higher risk of falls and fractures. Jones and colleagues aimed to determine the risk of fractures in stroke patients treated with SSRIs via a systematic review and meta-analysis.

A study was eligible for inclusion if it met the following criteria: 1) RCT, 2) included adult patients with previous hemorrhagic or ischemic stroke, 3) compared an SSRI to either placebo or no intervention, and 4) included incident fractures as an outcome. The authors searched for studies using combinations of key terms and subject headings without language restrictions in several databases and clinical trial registers, as well as used the references of included studies to identify other studies for possible inclusion. The results were independently evaluated by two reviewers.

By |September 17th, 2021|clinical|0 Comments

Sex Differences in Stroke Treatment Narrow Between 2005 to 2018 in Sweden

Hannah Roeder, MD, MPH

Eriksson M, Åsberg S, Sunnerhagen KS, von Euler M, on behalf of the Riksstroke Collaboration. Sex Differences in Stroke Care and Outcome 2005–2018: Observations From the Swedish Stroke Register. Stroke. 2021.

In this article, Eriksson et al. investigate whether stroke incidence, care, outcome, and sex differences changed between the years 2005 and 2018 in Sweden. Using data from the Swedish Stroke Register, a national registry including all Swedish hospitals admitting acute stroke patients, the authors highlight improvements in stroke care and narrowing sex gaps.

Sweden had a decreasing incidence of stroke over the 14-year period despite an aging and growing population. The authors propose that primary prevention and behavioral changes, such as less tobacco use, in the population contributed.

By |September 16th, 2021|clinical|0 Comments

Does Concurrent COVID-19 Infection Affect Functional Outcomes of Patients With Acute Ischemic Stroke?

Mona Al Banna, MB BCh, Msc(Res)

Martí-Fàbregas J, Guisado-Alonso D, Delgado-Mederos R, Martínez-Domeño A, Prats-Sánchez L, Guasch-Jiménez M, Cardona P, Núñez-Guillén A, Requena M, Rubiera M, et al. Impact of COVID-19 Infection on the Outcome of Patients With Ischemic Stroke. Stroke. 2021.

Various studies are showing that neurologic complications, including stroke, occur frequently in COVID-19 patients. In addition, the COVID-19 pandemic has compromised the delivery of well-established time-sensitive therapies and system delivery in stroke care. The authors of this study set out to determine whether patients with stroke and COVID-19 had worse functional outcomes compared to patients without COVID-19 and, if so, evaluate whether this was attributable to direct effects of the virus itself or due to logistical difficulties of providing care during a global pandemic.

The authors conduced a prospective multicentered cohort study of 19 hospitals in Catalonia, Spain, from mid-March to May 15, 2020. Patients were eligible if they had an acute ischemic stroke with a previous modified Rankin Scale (mRS) of 0-3. Patients were then classified according to their SARS-CoV-2 PCR status. The authors then collected various data variables, including demographic data, vascular risk factor profiles, pre-admission medications, NIHSS on admission and at 72 hours, imaging data, reperfusion therapies (and, if applicable, TICI scores), time metrics (e.g., door to needle, door to groin), stroke etiology and functional outcome at 3 months.  

Benefit of Mechanical Thrombectomy in M2 Occlusions: A STRATIS Registry Subgroup Analysis of M2 Versus M1 Occlusions

Karissa C Arthur, MD

Jumaa MA, Castonguay AC, Salahuddin H, Jadhav AP, Limaye K, Farooqui M, Zaidi SF, Mueller-Kronast N, Liebeskind DS, Zaidat OO, Ortega-Gutierrez S. Middle Cerebral Artery M2 Thrombectomy in the STRATIS Registry. Stroke. 2021.

Middle cerebral artery M2 segment occlusions represent about one-sixth of large vessel occlusions in the United States, though were underrepresented in early time window mechanical thrombectomy (MT) trials. However, data from several of these trials suggest that MT for M2 occlusions is safe with low risk of intracerebral hemorrhage and has similar clinical outcomes and mortality to M1 occlusions. Given the paucity of data on the safety and feasibility of MT for M2 occlusions, Jumaa et al. sought to evaluate the STRATIS registry to compare MT safety, rate of good clinical outcomes, and time dependence of MT benefit between M2 and M1 occlusions.

The STATIS registry is a prospective, multicenter, nonrandomized, observational study that evaluated the use of the Solitaire stent retriever in large vessel occlusions. It consists of 1,000 patients aged 18 or older with confirmed anterior circulation large vessel occlusions at 55 centers between August 2014 and June 2016. This subgroup analysis compared patients with M1 occlusions to those with M2 occlusions in terms of baseline characteristics, baseline National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS), IV recombinant tissue plasminogen activator (tPA) use, and workflow and procedural characteristics. Outcomes included good functional outcome (mRS of 0 to 2 at 90 days), successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] ≥ 2b), as well as safety outcomes such as symptomatic intracranial hemorrhage, worsening of NIHSS ≥4 within 24 hours, or vessel perforation during MT. The authors also dichotomized the M2 group into 90-day mRS score of 0-2 versus 0-1 to identify factors that influenced clinical outcome.

By |September 13th, 2021|clinical|0 Comments

Article Commentary: “Fluid-Attenuated Inversion Recovery May Serve As a Tissue Clock in Patients Treated With Endovascular Thrombectomy”

Parth Upadhyaya, DO

Aoki J, Sakamoto Y, Suzuki K, Nishi Y, Kutsuna A, Takei Y, et al. Fluid-Attenuated Inversion Recovery May Serve As a Tissue Clock in Patients Treated With Endovascular Thrombectomy. Stroke. 2021;52:2232–2240.

Based on WAKE-UP (2018), THAWS (2020), and smaller single-center trails, the concept of FLAIR signal change as a surrogate timekeeper in hyperacute stroke has shown both safety and efficacy for intravenous thrombolysis. Now, in the age of extended window endovascular thrombectomy (EVT), predictors of good clinical outcome beyond time, age and medical risk factors become prudent for patient selection. In this study, Aoki et al. hypothesize if FLAIR signal change can predict clinical outcome after EVT.

From a prospective registry of 324 consecutive EVT patients presenting with acute ischemic stroke, 227 were retrospectively enrolled from September 2014 to December 2018. Those with premorbid mRS score 0 to 1 with available FLAIR imaging were included; patients with contraindications to MRI were excluded. FLAIR positivity was defined by new hyper-intense signal at DWI-positive lesion site; subtle changes were measured using contralateral signal intensity ratio of 1.2. The median age of patients was 74, NIHSS 15, and symptoms onset to imaging 155 minutes. Ischemic core volume and NIHSS were not significantly different in timing to FLAIR imaging from less than 2 hours to greater than 12 hours. 

By |September 10th, 2021|clinical, treatment|0 Comments