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Childhood Ischemic Stroke and SARS-CoV-2

Kevin O’Connor, MD

Beslow LA, Agner SC, Santoro JD, Ram D, Wilson JL, Harrar D, Appavu B, Fraser SM, Rossor T, Torres MD, et al. International Prevalence and Mechanisms of SARS-CoV-2 in Childhood Arterial Ischemic Stroke During the COVID-19 Pandemic. Stroke. 2022.

Over the last two years, data have shown an increased risk of ischemic stroke in the setting of SARS-CoV-2 infection. Beslow et al. explored the relationship between SARS-CoV-2 and childhood (age 29 days to 18 years) ischemic stroke based on data from multiple sites across 21 countries.

The sites reported 373 acute ischemic strokes from June to December 2020 during the same time that they recorded 7,231 pediatric SARS-CoV-2 hospitalizations. Of 335 (89.8%) childhood ischemic strokes that underwent testing for SARS-CoV-2, 23 (6.9%) were positive for the virus, and clinical information was available for 22 cases. The overall risk of childhood ischemic stroke in children hospitalized for SARS-CoV-2 was low at 0.32% (95% binomial exact CI, 0.20%-0.48%), but this may include children in whom the infection was found incidentally.

By |April 27th, 2022|clinical|Comments Off on Childhood Ischemic Stroke and SARS-CoV-2

Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”

Hannah Roeder, MD, MPH

Hahn M, Gröschel S, Hayani E, Brockmann MA, Muthuraman M, Gröschel K, Uphaus T, on behalf of the German Stroke Registry—Endovascular Treatment (GSR-ET) Study Group. Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy. Stroke. 2022.

For working-age stroke patients, returning to work (RTW) is a yardstick for functional recovery and is associated with improved well-being. Patients who suffer large vessel occlusion (LVO) are at greater risk for persistent neurological deficits; however, in the mechanical thrombectomy era, even patients with LVO may have a favorable outcome allowing RTW. Hahn and colleagues used data from the German Stroke Registry Endovascular Treatment (GSR-ET) to explore the likelihood and predictive factors for RTW with particular attention to sex differences.

The investigators included patients in the GSR-ET who were known to be employed prior to their stroke and were less than 65 years of age (the retirement age in Germany), and excluded patients who did not receive thrombectomy or were deceased by day 90. After application of inclusion/exclusion criteria, about one-tenth of patients in the GSR-ET were eligible (606 out of 6635). Of eligible patients, 35.6% (216) were re-employed at 3 months post-stroke.

By |April 25th, 2022|clinical, outcomes, prognosis|Comments Off on Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”

Endovascular Treatment for Ischemic Stroke: Do We Need General Anesthesia?

Tolga D Dittrich, MD
@to_dittrich

Wagner B, Lorscheider J, Wiencierz A, Blackham K, Psychogios M, Bolliger D, De Marchis GM, Engelter ST, Lyrer P, Wright PR, et al. Endovascular Treatment for Acute Ischemic Stroke With or Without General Anesthesia: A Matched Comparison. Stroke. 2022.

Endovascular treatment (EVT) effectively treats acute ischemic stroke and has gained increasing importance over the last few years. An important peri-procedural question is the choice of anesthesia type, especially whether conscious sedation (CS) is preferable to general anesthesia (GA). The current recommendation is that this decision should be made individually based on patient characteristics (e.g., aspiration risk) and technical feasibility.1 Based on data from the Swiss Stroke Registry, Wagner and colleagues investigated the influence of anesthesia type on functional outcome at three months in patients receiving EVT for anterior circulation stroke.

By |April 20th, 2022|clinical, treatment|Comments Off on Endovascular Treatment for Ischemic Stroke: Do We Need General Anesthesia?

Article Commentary: “Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke”

Dixon Yang, MD

Dicpinigaitis AJ, Gandhi CD, Pisapia J, Muh CR, Cooper JB, Tobias M, Mohan A, Nuoman R, Overby P, Santarelli J, et al. Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke. Stroke. 2022.

Pediatric acute ischemic stroke (AIS) is an uncommon and poorly understood clinical entity, but its absolute incidence has been increasing and may represent significant cause of disability. In 2019, the American Heart Association Stroke Council and Council of Cardiovascular and Stroke Nursing issued a statement suggesting emergent therapies and endovascular therapies be limited to consideration of children with persistent neurologic deficits (pediatric NIHSS >/= 6), radiographically confirmed large vessel occlusion, and those with a large body habitus due to technical considerations and risks with exposure to radiation and contrast.

In absence of high-quality data and trials, optimal management for pediatric acute ischemic stroke remains unclear. Therefore, Dicpinigaitis and authors performed a large cross-sectional analysis using an administrative inpatient care registry in the United States from the Healthcare Cost and Utilization Project to characterize patient profiles and clinical course of endovascular therapy (EVT) in pediatric patients for AIS.

By |April 18th, 2022|clinical|Comments Off on Article Commentary: “Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke”

Optimal Timing of Carotid Revascularization

Kevin O’Connor, MD

Cui CL, Dakour-Aridi H, Lu JJ, Yei KS, Schermerhorn ML, Malas MB. In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis. Stroke. 2022;53:100-107.

When a patient presents with a symptomatic carotid lesion, what is the optimal time to revascularize and with what procedure? Cui et al. explored this in their retrospective cohort study comparing outcomes among carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) who underwent their respective procedures urgently (0-2 days from latest symptoms), early (3-14 days), or late (15-180 days). From 2016-2019, there were 2006 urgent revascularizations (CEA, n=1112; TCAR, n=144; TFCAS, n=750), 7423 early revascularizations (CEA, n=5126; TCAR, n=929; TFCAS, n=1369), and 9214 late revascularizations (CEA, n=6060; TCAR, n=1536; TFCAS, n=1618). Analysis compared outcomes between TCAR and CEA and between TFCAS and CEA for each timeframe.

By |April 15th, 2022|clinical|Comments Off on Optimal Timing of Carotid Revascularization

AST-004 Treatment Reduces Brain Infarct Volume in a Nonhuman Primate Ischemic Stroke Model

Kristina Shkirkova, BSc
@KShkirkova

Liston TE, Hama A, Boltze J, Poe RB, Natsume T, Hayashi I, Takamatsu H, Korinek WS, Lechleiter JD. Adenosine A1R/A3R (Adenosine A1 and A3 Receptor) Agonist AST-004 Reduces Brain Infarction in a Nonhuman Primate Model of Stroke. Stroke. 2022;53:238-248. 

Adenosine A1 and A3 receptors (A1R and A3R) are involved in supply of energy, oxygen, and nutrients to the brain. Under pathological conditions of brain injury, these receptors may play an important role in functional balance and neuroprotection.1 Studies in mice have shown that activation of A1R and A3R with agonists results in reduction of cerebral lesion volume in ischemic stroke models. Adenosine A1 and A3 receptors are viable therapeutic targets for stroke treatment; however, there remains a need to establish appropriate dosing and timing of A1R/A3R agonist treatment that could be translated for its use in clinical studies.

By |April 13th, 2022|basic sciences|Comments Off on AST-004 Treatment Reduces Brain Infarct Volume in a Nonhuman Primate Ischemic Stroke Model

Sex-Specific Risk Factors: Complications of Pregnancy Can Increase Risk of Stroke

Arooshi Kumar, MD
@ArooshiK

Liang C, Chung HF, Dobson AJ, Mishra GD. Infertility, Miscarriage, Stillbirth, and the Risk of Stroke Among Women: A Systematic Review and Meta-Analysis. Stroke. 2022;53:328–337.

It is well established that stroke is a leading cause of mortality and disability around the world. It is more recently accepted that sex-related differences exist for stroke prevalence and outcomes, and that females might carry additional risk factors transcending the traditional vascular risk factors. To that end, pregnancy and childbirth mark a uniquely special experience for females. A growing body of evidence suggests that pregnancy and complications of pregnancy are associated with long-term risk of stroke.1-2 Liang et al. published a comprehensive systematic review on the association between infertility, miscarriage, stillbirth, and stroke.

By |April 11th, 2022|clinical, health care, policy|Comments Off on Sex-Specific Risk Factors: Complications of Pregnancy Can Increase Risk of Stroke

Deferoxamine and Outcomes in Mid-Volume Intracerebral Hemorrhage

Vignan Yogendrakumar, MD MSc
@VYogendrakumar

Wei C, Wang J, Foster LD, Yeatts SD, Moy C, Mocco J, Selim M. Effect of Deferoxamine on Outcome According to Baseline Hematoma Volume: A Post Hoc Analysis of the i-DEF Trial. Stroke. 2021.

Intracerebral hemorrhage is a complex disease because, truly, no two bleeds are ever the same. Hemorrhages can differ in size, location, or compartment, and the varying combinations of these elements can lead to dramatic differences in clinical severity and long-term outcome. A small but well-placed hemorrhage in the internal capsule can lead to contralateral hemiplegia, whilst a moderately sized lobar hemorrhage can sometimes present with minimal clinical symptoms. This heterogeneity has been a point of frustration in treatment trials that aim to improve clinical outcomes because a candidate therapy may have a significant effect on a portion of the trial population, but the treatment effect may be diluted when the whole population is assessed. Past trials have informed subsequent studies regarding patient selection, but even with the numerous lessons learned, identifying patients that are most likely to benefit from a candidate therapy remains a difficult task.

By |April 8th, 2022|clinical|Comments Off on Deferoxamine and Outcomes in Mid-Volume Intracerebral Hemorrhage

Microvascular Circadian Rhythmicity and Subarachnoid Hemorrhage-Induced Injury

Kristina Shkirkova, BSc
@KShkirkova

Lidington D, Wan H, Dinh DD, Ng C, Bolz SS. Circadian Rhythmicity in Cerebral Microvascular Tone Influences Subarachnoid Hemorrhage–Induced Injury. Stroke. 2022;53:249–259.

Clinical and epidemiological evidence suggests that cerebrovascular events are influenced by circadian rhythms. Due to changes in coagulative balance and vascular tone during a 24-hour period, strokes are observed to occur more often in the mornings followed by evenings, the second most prevalent time.1 Similarly, it was previously reported that variations in circadian blood pressure and microvascular perfusion influenced the incidence of subarachnoid hemorrhage (SAH).2

SAH neuronal damage and poor outcomes have been associated with changes to tissue perfusion. Since cellular mechanisms controlling circadian rhythms play an important role in cerebral blood flow autoregulation, circadian oscillation of microcirculation following SAH drive the cerebral perfusion rhythm. However, the evidence of circadian influence on neuronal injury after SAH remains elusive. The authors of the study by Lidington et al., recently published in Stroke, looked at cerebral resistance artery myogenic reactivity, a mechanism of cerebral blood flow autoregulation, which is strongly correlated with cerebral perfusion and neuronal injury after SAH. 

By |April 6th, 2022|basic sciences|Comments Off on Microvascular Circadian Rhythmicity and Subarachnoid Hemorrhage-Induced Injury

POST-NIHSS and Posterior Circulation Strokes

Kevin O’Connor, MD

Alemseged F, Rocco A, Arba F, Schwabova JP, Wu T, Cavicchia L, Ng F, Ng JL, Zhao H, Williams C, et al. Posterior National Institutes of Health Stroke Scale Improves Prognostic Accuracy in Posterior Circulation Stroke. Stroke. 2021.

The NIH Stroke Scale (NIHSS) is an indispensable part of acute stroke evaluations, but its components focus more on anterior circulation deficits than posterior circulation deficits. Alemseged et al. developed the POST-NIHSS to augment the NIHSS with additional posterior circulation deficits based on retrospective analysis of 202 patients with clinical and radiographic evidence of posterior circulation stroke and NIHSS score <10 who did not undergo mechanical thrombectomy from the Basilar Artery Treatment and Management registry. They then validated their POST-NIHSS with 65 prospectively recruited patients.

Clinical features of posterior circulation strokes may include gait/truncal ataxia, diplopia, ptosis, nystagmus, internuclear ophthalmoplegia, vertical gaze impairment, Horner syndrome, palatal palsy, tongue deviation, and abnormal cough. The retrospective analysis identified gait/truncal ataxia (OR, 3.14 [95% CI, 1.24–7.92], P=0.02), dysphagia (OR, 5.22 [95% CI, 1.63–16.7], P=0.005), and abnormal cough (OR, 8.17 [95% CI, 1.49–44.8], P=0.02) as significantly associated with poor outcome. To the standard NIHSS, the POST-NIHSS adds 3 points for gait/truncal ataxia when assessing item 7 and a new item 12 to assess for abnormal cough (5 points) and dysphagia (4 points). In a ROC analysis for age-adjusted poor outcome, POST-NIHSS performed better than NIHSS (POST-NIHSS AUC, 0.80 [95% CI, 0.73–0.87] versus NIHSS AUC, 0.73 [95% CI, 0.64–0.83]). In a subgroup sensitivity analysis of 156 of the 202 patients with NIHSS 0-5 (77%), POST-NIHSS remained associated with age-adjusted poor outcome (OR, 1.40 [95% CI, 1.14–1.70], P=0.01) while NIHSS was not (OR, 1.12 [95% CI, 0.82–1.56], P=0.46).

By |April 4th, 2022|clinical, outcomes, prognosis|Comments Off on POST-NIHSS and Posterior Circulation Strokes