American Heart Association

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Readmission after Subarachnoid Hemorrhage

Pouya Tahsili-Fahadan, MD

Dasenbrock HH, Angriman F, Smith TR, Gormley WB, Frerichs KU, Aziz-Sultan MA, et al. Readmission After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Readmission Database Analysis. Stroke. 2017

Readmission (within a pre-defined period of time from discharge) is frequently measured and reported as a quality measure for care provided by physicians and hospitals. However, it is debatable whether this measure is an appropriate quality metric for various indications and etiologies of the index hospitalization. Dasenbrock et al. investigated this question by analyzing the Nationwide Readmission Database (NRD) for readmission after aneurysmal subarachnoid hemorrhage (SAH).

Data from this longitudinal administrative database within 21 states were extracted for 3806 non-elective adult patients admitted for treatment of aneurysmal subarachnoid or intracerebral hemorrhage and discharged alive in 2013. Mortality during the index hospitalization and readmission were 11% and 1.7%, respectively, and about two thirds of survivors were discharged home. The median cost of the index and readmission hospitalizations were $266,304 and $45,091, respectively, and readmission was associated with increased total costs. Within the next 30 days from discharge, 10.2% of patients were readmitted with 34.4%, 65.6%, and 82.4% of readmissions within 1, 2, and 3 weeks from discharge, respectively. As expected, patients who were readmitted had higher SAH severity scale, higher incidence of cerebral edema, and complications during their index hospitalization, and were more likely to undergo tracheostomy or gastrostomy, and less likely to be discharged home. Treatment modality (clipping versus coiling) was not associated with increased rate of readmission. Independent predictors for readmission, however, were identified as comorbidity score equal or more than 3, higher SAH severity, and discharge destination other than home; the more predictors, the higher chance of readmission. Of note, high-volume institutions had lower risk of readmission and mortality. The most common reasons for readmission included hydrocephalus, other neurological complications, infections, and thromboembolic events. Neurosurgical procedures and surgeries were among the most common operations performed after readmission. Importantly, hydrocephalus during index hospitalization was associated with increased risk of readmission for hydrocephalus.

Is It Possible to Predict the Occurrence of Cerebral Edema After Intravenous Thrombolysis? An Exploratory Analysis From the SITS-ISTR Registry

Aristeidis H. Katsanos, MD, PhD

Thorén M, Azevedo E, Dawson J, Egido JA, Falcou A, Ford GA, et al. Predictors for Cerebral Edema in Acute Ischemic Stroke Treated With Intravenous Thrombolysis. Stroke. 2017

Even though cerebral edema (CED) is one of the most severe complications of acute ischemic stroke (AIS) and the cause of mortality in 5% of all AIS patients, there are scarce data on risk factors predicting the development of CED following AIS — including the subgroup of AIS patients treated with intravenous thrombolysis (IVT).

Thorén and colleagues aimed to determine potential baseline clinical and radiological predictors of CED after IVT by analyzing data from 42,187 AIS patients recorded in the Safe Implementation of Treatments in Stroke International Register (SITS-ISTR) during a 10-year period. After performing an image-based classification on the severity of post-IVT CED, they found that increased baseline stroke severity, high blood glucose, decreased level of consciousness, the presence of hyperdense artery sign and signs of infract on baseline neuroimaging were the most important baseline predictors for early CED. As expected, patients with CED had worse 3-month functional outcomes and increased mortality rates —proportionally to the severity of edema — compared to patients without CED. Moreover, the authors found increased risk of symptomatic intracerebral hemorrhage in patients with severe CED, providing further support to the hypothesis of a blood-brain disruption induced common pathway leading to both cerebral edema and hemorrhage in the acute phase of cerebral ischemia.

Ticagrelor Versus Aspirin — A Closer Look at ESUS in SOCRATES

Kevin S. Attenhofer, MD

Amarenco P, Albers GW, Denison H, Easton JD, Evans SR, Held P, et al. Ticagrelor Versus Aspirin in Acute Embolic Stroke of Undetermined Source. Stroke. 2017

Embolic stroke of undetermined source is a sub-classification of cryptogenic stroke which describes non-lacunar stroke without an identified cardio embolic source or occlusive atherosclerosis. While multiple pathologies may be at the heart of ESUS, it is thought that the undiagnosed embolic phenomenon driving the ischemia could be treated with anticoagulation. Multiple ongoing and recent trials seek to determine the optimal secondary stroke prevention in patients with ESUS by comparing aspirin to various direct oral anticoagulants (RESPECT-ESUS, NAVIGATE-ESUS, ARCADIA, ATTICUS). Considering the possibility that these studies may be neutral or negative, Amarenco et al. examined the use of antiplatelet agents for ESUS. The authors used data from the Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES) trial to retrospectively compare ticagrelor and aspirin for ESUS. Their hypothesis was that all or some patients with ESUS would show greater benefit from ticagrelor than aspirin.

Importance of Intravenous Thrombolysis for Large Vessel Anterior Circulation Stroke in the Era of Endovascular Therapy

Tapan Mehta, MBBS, MPH

Mistry EA, Mistry AM, Nakawah MO, Chitale RV, James RF, Volpi JJ, et al. Mechanical Thrombectomy Outcomes With and Without Intravenous Thrombolysis in Stroke Patients. Stroke. 2017

Mechanical thrombectomy (MT) has been proven to be superior to intravenous thrombolysis (IVT) in proximal large vessel anterior circulation strokes (LVO); however, the standard of care is still to provide IVT to eligible patients before MT. Rigorous data is lacking, however; the need for IVT in the patients with LVO who are eligible for MT is being questioned.

The article by Mistry et al is an important meta-analysis of 13 studies that explored the differences in clinical outcomes (mortality, morbidity with mRS (Modified Rankin Scale; 0-2 defined as good outcome), symptomatic intracranial hemorrhagic (sICH), and successful recanalization rates for patients receiving MT+IVT versus only MT (MT – IVT)). This meta-analysis included studies from 2006 to 2016. Separate sub-group analyses were performed for randomized clinical trials (RCT) and non-randomized studies each. Sub-group analysis for the RCT group demonstrated higher, but nonsignificant, Odds Ratio (OR) for good functional outcomes (OR, 1.28 [95% confidence interval (CI), 0.93–1.75], P=0.12) and a significantly lower OR for mortality (OR, 0.56 [95% CI, 0.36–0.86], P=0.007) in MT+IVT compared with MT−IVT patients. The sub-group analysis of patients in nonrandomized studies demonstrated a strong trend with quantitatively similar OR of 1.31 (95% CI, 0.99–1.73, p=0.06) for good functional outcomes and OR 0.76 (95% CI, 0.56–1.03, p=0.08) in MT+IVT compared to MT−IVT patients.

Who Are You? Where Are You From? Mr. Clot?

Qing Hao, MD

Sporns PB, Hanning U, Schwindt W, Velasco A, Minnerup J, Zoubi T, et al. Ischemic Stroke: What Does the Histological Composition Tell Us About the Origin of the Thrombus? Stroke. 2017

During the hyperacute phase of stroke, we all get excited when the interventionists show a piece of clot attached to the device, and then we primarily focus on the cause of the clot by performing various workups, although many times the answer is “unknown.” Can we get some clues from the clot itself?

Sporns and colleagues analyzed the histological clot composition with the aim to define characteristics that would further help to determine the cause of stroke. Clots were collected from 187 acute stroke patients with carotid-T or middle cerebral artery occlusion who underwent thrombectomy at a university medical center. In addition to quantification of fibrin, RBC, and WBC, immunohistochemistry for CD3, CD20, and CD68/KiM1P was also performed.

By |October 4th, 2017|clinical|0 Comments

Neurons Over Nephrons Still Holds True

Sami Al Kasab, MD

Brinjikji W, Demchuk AM, Murad MH, Rabinstein AA, McDonald RJ, McDonald JS, et al. Neurons Over Nephrons: Systematic Review and Meta-Analysis of Contrast-Induced Nephropathy in Patients With Acute Stroke. Stroke. 2017

In the era of mechanical thrombectomy, the use of advanced imaging, such as computed tomographic angiography (CTA) and CT perfusion, has become an essential component in the evaluation of patients presenting with acute stroke symptoms. Due to the concern of acute kidney injury (AKI) that might result from the use of iodine contrast, many stroke centers require having a baseline serum creatinine prior to performing the CTA/CTP imaging; this, however, might lead to delay in obtaining the imaging, which could delay time to treatment.

Previous studies have evaluated the risk of AKI in stroke patients undergoing CTA/CTP; however, the risk remains unclear, with no major impact on the current clinical practice.

In this study, Drs. Brinjikji et al perform a systematic review and meta-analysis of the literature to determine whether acute ischemic stroke (AIS) patients receiving CTA/CTP are at higher risk for AKI than those receiving only non-contrast head CT (NCCT). The authors aim to determine the overall rate of AKI among patients with AIS undergoing CTA/CTP, and whether having chronic kidney disease is a risk factor for AKI after receiving CTA/CTP.

By |October 3rd, 2017|clinical|0 Comments

Sleep Apnea and Stroke: Interview with Antonio Culebras, MD

Antonio Culebras

Antonio Culebras

A conversation with Antonio Culebras, MD, Professor of Neurology, SUNY Upstate Medical University, about the association between sleep apnea and stroke.

Interviewed by Gurmeen Kaur, MBBS, Vascular Neurology Fellow, Icahn School of Medicine at Mount Sinai.

Dr. Kaur: What can you tell us about the association between sleep apnea and atrial fibrillation? What is the strength of the evidence supporting this association?

Dr. Culebras: Obstructive sleep apnea is a risk factor for stroke because of its association with systemic hypertension and other risk factors for stroke, including atrial fibrillation. The Stroke Risk in Atrial Fibrillation Working Group 2007 demonstrated a 5–10% increase in risk of stroke in patients with atrial fibrillation.

Gami et al studied a cohort of over 3000 patients over 65 years who underwent polysomnography. Over a 5-year follow-up period, nocturnal oxygen desaturations emerged as a predictor for new onset atrial fibrillation. In a study of 47 women and 111 men with subacute ischemic stroke admitted for neurorehabilitation (Chen et al, 2017), mean nocturnal desaturation was significantly associated with atrial fibrillation after adjusting for age, neck circumference, Barthel index, and high-density lipoprotein level. Poli et al also concluded that there is a strong correlation between age and sleep apnea that drives the increased frequency of stroke related to atrial fibrillation.

In-Patient Code Strokes — A Need for Speed

Hatim Attar, MD

Kassardjian CD, Willems JD, Skrabka K, Nisenbaum R, Barnaby J, Kostyrko P, et al. In-Patient Code Stroke: A Quality Improvement Strategy to Overcome Knowledge-to-Action Gaps in Response Time. Stroke. 2017

On account of various comorbidities, procedures, and acute ongoing illnesses, hospitalized patients suffer an increased risk of strokes as compared to the general population. About 7–15% of all acute cerebrovascular insults affect in-patients. A larger percent of these strokes are noted in the peri-operative period and following cardiac procedures. The authors point out that an intuitive assumption would suggest that in-hospital strokes would meet with better outcome. This would be due to a presumed higher rate of stroke symptom recognition, immediate availability of nurses and physicians, proximity to neuroimaging, and a streamlined system for management. However, time and again, it has been seen that in-patient strokes are paradoxically associated with worse outcomes. Prior studies that have been cited in this paper have identified various factors, like inadequate education about stroke symptoms, delayed notification of the appropriate personnel, and poor communication of symptoms between the different teams and need for urgent evaluation and management.

In this original study, Kassardjian et al have identified and confirmed these gaps by interviewing all personnel involved in the acute stroke process. The authors then successfully administered educational sessions, which had well-described learning objectives, including the ability to identify different types of stroke, understand the ramifications of acute stroke and available interventions, and describe the role of the medical teams in code stroke. An algorithm was created and made readily available throughout a tertiary care academic teaching hospital.

By |September 25th, 2017|clinical|0 Comments

Cerebral Microbleeds: A Risk Factor for Intracranial Hemorrhage and Worse Outcomes After Thrombolytic Therapy for Acute Ischemic Stroke

Mark R. Etherton, MD PhD

Charidimou A, Turc G, Oppenheim C, Yan S, Scheitz JF, Erdur H, et al. Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis: Individual Patient Data Meta-Analysis. Stroke. 2017

In this entry, I discuss the recent meta-analysis, using individual patient data, by Andreas Charidimou and colleagues on cerebral microbleeds (CMB) and the risk of intracerebral hemorrhage (ICH) and poor functional outcomes after intravenous thrombolytic therapy for acute ischemic stroke.

Prior to this study, a recent meta-analysis had demonstrated that the mere presence of pre-treatment CMBs was associated with increased odds of symptomatic intracerebral hemorrhage (sICH) after intravenous thrombolytic therapy for acute ischemic stroke (Charidimou et al. Stroke. 2015). Building on this study, the authors performed a pooled, individual patient data meta-analysis to evaluate several hypotheses pertaining to the presence, quantity, and location of pre-treatment CMBs in relation to ICH risk and post-stroke outcomes.

By |September 20th, 2017|clinical|0 Comments

Beyond Drip and Ship: The Role of Baseline Vascular Imaging for Referring Hospitals in Acute Ischemic Stroke Triage for the Endovascular Era

Danny R. Rose, Jr. MD

Boulouis G, Siddiqui K, Lauer A, Charidimou A, Regenhardt R, Viswanathan A, et al.  Immediate Vascular Imaging Needed for Efficient Triage of Patients With Acute Ischemic Stroke Initially Admitted to Nonthrombectomy Centers. Stroke. 2017

The landmark publication of multiple positive endovascular thrombectomy (EVT) trials in 2015 was a pivotal moment for treatment of acute ischemic stroke. The most significant development in acute stroke treatment in the nearly twenty years since the FDA approval of tissue plasminogen activator in 1996 has led to much discussion with respect to improving stroke systems of care to be able to provide this treatment to as many eligible patients as possible. Reflecting this new development in acute stroke treatment, the American Heart Association released a focused update to their guidelines on acute stroke treatment that recommended endovascular therapy be offered to patients who present within 6 hours of last known normal and have a favorable imaging profile and a National Institutes of Health Stroke Scale (NIHSS) of 6 or greater.

Just as the time-sensitive nature of intravenous thrombolytic administration led to the development of prehospital stroke scales and the stroke alert process, the most effective way to triage and treat patients with suspected emergent large vessel occlusions (LVO) amenable to endovascular treatment is a topic of ongoing research and debate. An important facet of this discussion concerns the most effective method to triage and transfer patients with suspected LVO to a thrombectomy-capable stroke center. A cohort by Sarraj et al. presented at the 2017 International Stroke Conference showed comparably good outcomes for patients transferred to thrombectomy-capable centers as compared to patients who presented directly to the facility, suggesting that the “drip and ship” transfer paradigm can be successfully augmented to accommodate endovascular therapy.