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Diabetes Mellitus, But Not Prediabetes, Associated With Poorer Cognitive Performance After Stroke

Lina Palaiodimou, MD

Lo JW, Crawford JD, Samaras K, Desmond DW, Köhler S, Staals J, et al. Association of Prediabetes and Type 2 Diabetes With Cognitive Function After Stroke: A STROKOG Collaboration Study. Stroke. 2020.

Diabetes mellitus (DM) affects about 422 million people and is one of the leading causes of death worldwide (World Health Organization). More importantly, the burden of type 2 diabetes (T2D) has been rising relentlessly in all countries in the past three decades. However, it is estimated that a significant percentage of cases of T2D remain undiagnosed. DM is one of the major modifiable risk factors for stroke. In addition, it has been associated with adverse outcomes after stroke, including higher mortality, poorer neurological and functional outcomes, longer hospital stay, higher readmission rates, and stroke recurrence. Another outcome, the post-stroke cognitive function, and its relationship with DM, are being evaluated in the STROKOG collaboration study.

Lo et al. for the STROKOG collaboration present a meta-analysis of individual participant data (IPD) derived from seven international post-stroke cohorts with the aim to investigate the relationship between T2M and prediabetes with cognitive impairment after stroke.

ESO-WSO Large Clinical Trials Webinar: BASICS

Rachel Forman, MD
@bustinclots247

I was happy to see that although the ESO-WSO 2020 annual meeting was postponed, we still had the opportunity to virtually hear the results of some recent large clinical trials. One of the five trials presented was the Basilar Artery International Collaboration Study (BASICS) presented by Dr. Wouter Schonewille from The Netherlands. Posterior circulation occlusions have been largely excluded from the main endovascular randomized control trials, so these results were highly anticipated. 

Many of us are familiar with the devastating effects of a basilar artery occlusion (BAO), and from a personal experience, some of these cases have been very challenging without having the guidance of large trials as we do with anterior circulation occlusions. The clinical presentations, stroke severity, and collateral patterns are inherently different. This trial was an international, multicenter, controlled trial with randomized treatment-group assignments investigating the efficacy and safety of endovascular therapy (EVT) plus best medical management (BMM) versus BMM alone <6 hours of estimated time of BAO. Patients were randomly assigned (1:1 ratio) to EVT+BMM or BMM alone and stratified according to: randomizing center, use of IVT, and NIHSS (<20 vs >20). The enrollment period was from 2011 through 2019. Patients were excluded with intracranial hemorrhage, extensive brainstem ischemia, or cerebellar mass effect/acute hydrocephalus. The calculated sample size was 300 patients assuming favorable outcome in 46% with EVT+BMM and 30% with BMM. Primary outcome was mRS <3 at 90 days. Secondary outcome measures included clinical outcomes (mRS 0-2 at 90 days and mRS distribution) and imaging outcomes (posterior circulation ASPECTS score at 24 hours and basilar artery patency at 24 hours). 

COVID-19 Pandemic Pre-Hospital Acute Stroke Triage: Things to Consider

Elizabeth M. Aradine, DO

Goyal M, Ospel JM, Southerland AM, Wira C, Amin-Hanjani S, Fraser JF, et al. Prehospital Triage of Acute Stroke Patients During the COVID-19 Pandemic. Stroke. 2020.

The COVID-19 pandemic has changed the process of pre-hospital acute stroke triage. Actions such as EMS providers assessing a patient, walking into a patient’s room, transferring a patient to a comprehensive stroke center: These are things we once did without considering if we will contract or spread a virulent airborne virus. Now, special precautions are needed to provide acute stroke care, and they pose various challenges to the process of pre-hospital acute stroke triage. The authors of “Pre-hospital Triage of Acute Stroke Patients During the COVID-19 Pandemic” have established a guide to address these issues, and below is each challenge and possible solution. 

EMS providers need to obtain additional history regarding COVID-19 symptoms or exposures which may not be readily available. The authors propose that EMS providers use the COVID-19 Screening Tool, 5 questions on signs, symptoms, COVID-19 contacts, and patient age plus non-respiratory symptoms, as a quick way to assess for COVID-19. EMS providers can then communicate a positive screen to the receiving hospital so they can efficiently prepare for a protected stroke code.  Proper donning of PPE can be time consuming, thus the authors propose donning PPE prior to the patient’s arrival to minimize delay in the acute stroke evaluation. Symptomatic COVID-19 patients may need supplemental oxygen or intubation before arrival to the hospital. The authors propose continuous monitoring of vitals and to provide necessary emergent respiratory treatments by EMS after donning appropriate PPE. Staff shortages can occur due to quarantine or illness, leaving these duties to be covered by other providers who may be unfamiliar with acute stroke care. Simulation training can provide training for these new roles. COVID-19 positive stroke patients may need treatment at comprehensive stroke centers, but initially may not be transported directly to one due to location or other factors. Additionally, inter-facility transfers may be delayed due to unavailable transport staff for a COVID-19 positive stroke patient. The authors propose coordination between EMS and hospitals to facilitate re-routing patients to the appropriate hospital, for example, routing suspected LVO patients directly to a comprehensive stroke center. Not only could this prevent delay in acute stroke treatment, but it could also minimize PPE use and unnecessary staff exposure to COVID-19.

Vitamin K Antagonists: Insufficient Aid for Embolism and Risky for Intracranial Hemorrhage

Elena Zapata-Arriaza, MD
@ElenaZaps

Meinel TR, Kniepert JU, Seiffge DJ, Gralla J, Jung S, Auer E, et al. Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients. Stroke. 2020;51:892–898.

Symptomatic intracranial hemorrhage (sICH) involves a potential complication in patients treated with rtpa or mechanical thrombectomy (MT), which influences functional and vital prognosis of ischemic stroke patients. Patients under oral anticoagulation (OAC) suffer higher risk of sICH per se; however, the association of mentioned oral treatment with recanalization therapies (IV fibrinolysis or MT) may increase cerebral bleeding. This is the aim of Dr. Meinel and colleagues, among others, like mortality and sICH risk in MT patients under OAC, sensitivity analysis with patients with confirmed therapeutic anticoagulation activity, and finally the presentation of a meta-analysis about the topic.

The authors performed a retrospective, multicenter non-randomized observational study to investigate safety and efficacy of a market-release neurothrombectomy device, including their data in the BEYOND-SWIFT registry. Patients were grouped according to their OAC intake prior to admission: Group 1: VKA (vitamin K antagonist); Group 2: DOACs (Direct oral anticoagulants); Group 3: No OAC. The primary endpoint was sICH rate (according to ECASS II (European Co-Operative Acute Stroke Study-II) criteria). The secondary endpoints were technical efficacy and all-cause mortality at 3 months.

Article Commentary: “Machine Learning–Enabled Automated Determination of Acute Ischemic Core From Computed Tomography Angiography”

Muhammad Taimoor Khan, MD

Sheth SA, Lopez-Rivera V, Barman A, Grotta JC, Yoo AJ, Lee S, et al. Machine Learning–Enabled Automated Determination of Acute Ischemic Core From Computed Tomography Angiography. Stroke. 2019;50:3093–3100.

As a vascular neurology fellow, an understanding of the automated tools available for immediate diagnosis of large vessel occlusion (LVO), estimation of core and penumbra in the context of treatment decision making has become critical in the era of endovascular therapy. In the article “Machine Learning–Enabled Automated Determination of Acute Ischemic Core From Computed Tomography Angiography,” the authors developed, validated, and reported a deep learning method called “DeepSymNet” that evaluates for ischemic core volume using computed tomography angiogram (CTA) source images. The study included patients with acute ischemic stroke and stroke mimics with CTA and CT perfusion (CTP) using the RAPID software and trained their algorithm against RAPID CTP determinations of ischemic core.

From 297 included patients, 224 (75%) had acute ischemic stroke, of which 179 (60%) had large vessel occlusion. The mean RAPID CTP based ischemic core volume was 23±42 cc. DeepSymNet learned to identify vessels on CTA, detect LVO autonomously and ischemic core of less than or equal to 30 cc and 50 cc with AUC 0.88 and 0.90 (ischemic core ≤30 mL and ≤50 mL) to CTP-RAPID ischemic core volume both in early, 0 to 6 hours and late 6-24 hours time windows. (AUCs 0.90 and 0.91, ischemic core ≤50 mL).

Article Commentary: “Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams”

Gurmeen Kaur, MBBS
@kaurgurmeen

Nguyen TN, Abdalkader M, Jovin TG, Nogueira RG, Jadhav AP, Haussen DC, et al. Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams: A Guidance Statement From the Society of Vascular and Interventional Neurology. Stroke. 2020.

With the COVID-19 pandemic taking more than 50,000 lives in the United States, emergency medical services are being forced to change their triage policies in order to ensure safety of both the patients and the health care personnel involved.

Stroke and STEMI triage systems are among the first to be affected, especially because there is some evidence for the increased incidence of acute ischemic strokes in COVID-19 patients, secondary to the hypercoagulability.

The Society of Vascular and Interventional Neurology has issued a guidance statement highlighting practices that all institutes should be incorporating into their routine stroke workflow — pre-, intra- and post-mechanical thrombectomy. These guidelines serve as pointers that can be used to modify our existing protocols. Because we are going to continue to see the effect of COVID-19 through the summer, especially in highly impacted states like New York, Massachusetts and Illinois, and there is also a potential second wave predicted for fall and winter 2020, it is prudent that all centers adopt these best practice guidelines in their daily stroke triage and workflow.

Determining Prognosis of Intracerebral Hemorrhage by Imaging: Wait (24 Hours) and See

Raffaele Ornello, MD

Lun R, Yogendrakumar V, Demchuk AM, Aviv RI, Rodriguez-Luna D, Molina CA, et al. Calculation of Prognostic Scores, Using Delayed Imaging, Outperforms Baseline Assessments in Acute Intracerebral Hemorrhage. Stroke. 2020;51:1107–1110.

The prognosis of intracerebral hemorrhage (ICH) is poor, and it is hard to identify factors which can predict a good or bad outcome. Besides, ICH is usually a fast-progressing clinical picture, in which early and delayed imaging may show completely different pictures.

The multicenter, prospective, observational cohort of the PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign) included 280 patients with a 90-day case-fatality of 25%. The study assessed the predictive accuracy for 90-day mortality of the ICH Score, FUNC Score, and modified ICH Score using imaging data at initial presentation and at 24 hours. Analyses were performed using receiver operating characteristic curves. Compared with early imaging, brain imaging performed 24 hours after ICH onset significantly improved the accuracy of prognostic scores; in detail, the area under the curve increased from 0.78 to 0.82 for ICH score, from 0.76 to 0.84 for FUNC Score, and from 0.74 to 0.82 for modified ICH score. The study findings are limited by the absence of complete 24-hour clinical data. Nevertheless, the study points out that waiting 24 hours from symptom onset might improve the prediction of ICH prognosis.

A possible consequence of this study is that early withdrawal of ICH care might be unjustified, as physicians can provide reliable estimates of patients’ prognosis only after several hours from ICH onset. More interventions in the hyperacute phase of ICH might be needed, and several studies suggest the efficacy of such early interventions. Waiting 24 hours before withdrawing care might be a viable option in ICH.

Article Commentary: “Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection”

Muhammad Rizwan Husain, MD
@RIZWANHUSAINMD

Markus HS, Levi C, King A, Madigan J, Norris J, for the Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol. 2019;76:657-664.

Cervical artery dissection (CAD) has an annual incidence of about 2.9% per 100,000, though that seems to be under-reported, as many patients usually do not present for evaluation or undergo routine vessel imaging for local symptoms like pain or headache. At the same time, even though CAD accounts for about 1-2% of total ischemic strokes, it can be the cause of up to 25% of strokes in the young population.

The Cervical Artery Dissection in Stroke Study (CADISS) is the only prospective randomized clinical trial to date that evaluated if there was a reduction in subsequent stroke in patients treated with either antiplatelet or anticoagulation. It also looked at the presence of arterial recanalization between the two groups.

Evolocumab as Part of the Armory for Stroke Prevention

Lina Palaiodimou, MD

Giugliano RP, Pedersen TR, Saver JL, Sever PS, Keech AC, Bohula EA, et al; on behalf of the FOURIER Investigators. Stroke Prevention With the PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9) Inhibitor Evolocumab Added to Statin in High-Risk Patients With Stable Atherosclerosis. Stroke. 2020.

Alberts MJ, Thompson PD. PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9) Inhibition and Stroke Prevention: Another Step Forward. Stroke. 2020.

During the last decades, stroke primary and secondary prevention has been significantly improved by systematic lipid control. Ever since the first description of low-density lipoprotein cholesterol (LDL-C) as a stroke risk factor, published guidelines have been suggesting increasingly lower LDL-C values as the target levels. According to the most recent Guidelines on Management of Blood Cholesterol, when evaluating patients with very high atherosclerotic cardiovascular disease (ASCVD) risk, it is recommended to preserve LDL-C values up to a threshold of 70 mg/dl (Grundy, 2019). In order to achieve such a therapeutic target, clinicians should use high-intensity statins with co-administration of ezetimibe when needed. In the case that LDL-C control is proven to be inadequate, even under the combination of high-intensity statin and ezetimibe, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor should be considered as an add-on therapy.     

Evolocumab is a monoclonal antibody that binds to and inhibits PCSK9 and is a very potent lipid-lowering drug. It has been approved as an adjunctive LDL-C lowering therapy for adults with established ASCVD and is administered as a subcutaneous injection either every two weeks (140mg) or once monthly (420mg). Administration of evolocumab, as the experimental arm of the FOURIER study, proved to be effective in lowering LDL-C levels below current targets and was beneficial for ASCVD patients (Sabatine, 2017). The study population consisted of patients with a history of myocardial infarction, non-hemorrhagic stroke, or symptomatic peripheral artery disease, and also had additional characteristics for high ASCVD risk. The primary end point was the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization.

By |April 21st, 2020|clinical|0 Comments

Endovascular Thrombectomy With Improved Reperfusion Leads to Long-Term Public Health and Societal Cost Benefits

Melissa Trotman-Lucas, PhD
@TrolucaM

Kunz WG, Almekhlafi MA, Menon BK, Saver JL, Hunink MG, Dippel DWJ, et al. Public Health and Cost Benefits of Successful Reperfusion After Thrombectomy for Stroke. Stroke. 2020;51:899–907.

The number of deaths due to stroke is 10 million per year globally, with a prevalence of 42 million. Large vessel occlusions (LVO) account for a third of all occlusive ischemic strokes and are the largest contributor to the morbidity and mortality associated with ischemic stroke. The evolution and use of endovascular thrombectomy (EVT) for these patients have transformed stroke treatment and care; clinical trials utilizing EVT demonstrated the benefits of this technique during post-stroke recovery, including reduced disability and improved outcome. In multiple countries, EVT has been adopted as the standard of care for LVO and is recommended for use where possible in other countries — limits come from availability of suitably trained staff and equipment.