American Heart Association

clinical

NASAM Stroke Games 2019 and Stroke in Malaysia

Lin Kooi Ong, PhD
@DrLinOng

The National Stroke Association of Malaysia (NASAM) Stroke Games 2019, an amazing event showcasing remarkable possibilities of #LifeAfterStroke, kicked off with an inspiring start at the Panasonic National Sports Complex in Malaysia on October 19. This event is in conjunction with the World Stroke Organisation – World Stroke Day, Southeast Asia Route. Over 800 participants from different states, including Penang, Sabah and Johor, as well as Singapore, participated in 25 events. The youngest athlete was 16 years old, and the oldest was 81 years old. The games kicked off with seated volleyball and hand cycle. The event closed on October 20 with Janet Yeo, stroke survivor and founder chairman of NASAM, putting out the flame.

The NASAM Stroke Games 2019 was declared open.
The NASAM Stroke Games 2019 was declared open. Left to right are: Dato’ Wan Hashimi Albakri, Acting Group CEO, Sime Property Berhad; Tun Jeanne Abdullah, Patron of the Malaysian Paralympic Council; Janet Yeo, NASAM Founder Chairman; Hannah Yeoh, Deputy Minister, Ministry of Women, Family and Community Development; Stuart Milne, CEO, HSBC Bank Malaysia Berhad; Toh Puan Dato’ Seri Hajjah Dr Aishah Ong, Patron of NASAM; and Ruchira Gupta, NASAM Senior Advisor. Photo provided by Frankie Goh, NASAM, with permission.

“The Games is NASAM’s contribution to the stroke community around the world,” said Yeo. “We wish that this fighting spirit of a stroke champion is ignited into every person affected by a stroke no matter where they are.”

World Stroke Day: Staying Above the Fray

Burton J. Tabaac, MD

Join the fight against stroke!

In 2015, the World Stroke Campaign focused on raising awareness of stroke prevention and risk among women using the tagline “I am Woman – Stroke Affects Me, Stroke Affects Everyone.” In 2016, World Stroke Day was marked by recognizing that although stroke is a complex medical issue, there are ways to significantly reduce its impact. The World Stroke Organization built a campaign to underscore that “Stroke is Treatable.” The World Stroke Day 2017 campaign focused on risk awareness and prevention. Last year, World Stroke Day 2018 emphasized that there are resources and a network to assist those who have suffered from stroke, underscoring that you are not in it alone. #UpAgainAfterStroke was used as a rallying cry to inform the public about the well-developed network for caregivers, families, and friends affected by stroke who can help their loved ones.

This year, 2019, calls attention to prevention.

Article Commentary: “Phase I/II Study of Safety and Preliminary Efficacy of Intravenous Allogeneic Mesenchymal Stem Cells in Chronic Stroke”

Yan Hou, MD, PhD

Levy ML, Crawford JR, Dib N, Verkh L, Tankovich N, Cramer SC. Phase I/II Study of Safety and Preliminary Efficacy of Intravenous Allogeneic Mesenchymal Stem Cells in Chronic Stroke. Stroke. 2019;50:2835–2841.

Substantial preclinical data support the safety and efficacy of mesenchymal stem cells (MSC) to improve outcomes during the chronic phase of stroke. Initial human studies of MSC after stroke focused on autologous cell therapies, whereby bone marrow is taken from each patient to produce his/her own MSC batch, and found MSC infusion to be safe. Compared to autologous cells, allogeneic MSC can be manufactured to enables broad clinical application, and it have been found to be safe without use of concomitant immunosuppression, because MSC are relatively immunoprivileged given their very low levels of human leukocyte antigen molecule expression. Studies of allogeneic MSC poststroke have focused on using an invasive procedure to implant cells intracerebrally. An intravenous method of introducing MSC if comparably efficacious might facilitate widespread implementation and also avoid adverse events attributable to invasive procedures.

The authors performed a phase I/II multi-center, open-labeled, dose-escalation trial that examined effects of a single intravenous infusion of allogeneic ischemia-tolerant MSC in patients with chronic ischemic stroke (>6 month from onset) and substantial functional deficits. MSC were grown from the bone marrow of a single human donor and are from the same batch used in prior preclinical and clinical studies. Thirty-six patients were enrolled (75% were males, 86% were Caucasians, at age 61.1 ± 10.8, time from stroke to infusion was 4.2 ± 4.6 years). Part 1 of the study consisted of 3 cohorts (n=5 per cohort) in a dose-escalation manner, with subjects receiving one of 3 doses based on body weight (0.5, 1, and 1.5 million cells/kg). The target dose of 1.5 million cells/kg corresponds to allometric scaling from animal studies using the intravenous route in the post-acute period. In Part 2 of the study, 21 patients received a single dose of 1.5 million cells/kg. The primary outcome was safety, and preliminary estimates of treatment efficacy were also examined. Patients were followed for one year after MSC infusion without any restriction of other medications.

By |October 28th, 2019|clinical|0 Comments

Transradial Access in Neurointerventional Procedures: Advances and Challenges

Gurmeen Kaur, MBBS, and Kat Dakay, DO
@kaurgurmeen; @katarinadakay

Conventional cerebral angiography has been trans-femoral and has a consistent 2-3% rate of femoral arterial complications, including pseudo-aneurysms, retroperitoneal hematomas, and access site bleeding.

Interventional cardiology has promoted and adopted the trans-radial approach, significantly reducing access site complications. Large-scale cardiology trials (RIVAL, RIFLE) have even demonstrated the increased safety of percutaneous coronary interventions using the radial approach.1

Over the last two years, the use of the radial approach for neuro-interventional procedures has dramatically increased. Multiple studies have demonstrated improved patient experience and a reduction in access site complications using the radial approach. Another major advancement has been the use of distal radial access.2 The distal radial artery, located in the anatomical snuff box, is distal to the origin of the superficial palmer branch, which supplies numerous palmar collaterals to the deep palmar arch. This further reduces the incidence of ischemic hand from radial artery occlusion and is more ergonomic for the operators.3 Additionally, in a patient undergoing a diagnostic angiogram as part of treatment planning, the proximal radial artery, which has a bigger caliber, can be preserved for the interventional procedure.

By |October 25th, 2019|clinical|0 Comments

Clinical and Radiographic Predictors of Mortality After Intracerebral Hemorrhage

Elizabeth M. Aradine, DO

Fallenius M, Skrifvars MB, Reinikainen M, Bendel S, Curtze S, Sibolt G, et al. Spontaneous Intracerebral Hemorrhage: Factors Predicting Long-Term Mortality After Intensive Care. Stroke. 2019;50:2336-2343.

High mortality from a large spontaneous intracerebral hemorrhage (ICH) is somewhat intuitive, but whether this holds true months after the event is not well known. The authors sought to better elucidate this in “Spontaneous Intracerebral Hemorrhage: Factors Predicting Long-Term Mortality After Intensive Care.” This multicenter retrospective study included all adults admitted to the ICU in Finland from 2003 to 2013 with spontaneous ICH. Demographics and clinical data including age, admission GCS, anticoagulation use, and chronic medical comorbidities were recorded. A CT scan was required to evaluate the hemorrhage location and were categorized as supratentorial superficial, supratentorial deep, brainstem, and cerebellum. The volume of hemorrhage was calculated using the ABC/2 formula, which incorporates length, width, and shape of hemorrhage, as well as CT slice thickness and number of slices where hemorrhage is present. Three models (clinical, radiographic, and combined clinical and radiographic) were used to evaluate the predictability of mortality from ICH. Patients were followed for 12 months.

Article Commentary: “Leveraging Human Genetics to Estimate Clinical Risk Reductions Achievable by Inhibiting Factor XI”

Alan C. Cameron, MB ChB, BSc (Hons), MRCP

Georgi B, Mielke J, Chaffin M, Khera AV, Gelis L, Mundl H, et al. Leveraging Human Genetics to Estimate Clinical Risk Reductions Achievable by Inhibiting Factor XI. Stroke. 2019.

In this recent article, Georgi and colleagues highlight coagulation factor XI (FXI) as a promising new target for antithrombotic therapy to prevent ischemic stroke without an increased risk of major bleeding. The authors analyzed data from the UK Biobank and two large genome wide association studies to formulate a genetic score standardized to a 30% increase in relative activated partial thromboplastin time, which is equivalent to effects achieved by pharmacological FXI inhibition compared to enoxaparin for the prevention of venous thromboembolism after total knee arthroplasty. 

The results herald what could potentially be a game-changer in antithrombotic therapy for stroke prevention. The authors demonstrate that genetic predisposition to lower FXI levels is associated with a 53% reduction in risk of ischemic stroke (OR 0.47, 95% CI 0.36–0.61; p=1.5×10−8) and a 90% reduction in risk of venous thrombosis (OR 0.1, 95% CI 0.07–0.14; p=3.03×10−43) without an increase in major bleeding (OR 0.69, 95% CI 0.45–1.04; p=0.0739). The reductions in risk of ischemic stroke are similar in patients with or without a history of atrial fibrillation (AF), suggesting that absolute risk reductions are higher in patients with AF. The authors went on to apply a calibration factor to estimate the effects of genetically lower FXI levels compared to placebo and demonstrate an estimated risk reduction of 56% (OR 0.44, 95% CI 0.31–0.62); this is broadly comparable to relative risk reductions observed with warfarin compared to placebo.

Hope for the Brokenhearted

Rachel Forman, MD

Siedler G, Sommer K, Macha K, Marsch A, Breuer L, Stoll S, et al. Heart Failure in Ischemic Stroke: Relevance for Acute Care and Outcome. Stroke. 2019.

The topic of heart failure (HF) is not uncommon in the stroke world. It is a known risk factor for stroke and is related to prothrombotic/proinflammatory states, worsening of cerebral tissue oxygenation, and hemodynamic impairment. There is also consideration if HF may affect the safety and efficacy of acute stroke therapies. Some concerns include reduced circulation after tPA with low cardiac output or difficulties with anesthesia management during MT. This study by Siedler et al. aimed to look at the effects of HF on stroke patients who received tPA, mechanical thrombectomy (MT), or both. The authors note the importance of this study and that many of the prospective clinical trials have excluded HF patients.

Patients who received tPA or MT at a university stroke center were included into a prospective registry. Patients with HF were identified based on their echocardiograms (transthoracic or transesophageal) done as a part of the stroke evaluation. The impairment of left ventricular ejection fraction (LVEF) was categorized as mild if >35% EF, moderate if 25-35% EF, and severe if <25% EF. Functional outcome was assessed after 90 days by telephone interviews and favorable outcome was considered mRS 0-2.  

Article Commentary: “Low-Dose Tirofiban Treatment Improves Neurological Deterioration Outcome After Intravenous Thrombolysis”

Wayneho Kam, MD

Wu C, Sun C, Wang L, Lian Y, Xie N, Huang S, et al. Low-Dose Tirofiban Treatment Improves Neurological Deterioration Outcome After Intravenous Thrombolysis. Stroke. 2019.

The current standard of practice is to avoid the use of antithrombotic agents within the first 24 hours after receiving intravenous thrombolytics. This is due to concern that the concurrent use of antiplatelets or anticoagulants with recent thrombolytic administration may increase the risk for bleeding events. The concern may be unfounded, however, particularly given the relatively short half-life of alteplase.

There are instances, of course, when use of such medications within 24 hours of alteplase administration may be warranted, such as with concomitant endovascular therapy with stent placement or acute myocardial infarction.

What if early neurological deterioration occurs in patients after they received tPA, in the absence of a clear explanation, such as hemorrhagic conversion or cerebral edema? Will these patients benefit from early initiation of antiplatelet therapy?

Investigating the Causes of Declining Carotid Endarterectomies

Raffaele Ornello, MD

Johal AS, Loftus IM, Boyle JR, Naylor AR, Waton S, Heikkila K, et al. Changing Patterns of Carotid Endarterectomy Between 2011 and 2017 in England: A Population-Based Cohort Study. Stroke. 2019;50:2461–2468.

Carotid endarterectomy (CEA) is effective for secondary stroke prevention in symptomatic patients, while its effectiveness in asymptomatic patients is a matter of debate. Data suggest that CEAs are declining worldwide; however, the reasons for that decline are unclear.

To investigate those possible causes, the authors reviewed data from the English National Vascular Registry in the 2011-2017 period and confirmed a decline of CEAs in both symptomatic and asymptomatic patients. In detail, CEAs performed in asymptomatic patients declined by 63%, from 722 in 2011 to 265 in 2017, while those performed in symptomatic patients declined by 25%, from 4992 in 2011 to 3482 in 2017.

Article Commentary: “Cannabis and Cannabinoid Biology in Stroke”

Pamela Cheng, DO

Choi S-H, Mou Y, Silva AC. Cannabis and Cannabinoid Biology in Stroke: Controversies, Risks, and Promises. Stroke. 2019;50:2640–2645.

Stroke remains one of the leading causes of death and disability in the United States. Currently, the main therapeutic approach includes thrombolysis and mechanical thrombectomy. However, immediate reperfusion therapy does not tell the whole story. Following a stroke, there are complex biochemical events that occur that lead to excitotoxicity and oxidative stress, which may contribute to long-term functional outcomes. As such, there has been great interest and research in the field of neuroprotection. While there are currently no approved neuroprotective treatment options for stroke, there have been some promising yet conflicting results on the endocannabinoid system (ECS).

The ECS is composed of endogenous, lipid-based neurotransmitters that bind to the cannabinoid receptors. The ECS has shown promise in a wide range of pathological conditions and neurological disorders. In stroke, there is evidence that the ECS is altered in both animals and humans, and may contribute to the consequences of ischemic stroke. While studies have been conflicting in either supporting or refuting the use of cannabinoids, they remain a prominent research focus.