American Heart Association

clinical

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

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

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

Article Commentary: “Endovascular Treatment for Posterior Circulation Stroke in Routine Clinical Practice”

Tolga D. Dittrich, MD

Pirson FAV, Boodt N, Brouwer J, Bruggeman AAE, den Hartog SJ, Goldhoorn R-JB, Langezaal LCM, Staals J, van Zwam WH, van der Leij C, et al., and on behalf of the MR CLEAN Registry Investigators. Endovascular Treatment for Posterior Circulation Stroke in Routine Clinical Practice: Results of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry. Stroke. 2021.

In contrast to anterior circulation stroke, the evidence for endovascular treatment (EVT) of posterior circulation stroke remains low. In practice, this means that clinicians still face uncertainties regarding the benefit of EVT, with the decision often based on the individual assessment of the treating physician.

In their observational study, Pirson and colleagues compared outcomes of patients who received EVT outside of the BASICS trial at study centers with those from non-study centers. Of 264 patients included, the majority (77%) had basilar artery involvement, with 51% receiving intravenous thrombolysis. A modified Rankin Scale score of 0 to 3 was achieved by 46% (115/252), and 43% (109/252) of patients died. Successful reperfusion was established in 75% (178/238), and symptomatic intracranial hemorrhage was rare, totaling 3% (9/264). Functional outcome was comparable between BASICS study centers and non-study centers (cOR: 0.77 [95%CI, 0.5-1.2]).

By |April 1st, 2022|clinical|Comments Off on Article Commentary: “Endovascular Treatment for Posterior Circulation Stroke in Routine Clinical Practice”

Target: Stroke: A Quality Improvement Measure That Successfully Reduced IV tPA Door-To-Needle Times

Mona Al Banna, MB BCh, Msc(Res)
@DrMonaAlBanna

Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke. 2021.

Thrombolysis trials have shown that the benefits of tPA are time dependent, with the number needed to treat increasing from 4.5 when treated in the first 90 minutes to 14.9 when treated in the 3 to 4.5 hour window.1 National guidelines have established target goals for door-to-needle (DTN) times. However, rapid delivery thrombolytic therapy occurs infrequently in hospitals in the United States, and often these target goals are not met.

The authors of this study set out to evaluate DTN times and clinical outcomes in patients pre- and post- two successive nationwide quality improvement intervention initiatives between April 2003 and September 2018. The intervention was Target: Stroke, which is a QI initiative sponsored by the American Heart Association/American Stroke Association (AHA/ASA) to assist hospitals in improving DTN times. Target Stroke I provided participating hospitals with best practice strategies, supporting tools, and educational resources. An expert working group performed a systematic review and identified 10 best practice strategies that could be rapidly, feasibly, and cost-effectively adopted. These strategies included things such as EMS pre-notification, rapid acquisition of brain imaging and premixing tPA. In addition, an annual honor roll recognition program for hospitals achieving the DTN goal was also implemented to incentivize institutions. For Target: Stroke phase II, best practice strategies of direct EMS transfer of patients to imaging, updated comprehensive educational materials, customizable clinical decision support tools and performance feedback were made available to the participating institutions. The goal of Target: Stroke Phase I was to achieve DTN times within 60 minutes in at least 50% of ischemic stroke patients treated with tPA. Target: Stroke Phase II set the goal of achieving DTN times ≤60 minutes in 75% and ≤45 minutes in 50% of patients treated with tPA. The authors also evaluated clinical outcomes, including mortality, symptomatic ICH, discharge destination and functional outcomes at discharge and analyzed these trends before and after the initiation of Target: Stroke Phase I and Phase II programs.

By |March 31st, 2022|clinical|Comments Off on Target: Stroke: A Quality Improvement Measure That Successfully Reduced IV tPA Door-To-Needle Times

Stroke Risk Factors in Young Black and White Patients

Kevin O’Connor, MD

Aradine EM, Ryan KA, Cronin CA, Wozniak MA, Cole JW, Chaturvedi S, Dutta TLM, Hou Y, Mehndiratta P, Motta M, et al. Black-White Differences in Ischemic Stroke Risk Factor Burden in Young Adults. Stroke. 2022;53:e66–e69.

Aradine et al. explore differences in diabetes, hypertension, and smoking in Black patients and White patients as risk factors for ischemic stroke using data from the Stroke Prevention in Young Adults Study. The study population (1044 cases and 1099 controls, aged 15-49 years) was recruited from first-time ischemic stroke patients in the Baltimore, Maryland, and Washington, DC, area between 1992 and 2008.

Black patients, regardless of gender, had a higher prevalence of diabetes, hypertension, and smoking than White patients. There was no significant difference in odds ratio (OR) for diabetes among men (Black OR 3.2, versus White OR, 3.6; P=0.77) or women (Black OR, 2.7 versus OR, 5.2; P=0.71). Although Black men had a higher OR for hypertension than White men (OR, 3.9 versus OR, 1.8; P=0.0008), there was no significant difference among women (Black OR, 2.4 versus White OR, 3.8; P=0.93). The OR for smoking, however, was higher among White men (OR, 2.2 versus OR, 1.5; P=0.03) and White women (OR, 2.9 versus OR, 1.7; P=0.007).

By |March 30th, 2022|clinical|Comments Off on Stroke Risk Factors in Young Black and White Patients