American Heart Association

clinical

Is Atrial Fibrillation an Independent Risk Factor for Venous Thromboembolism?

Wern Yew Ding, MBChB

Hornestam B, Adiels M, Wai Giang K, Hansson PO, Björck L, Rosengren A. Atrial fibrillation and risk of venous thromboembolism: a Swedish Nationwide Registry Study. Europace. 2021;23:1913-1921.

Thromboembolism is a major cause of global mortality. The risk of thromboembolism with atrial fibrillation (AF) is well established. However, most studies on this topic have focused on the risk of stroke and systemic arterial embolism. The risk of venous thromboembolism (VTE) in association with AF is less studied or even recognized in clinical practice.

In this study, Hornestam and colleagues investigated the relationship between AF and total VTE, including pulmonary embolism (PE) and deep venous thrombosis (DVT). The authors utilized the Swedish National Inpatient Register to identify patients with a first diagnosis of AF and no prior history of stroke, PE, DVT, or pulmonary hypertension along with matched controls by sex, age, and county from 1987 to 2013. The final cohort consisted of 463,244 patients with AF and 887,336 controls without AF. The main findings of the study were that patients with AF had a significantly greater risk of PE, DVT, and VTE compared to matched controls, particularly in younger patients and females, after accounting for other risk factors. Moreover, patients were at greatest risk of VTE (and DVT and PE) during the initial 1 month (male: HR 6.64 [95% CI, 5.74 – 7.69]; female: HR 7.56 [95% CI, 6.47 – 8.83]), but this risk declined over time and did not persist beyond the first year.

By |March 28th, 2022|clinical|Comments Off on Is Atrial Fibrillation an Independent Risk Factor for Venous Thromboembolism?

Article Commentary: “Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window”

Karissa C. Arthur, MD
@KCArthurMD

Jadhav AP, Goyal M, Ospel J, Campbell BC, Majoie CBLM, Dippel DW, White P, Bracard S, Guillemin F, Davalos A, et al. Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data. Stroke. 2022.

Computed tomography perfusion (CTP) imaging is currently used for patients with large vessel occlusions presenting in the late time window. However, it is uncertain if CTP adds value to decision making in the early time window. In this study, Jadhav et al. set out to compare post-endovascular thrombectomy (EVT) outcomes between patients who received the standard noncontrast CT and CT angiography (CTA) versus those who received additional imaging with CTP. They further determined the association between CTP and clinical outcomes.

By |March 23rd, 2022|clinical|Comments Off on Article Commentary: “Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window”

Article Commentary: “Bilateral Transcutaneous Electrical Nerve Stimulation Improves Upper Limb Motor Recovery in Stroke”

Hannah Roeder, MD, MPH

Chen P, Liu T-W, Kwong PWH, Lai CKY, Chung RCK, Tsoh J, Ng SSM. Bilateral Transcutaneous Electrical Nerve Stimulation Improves Upper Limb Motor Recovery in Stroke: A Randomized Controlled Trial. Stroke. 2022.

Transcutaneous electrical nerve stimulation (TENS) has been regularly employed over the last half century as a pain modulatory therapy,1 and it has been explored as a therapy to improve sensorimotor function in chronic stroke patients since the 1980s. Early studies among chronic stroke patients found unilateral TENS (over the affected leg) improved lower limb spasticity and strength.2 Subsequently, unilateral TENS plus task-related training was found to be superior to TENS alone in improving lower extremity spasticity, strength, and gait velocity.3 Similar benefits of adding task-related training to TENS were subsequently shown for upper limb motor function.4 More recently, bilateral TENS (Bi-TENS) combined with task-oriented training (TOT) was superior to unilateral TENS (Uni-TENS)+TOT in a trial investigating lower extremity strength and gait performance.5 The current study by Chen and colleagues investigates Bi-TENS+TOT in upper limb motor recovery.

By |March 22nd, 2022|clinical, treatment|Comments Off on Article Commentary: “Bilateral Transcutaneous Electrical Nerve Stimulation Improves Upper Limb Motor Recovery in Stroke”

The Link Between Inflammation and Vascular Brain Health

Tolga D Dittrich, MD
@to_dittrich

Mun KT, Hinman JD. Inflammation and the Link to Vascular Brain Health: Timing Is Brain. Stroke. 2022;53:427–436.

Over the past years, research has yielded several interesting new insights into the role of inflammation in the different stages of cerebrovascular injury. The development of therapeutic approaches is still in its beginning. It ranges from broadly effective anti-inflammatory agents to very specific drugs that interfere with the signaling pathways of the inflammatory cascade. This comprehensive article by Mun and Hinman presents the current state of knowledge on fundamental inflammatory mechanisms associated with cerebrovascular injury and illustrates the role of inflammation as a therapeutic target.

The immunological mechanisms underlying cerebrovascular injury are incredibly complex. Both intravascular and parenchymal inflammatory processes are driven by the invasion of inflammatory cells (e.g., neutrophil granulocytes) and the release of humoral factors (e.g., cytokines, complement factors, and acute-phase proteins) and may lead to the formation of microvascular thrombi and vascular leaks.

By |March 21st, 2022|clinical|Comments Off on The Link Between Inflammation and Vascular Brain Health

Life Course Epidemiological Trends and Social Determinants in Brain Health

Dixon Yang, MD

Hilal S, Brayne C. Epidemiologic Trends, Social Determinants, and Brain Health: The Role of Life Course Inequalities. Stroke. 2022;53:437–443.

In this focused update, Drs. Hilal and Brayne discuss the role of life course inequalities in brain health and successful aging. Brain health is defined as the development and preservation of optimal brain integrity and neural network functioning for a given age [1]. Sustained brain health over a lifespan is important in the maintenance of an individual’s ability and independence. Poor brain health may manifest as cognitive impairment or stroke in later life. Especially as the proportion of the older population increases worldwide, maintaining brain health will likely become a growing public health challenge. In this article, the authors outline the epidemiological trends and social determinants of health that underpin healthy brain aging. As many of these trends start early in life, Drs. Hilal and Brayne discuss possible mechanisms for healthy brain aging and opportunities for research and societal approaches towards promoting brain health across the lifespan.

By |March 18th, 2022|clinical|Comments Off on Life Course Epidemiological Trends and Social Determinants in Brain Health

Article Commentary: “Imaging Markers of Vascular Brain Health: Quantification, Clinical Implications, and Future Directions”

Ammad Mahmood, MBChB
@AMahmoodNeuro

Vemuri P, Decarli C, Duering M. Imaging Markers of Vascular Brain Health: Quantification, Clinical Implications, and Future Directions. Stroke. 2022;53:416–426.

Small vessel disease is a common finding on brain imaging which is increasingly identified with the widespread use of MRI. The clinical significance of this finding remains an area requiring further research. This review begins by defining the components and patterns of abnormalities that are encompassed by the term “small vessel disease,” which is widely used but ambiguous in its meaning. Techniques which identify earlier structural and functional changes in the brain in response to vascular risk factors are then discussed. Finally, the clinical implications of these findings and further opportunities for research in this area are highlighted.

By |March 17th, 2022|clinical|Comments Off on Article Commentary: “Imaging Markers of Vascular Brain Health: Quantification, Clinical Implications, and Future Directions”

ISC 2022 Session: ICH Management: Now and Into the Next Decade

Nurose Karim, MD 

International Stroke Conference 2022 
February 9–11, 2022 
Session: ICH Management: Now and Into the Next Decade 

ICH is a process that leads to many potential targets for intervention. Baseline characteristics (size, GCS, IVH, location and age) predict the outcome. Early hematoma growth leads to tissue disruption and activation of inflammatory markers causing toxic effects and oxidative injury. This causes neuronal injury followed by phagocytosis and active resolution of the inflammation.

Hematoma expansion occurs early, and in about a third of patients, it occurs in the first three hours. The sooner we identify and treat, the earlier we can prevent injury. For ICH, fortunately, we have better metrics. The goal of metrics is to reduce heterogenicity across the board and prevent early neurological deterioration. Due to COVID-19, we have a shortage of beds and nursing staff, and patients are staying in the ED longer than expected. Therefore, we need to train our ED staff to take care of ICH patients and need time metrics to consider: when to repeat imaging? time to ventricular drainage, if indicated? time to operative procedures?

By |March 16th, 2022|clinical, Conference|Comments Off on ISC 2022 Session: ICH Management: Now and Into the Next Decade

Author Interview: Dr. Steven M. Greenberg on “Vascular Contributions to Brain Health”

Dr. Steven M. Greenberg

A conversation with Dr. Steven M. Greenberg, MD, PhD, Professor of Neurology at Harvard Medical School and John J. Conway Endowed Chair in Neurology, Director of the Hemorrhagic Stroke Research Program and Vice-Chair for Faculty Development and Promotions at the Massachusetts General Hospital.

Interviewed by Kristina Shkirkova, Doctoral Candidate in Neuroscience at the University of Southern California. 

They will be discussing the article Vascular Contributions to Brain Health: Cross-Cutting Themes.” Published in the February 2022 issue of Stroke, the article introduces a series of Focused Updates articles on topics related to brain health.

Kristina Shkirkova: To set the stage for this interview, could you briefly summarize the current understanding about the importance of vascular health towards brain aging and health span in general?

Dr. Greenberg: We think of brain health as central to healthy aging. Everybody wants to live a long life, but no one wants to live it without the ability to do activities that make you who you are. There is no healthy aging without brain health. It is important to note that vascular brain health is not the only part of brain health, but it is certainly a major part. We see that diseases of the large blood vessels and the small blood vessels (the major focus of this review series) are very common as people age. So almost everybody has some degree of vascular disease with aging. It’s an interesting contrast with some diseases that are less common that cause severe illness. Vascular disease is different: It’s highly prevalent, meaning that many people have it. It’s almost unusual for someone not to have some evidence of vascular disease. The contribution of each individual vascular disease is modest, but it becomes significant when they co-occur and especially if they are added on top of the other kinds of brain changes, such as Alzheimer’s disease. It’s the combination that is worse than either one by itself.

By |March 15th, 2022|author interview, clinical|Comments Off on Author Interview: Dr. Steven M. Greenberg on “Vascular Contributions to Brain Health”

Slowing Down Progression of White Matter Hyperintensities by Antiplatelets — Too Good to Be True

Thomas Raphael Meinel, MD
@TotoMynell

Kim BC, Youn YC, Jeong JH, Han HJ, Kim JH, Lee J-H, Park KH, Park KW, Kim E-J, Oh MS, et al. Cilostazol Versus Aspirin on White Matter Changes in Cerebral Small Vessel Disease: A Randomized Controlled Trial. Stroke. 2021.

Small-vessel disease, including manifest stroke, but more frequently covert lesions, is a silent pandemic contributing considerably to dementia, frailty, gait problems and mood disorders worldwide.1 The imaging spectrum of small-vessel disease includes white matter hyperintensities (WMH), lacunes, acute small subcortical infarcts, cerebral microbleeds and dilated perivascular spaces.2

It is thus of utmost importance that Kim et al. undertook the work to perform a multicenter, double-blind, randomized controlled trial3 on whether cilostazol slow release (200 mg) as compared to aspirin (100 mg) might be able to slow down WMH progression over the follow-up duration of two years. For this trial, Korean patients aged 50-85 with (45%) and without (55%) manifest stroke were recruited from memory clinics or neurology outpatient clinics referred for memory problems, gait disturbances, personality changes or secondary prevention after a small subcortical infarction or TIA between 2013 and 2016. They had to have at least moderately severe WMH and at least one lacune. Exclusion criteria included contraindications to antiplatelets, significant atherosclerosis or cardioembolic heart disease amongst others. The methods included sophisticated brain imaging and neurocognitive assessments.

By |March 10th, 2022|clinical, treatment|Comments Off on Slowing Down Progression of White Matter Hyperintensities by Antiplatelets — Too Good to Be True

Article Commentary: “Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage”

Ayush Agarwal, MD, DM, DNB
@drayushagarwal

Qureshi AI, Huang W, Lobanova I, Chandrasekaran PN, Hanley DF, Hsu CY, Martin RH, Steiner T, Suarez JI, Yamamoto H, Toyoda K. Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage. Stroke. 2021.

The optimal management of hyperglycaemia in ICH continues to be a grey area with precise guidelines yet to be framed. This multi centric study sought to answer this query and evaluated the effect of persistent hyperglycaemia on the 90-day functional outcome (mRS) in patients with ICH, enrolled within 4.5 hours of symptom onset with hematomas<60ml and GCS>5. Moderate hyperglycaemia was defined as serum glucose concentrations between 140-180mg/dl and severe hyperglycaemia as beyond 180mg/dl. Blood sugar monitoring was done for 3 days (upon admission and successively at 24, 48 and 72 hours). 

The study found that moderate and severe persistent hyperglycaemia was associated with statistically significant worse outcomes (higher 90-day death or disability). These were mirrored in non-diabetic patients with ICH. However, statistical significance was not attained in the previously diagnosed diabetic group. The calculated risk was adjusted for Glasgow coma scale score, hematoma volume, intraventricular hemorrhage, hypertension, hyperlipidemia and cigarette smoking to rule out potential bias and confounding. No glycemic association with hematoma expansion was found.

By |March 8th, 2022|clinical|Comments Off on Article Commentary: “Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage”