Blogging Stroke

Article Commentary: “Magnitude of Blood Pressure Change After Endovascular Therapy and Outcomes: Insight From the BP-TARGET Trial”

Sishir Mannava, MD
@sishmannMD

Anadani M, Maïer B, Escalard S, Labreuche J, de Havenon A, Sabben C, Lapergue B, Gory B, Richard S, Sibon I, et al. Magnitude of Blood Pressure Change After Endovascular Therapy and Outcomes: Insight From the BP-TARGET Trial. Stroke. 2022.

Blood pressure (BP) control after endovascular therapy (EVT) for large vessel occlusion is an oft-debated topic. Many stroke providers, although aware of the potential harm of reperfusion injury, do not know how aggressive to be with BP lowering. The risk with acute lowering of BP is also the risk of hypoperfusion and placing the penumbra at risk of worsening ischemic damage. The authors of this work conducted a post-hoc analysis of the BP TARGET trial (recently published and showing neutral results from intensive BP lowering in patients with successful reperfusion after EVT) to assess the association between change in systolic blood pressure at different time intervals with clinical and radiographic outcomes.

This was a secondary observational post-hoc analysis of the original BP TARGET trial, which enrolled patients with anterior circulation large vessel occlusion stroke and had acute ischemic stroke with successful reperfusion with EVT but had SBP > 130 mmHg at end of procedure (considered the baseline SBP). Patients in the BP TARGET trial were randomized 1:1 to intensive SBP treatment to be achieved within 1 hour of randomization (target 100-129 mmHg) or standard SBP treatment (130-185mmHg). BP was measured every 15 minutes for 2 hours after randomization, then every 30 minutes for 6 hours and then every hour for the remaining 16 hours. The authors defined ΔSBP as baseline SBP minus the mean of achieved SBP levels during 3 periods post-reperfusion: 15 to 60 minutes (ΔSBP15–60M), 1 to 6 hours (ΔSBP1–6H), and 6 to 24 hours (ΔSBP6–24H).

By strokeblog|February 14th, 2022|clinical, Conference|Comments Off

Digital Health in Primordial and Primary Stroke Prevention: Feasible Solution During COVID-19 Pandemic?

Fransisca Indraswari, MD

Feigin VL, Owolabi M, Hankey GJ, Pandian J, Martins SC. Digital Health in Primordial and Primary Stroke Prevention: A Systematic Review. Stroke. 2022.

The COVID-19 pandemic has shifted healthcare towards digital devices to compensate for less physical interaction, without compromising on the quality of patient care. Stroke care has typically been focused on secondary prevention and acute management, i.e., thrombolysis and endovascular, while there are not many studies on primary prevention. Primordial stroke prevention refers to the activities to avoid development of risk factors for stroke, whereas primary stroke prevention refers to activities to treat or reduce exposure to risk factors for stroke. Feigin et al. have provided a systematic literature review on how primary and primordial stroke prevention can be achieved through technology. The unprecedented growth of smartphone or other digital technologies is being used in almost every area of healthcare, offering a unique opportunity to improve primordial and primary stroke prevention at the individual level. The aim of the study is to provide current knowledge, challenges and opportunities of digital health in primordial and primary stroke prevention.

By strokeblog|February 14th, 2022|clinical, Conference, health care, policy|Comments Off

Article Commentary: “Emergency Medical Service Time Intervals for Patients With Suspected Stroke in the United States”

Tolga D. Dittrich, MD
@to_dittrich

Cash RE, Boggs KM, Richards CT, Camargo Jr CA, Zachrison KS. Emergency Medical Service Time Intervals for Patients With Suspected Stroke in the United States. Stroke. 2022.

In acute stroke care, time is arguably the most critical outcome-determining factor. In addition to early recognition of stroke symptoms, prompt transport to a qualified hospital by emergency medical services (EMS) is essential to ensure optimal care. Cash and colleagues evaluated EMS time intervals for adults with suspected stroke in the United States between 2018 and 2019 and examined differences by geographic location.

Approximately 410,000 call-outs were considered, of which the vast majority of transports (98%) were ground-based. A comparison of ground-based and air-bound transports revealed that the time between dispatch and hospital arrival was considerably longer for air-bound transports (ground-based vs. air-bound (median, IQR): 35 min [27-45] vs. 56 min [43-70]), demonstrating disparity to the disadvantage of rural and border regions. In each transport group, 10% of the patients had pre-hospital times outside the target recommendations (≥58 minutes in the ground-based transport group, ≥86 minutes in the air-bound transport group).¹

By strokeblog|February 10th, 2022|clinical, Conference|Comments Off

DOACs: The Way Forward for Treating CVT

Ayush Agarwal, DM
@drayushagarwal

Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, Henninger N, Elnazeir M, Liberman AL, Moncrieffe K, et al. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke. 2022.

Cerebral venous sinus thrombosis (CVT) is an uncommon cause of stroke and commonly afflicts a relatively younger population. Anticoagulation is the treatment of choice. Warfarin has formed this backbone with a gradual shift towards the newer direct oral anticoagulants (DOACs) of late (based on the ease of administration and lack of therapeutic monitoring). However, the query exists whether these patients can safely and effectively be treated with DOACs?

Large scale randomized controlled trials are difficult to conduct on CVT patients because of low incidence (RESPECT-CVT had only 120 patients), and data from other relevant sources (recent studies on DOAC use in venous thromboembolism and non-valvular atrial fibrillation) is encouraging. Therefore, Yaghi et al. conducted this multicenter study to find the real-world data comparing the efficacy and safety outcomes in patients with CVT treated with DOACs and warfarin over a 6-year period. Efficacy was measured clinically by a recurrence of venous thrombosis and radiographically by recanalization rates. Safety was calculated based on the occurrence of bleeding manifestations (major and minor).

By strokeblog|February 10th, 2022|clinical, Conference, treatment|Comments Off

Carotid Intervention in Women: To Treat or Not to Treat?

Nurose Karim, MD

Rockman C, Caso V, Schneider PA. Carotid Interventions for Women: The Hazards and Benefits. Stroke. 2022.

Atherosclerotic carotid artery disease (CAD) is responsible for near 10-15% of strokes. Their prevalence increases with age, and there are racial and gender differences. The incidence is highest in Native American people followed by white. African American males and Asian females have the lowest prevalence. The estimated >50% sclerotic CAD prevalence in Caucasian males is 2.3% in their 60s, which increases to 6.0% in 70s and 7.5% in 80s. The corresponding prevalence in women is 2.0%, 3.6% and 5.0% in their 60s, 70s and 80s, respectively. Active smoking, diabetes and hypertension are strongly associated with increased carotid intima and media thickness and carotid plaque. Other cardiovascular risk factors include metabolic syndrome and hypertriglyceridemia. The age-related changes in the intima progresses faster in women after age 60 secondary to menopause, which causes stiffer arteries and hypertension.

It is a well-known fact that the ipsilateral stroke risk increases with the degree of stenosis which is independent of gender. The outcome of stroke and CAD is worse in women due to several reasons including disease pathophysiology, role of estrogen and other sex hormones, access to care, seeking medical attention, provider bias, and socioeconomic status. Women tend to present with uncommon symptoms including incontinence, nausea, loss of consciousness, and difficulty swallowing, which may lead to delay in diagnosis and treatment. The cerebral ischemic response is also thought to be different in men vs women.

By strokeblog|February 3rd, 2022|clinical|Comments Off

Article Commentary: “Health Screening Program to Enhance Enrollment of Women and Minorities in CREST-2”

Karissa Arthur, MD

Lal BK, Meschia JF, Jones M, Aronow HD, Lackey A, Lake R, Howard G, Brott TG. Health Screening Program to Enhance Enrollment of Women and Minorities in CREST-2. Stroke. 2022.

Enrollment of women and minorities into trials related to carotid disease is low, despite efforts to bolster recruitment of these groups. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) therefore sought to improve recruitment of women and minorities via a screening program. Life Line Screening (LLS) is a nationwide private health screening organization which helps to identify adults at risk for serious vascular diseases via screening events in local communities across the United States. The investigators developed a partnership (CREST-LLS partnership) in order to enhance identification of asymptomatic carotid stenosis among women and minorities.

For the CREST-LLS partnership, all LLS screening events occurring within a 50-mile radius of a CREST-2 center were identified for participation over the course of one year. Each event evaluates 25-100 participants who are recruited via targeted emails, local television and radio channels, newspapers, and direct mail. Cost to the participant was variable and depended on pre-arranged sponsorships, union health plans, and the assessments selected by participants. Available assessments included blood pressure measurements, ankle-brachial measurements, ECG, and blood lipid levels. If participants were over 50 with at least 2 vascular risk factors, carotid artery duplex ultrasound was performed by trained and certified vascular ultrasound technologists. If ultrasound peak systolic velocity was greater than or equal to 230 cm/s, participants were suspected of having high-grade carotid stenosis. These participants were provided the findings and informed about the opportunity to be evaluated at the nearest CREST-2 clinical center. Their consent to be contacted by study coordinators was also requested by non-medical staff.

By strokeblog|February 2nd, 2022|clinical|Comments Off

Article Commentary: “Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis”

Farah Aleisa, MD

Ali M, van Os HJA, van der Weerd N, Schoones JW, Heymans MW, Kruyt ND, Visser MC, Wermer MJH. Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis. Stroke. 2021.

In the literature, women do worse after stroke than men, mortality and severe stroke are higher among women, and atypical clinical presentation of acute stroke could explain the higher rate of misdiagnosis in women. Interestingly, a previous cohort study indicated that women who presented with a transient ischemic attack (TIA) or minor stroke more frequently received a diagnosis of stroke mimic compared with men with similar symptomatology; at the same time, stroke recurrence rate within 90 days of stroke onset were similar in both men and women, raising the possibility of sex biases in diagnosing acute stroke. Here, we will go through a systematic analysis of different acute stroke presentations between men and women.

By strokeblog|January 31st, 2022|clinical|Comments Off

Article Commentary: “Sex Difference and Rupture Rate of Intracranial Aneurysms”

Isabella Canavero, MD

Zuurbier CCM, Molenberg R, Mensing LA, Wermer MJH, Juvela S, Lindgren AE, Jääskeläinen JE, Koivisto T, Yamazaki T, Uyttenboogaart M, et al. Sex Difference and Rupture Rate of Intracranial Aneurysms: An Individual Patient Data Meta-Analysis. Stroke. 2022.

A higher prevalence of both intracranial aneurysms and aneurysmal subarachnoid hemorrhage (aSAH) in women than in men has been reported by many studies. However, female sex has not been identified as an independent risk factor in rupture rate of intracranial aneurysms according to the PHASES score, which is a validated scoring system that takes into account both patient- and aneurysm-related features, including geographic location, hypertension, age, history of aSAH, aneurysm size and location.

By hypothesizing a different prevalence of patient- or aneurysm-related risk factors for rupture (including the PHASES score, smoking, and a positive family history for aSAH) among sexes, Zuurbier and colleagues performed a pooled analysis of individual patient data from nine prospective cohort studies, examining about 10000 patients, to assess if sex is an independent risk factor for rupture.

By strokeblog|January 28th, 2022|clinical, hemorrhage|Comments Off

Article Commentary: “Sex-Related Differences in Outcomes After Endovascular Treatment of Patients With Late-Window Stroke”

Vignan Yogendrakumar, MD MSc
@VYogendrakumar

Bala F, Casetta I, Nannoni S, Herlihy D, Goyal M, Fainardi E, Michel P, Thornton J, Power S, Saia V, et al. Sex-Related Differences in Outcomes After Endovascular Treatment of Patients With Late-Window Stroke. Stroke. 2022.

To date, differences in clinical outcomes between males and females undergoing endovascular therapy (EVT) within the early time window have not been observed. Outcome data in the late window (> 6 hours from symptom onset) stratified by sex remains limited. To that effect, Bala and colleagues sought to use data from the SOLSTICE Consortium to investigate potential differences in outcomes between males and females undergoing EVT in the late window.

The SOLSTICE Consortium is an individual-patient level analysis of data from select registries and clinical trials. Patient selection for EVT in the late window was based on collateral or perfusion imaging. Outcomes evaluated in this analysis include functional independence (mRS ≤ 2), mRS shift, mortality at 90 days, and symptomatic intracranial hemorrhage.

By strokeblog|January 27th, 2022|clinical, treatment|Comments Off

Are Young Women at Higher Risk of Ischemic Stroke Than Their Male Counterparts?

Csilla Manoczki, MD

Leppert MH, Burke JF, Lisabeth LD, Madsen TE, Kleindorfer DO, Sillau S, Schwamm LH, Daugherty SL, Bradley CJ, Ho PM, Poisson SN. Systematic Review of Sex Differences in Ischemic Strokes Among Young Adults: Are Young Women Disproportionately at Risk? Stroke. 2022;53:319–327.

Historically, stroke epidemiological studies have reported a higher rate of incident strokes in men than women, regardless of age. In the last decade, increasing evidence suggest that there may be more complexity to this “gender gap”, including a shift towards increased incidence of ischemic strokes in younger women.

In this systematic review of 16 population-based studies with nearly 70,000 patients included between 2008 and 2021, stroke incidence rate ratios for women/men in adults younger than age 45 years were calculated and standardized for each study. Combined incidence rate ratios were estimated for three age groups (≤35, 35-45, ≤45 years), and by ischemic stroke vs. all stroke types. Overall effect on the estimates was calculated by the study weights based on variability of the incidence rate ratios.

By strokeblog|January 26th, 2022|clinical|Comments Off