American Heart Association

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Ischemic Stroke in Hospitalized COVID-19 Patients: Incidence, Risk Factors, and Outcomes

Melissa Bailey, MD

Sluis WM, Linschoten M, Buijs JE, Biesbroek JM, den Hertog HM, Ribers T, Nieuwkamp DJ, van Houwelingen RC, Dias A, van Uden IWM, et al. Risk, Clinical Course, and Outcome of Ischemic Stroke in Patients Hospitalized With COVID-19: A Multicenter Cohort Study. Stroke. 2021;52:3978–3986.

Stroke occurrence in COVID-19 patients has been widely observed, but our understanding of the incidence and outcomes associated with stroke in those with COVID-19 is still under investigation. The association between COVID-19 and thromboembolic events has been well established, and studies have reported varying incidences of ischemic stroke associated with this disease. However, few studies have analyzed the association between ischemic stroke and other cardiovascular risk factors in those with COVID-19. Sluis and colleagues investigated the incidence, associated risk factors, and outcomes in hospitalized patients in order to add to the growing body of literature regarding stroke and COVID-19.

By |December 8th, 2021|clinical|Comments Off on Ischemic Stroke in Hospitalized COVID-19 Patients: Incidence, Risk Factors, and Outcomes

Article Commentary: “Increased COVID-19 Mortality in People With Previous Cerebrovascular Disease”

Ericka Samantha Teleg, MD

Lazcano U, Cuadrado-Godia E, Grau M, Subirana I, Martinez-Carbonell E, Boher-Massaguer M, Rodríguez-Campello A, Giralt-Steinhauer E, Fernández-Pérez I, Jiménez-Conde J, et al. Increased COVID-19 Mortality in People With Previous Cerebrovascular Disease: A Population-Based Cohort Study. Stroke. 2021.

The COVID-19 pandemic has shaped and changed the diagnostic, treatment, and management landscape in stroke healthcare throughout the world. The authors of this study emphasized several important points in the beginning in defining their research question: Is previous stroke an independent risk factor for mortality after COVID-19?

At the start, COVID-19 had stroke specialists and other health care specialists analyze mortality and risk of cerebrovascular disease in a population-based cohort in a prospective methodology. This is the strength of this article; using a prospective methodology to answer a research question such as theirs is a challenge since the pandemic landscape is continuously evolving. Several other studies utilized hospital cohorts.

By |December 7th, 2021|clinical|Comments Off on Article Commentary: “Increased COVID-19 Mortality in People With Previous Cerebrovascular Disease”

World Stroke Congress: RAISE Session on New Frontiers in Neurocardiology in the 2020s

Sishir Mannava, MD
@sishmannmd

World Stroke Congress
October 28–29, 2021

Neurocardiology: The Neurologist’s Perspective – Dr. Edip Gurol

Dr. Gurol started by discussing the importance of the neurologist classifying stroke etiologies, and ultimately concern for cardioembolic infarct, and the importance of long-term cardiac monitoring in these patients as highlighted by the findings in the CRYSTAL-AF and REVEAL-AF studies. Another important role of neurologists in these patients is stratifying ICH risk if they require anticoagulation (AC). The FDA approved AC for stroke prevention, include warfarin, direct oral antiocoagulants (DOACs), and left atrial appendage closure (LAAC) with WATCHMAN/Amulet devices. Importantly, AC increased intracranial hemorrhage (ICH) risks, and outcomes of AC-associated ICH are extremely poor. High-risk categories include prior brain bleed (of many types), brain microbleeds on MRI (as highlighted in the CROMIS-2 study), white matter disease on MRI, and cognitive/gait problems. AC has been associated with between 5-7x the risk of ICH as compared to antiplatelets (AP). In a recent trial from the UK, which randomized patients to AC vs AP after spontaneous ICH, 8% (AC) as opposed to 4% (AP) had recurrent ICH. Mortality of AC-related ICH is very high, ~50%. Having a prior history of ICH related to hypertension < mixed-ICH < cerebral amyloid angiopathy ICH significantly increases recurrent ICH risk as well. This concept also applies to patients who have independent evidence of lobar microbleeds. Interestingly, Dr. Gurol highlighted a 2019 study from Neurology that showed moderate/severe white matter hyperintensities were associated with ~6% increased risk of ICH if given AC (Marti-Fabregas et al). Regarding LAAC in nonvalvular atrial fibrillation, the PRAGUE-17 trial showed that stroke prevention and bleeding risks were similar when comparing closure to DOACs. Dr. Gurol closed with discussion of patent foramen ovale (PFO) closure for stroke prevention, highlighting that hypercoagulable states and other causes should be evaluated prior to PFO closure. Ultimately, all decision-making regarding AC or device placement (LAAC, PFO) should be shared with the patient.

By |December 6th, 2021|clinical, Conference|Comments Off on World Stroke Congress: RAISE Session on New Frontiers in Neurocardiology in the 2020s

Declining Treatment Gaps in the United States

Sohei Yoshimura, MD, PhD
@sohei_y

Otite FO, Saini V, Sur NB, Patel S, Sharma R, Akano EO, Anikpezie N, Albright K, Schmidt E, Hoffman H, et al. Ten-Year Trend in Age, Sex, and Racial Disparity in tPA (Alteplase) and Thrombectomy Use Following Stroke in the United States. Stroke. 2021;52:2562-2570. 

Stroke is a common disease, but there have been reports of common stroke treatment disparities related to several factors, such as age, gender, and race. This study evaluated national trends in age-, sex-, and race-specific use of IV tPA and mechanical thrombectomy (MT), the most important quality indicators for standardized stroke treatment. The data was obtained from National Inpatients Samples (NIS), the largest publicly available inpatient healthcare database in the United States.  The authors used ICD-9-CM and ICD-10-MC/procedure coding system to identify exposures and outcomes. This study revealed that the overall frequency of IV tPA and MT utilization in the U.S. increased in all age, sex, and race groups over the last decade. The pace of the increase was more pronounced in ≥80 year old patients and in Black and Hispanic patients, leading to a decline in age- and race-associated treatment gaps over time. The faster increase of IV rPA usage in women also led to narrowing of sex-related treatment gaps.

By |November 29th, 2021|clinical|Comments Off on Declining Treatment Gaps in the United States

Article Commentary: “Demographic Disparities in Proximity to Certified Stroke Care in the United States”

Parth Upadhyaya, DO

Yu CY, Blaine T, Panagos PD, Kansagra AP. Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke. 2021;52:2571–2579.

In recent years, the widened net for time-dependent interventions of acute stroke finds a counterpoint with irregular geographic distribution of capable certified stroke centers. With this comes unequal access for varied demographics. The authors aim to identify these gaps to better focus resources on disparities as stroke care continues to evolve.

By using United States Census Bureau data, the authors first determined the location of population density centroids of each census tract (U.S. Census Bureau) and the three nearest certified stroke centers by linear distance. The shortest road distance designated the nearest stroke center to each given census tract. Age, race, ethnicity, insurance status and income for each census tract, in addition to urban versus nonurban location, were identified in relation to stroke centers. Urban was defined by population density of 1000 people per square mile with a minimum of 2,500 people. By creating a hypothetical urban and nonurban reference tract, confounding factors were controlled, and before-mentioned characteristics elucidated.

By |November 24th, 2021|clinical|Comments Off on Article Commentary: “Demographic Disparities in Proximity to Certified Stroke Care in the United States”

Racial Discrepancy in Blood Pressure Control

Nurose Karim, MD

Akinyelure OP, Jaeger BC, Moore TL, Hubbard D, Oparil S, Howard VJ, Howard G, Buie JN, Magwood GS, Adams RJ, et al. Racial Differences in Blood Pressure Control Following Stroke: The REGARDS Study. Stroke. 2021.

Hypertension (HTN) is defined as systolic blood pressure (SBP) >140 mm Hg and diastolic blood pressure (DBP) >90 mm Hg in patients without prior stroke. It is one of the leading causes of primary and recurrent strokes. HTN is the third leading cause of death in women and fifth leading cause in men. As it is one of the modifiable risk factors for future strokes, in 2017, the American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline set a lower BP target, SBP/DBP <130/80 mm Hg for patients with prior stroke. This study examines racial differences in BP control following a stroke using the 2017 ACC/AHA BP guideline thresholds and utilizing the data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. This study reviewed participants taking antihypertensive medication who did (n=306) and did not (n=7,693) experience an adjudicated stroke between baseline (2003-2007) and a second study visit (2013-2016).

By |November 23rd, 2021|clinical|Comments Off on Racial Discrepancy in Blood Pressure Control

Article Commentary: “Impact of Delirium on Outcomes After Intracerebral Hemorrhage”

Hannah Roeder, MD, MPH

Reznik ME, Margolis SA, Mahta A, Wendell LC, Thompson BB, Stretz C, Rudolph JL, Boukrina O, Barrett AM, Daiello LA, et al. Impact of Delirium on Outcomes After Intracerebral Hemorrhage. Stroke. 2021.

Delirium is defined by DSM-5 criteria as a change in functional status marked by disturbances in attention and awareness, which develop acutely, fluctuate, and are due to an underlying toxic or medical condition. Delirium frequently affects patients hospitalized with stroke. Its occurrence is associated with worse outcomes; however, there is no effective treatment. In the absence of effective treatment, can we still improve functional outcomes among stroke patients who develop delirium?

In the current study, Reznik and colleagues aim to define the extent of in-hospital delirium following intracerebral hemorrhage (ICH) and identify direct and indirect impacts on patient outcomes. In developing their hypotheses, they recognized that delirium may influence prognostication, intensity of care, and rehabilitation of neurocritical care patients. The authors explored several hypotheses, including that delirium portends worse outcomes, that delirium leads to lower likelihood of discharge to an inpatient rehabilitation facility (IRF), and that discharge disposition mediates poor outcomes. They also explored differences based on whether delirium resolves or persists at hospital discharge.

By |November 22nd, 2021|clinical, outcomes|Comments Off on Article Commentary: “Impact of Delirium on Outcomes After Intracerebral Hemorrhage”

AHA Scientific Sessions: “Updates in Stroke: Careers & Future Directions in Vascular Neurology”

Meghana Srinivas, MD

AHA Scientific Sessions 2021
November 13–15, 2021

Session: “Updates in Stroke: Careers & Future Directions in Vascular Neurology”
Panelists:
Drs. Anjail Sharrief, Ashutosh Jadhav, Louise McCullough, Alicia Zhao

This session kickstarted by highlighting the timeline to consider a career path as a neurology trainee and why it is important to do a fellowship. In current times, there is rapid growth in the field of medicine, and with this, there is an increased demand to have specialists, and hence choosing a fellowship is important. The panelists discussed extensively a career in vascular neurology and why we need more vascular neurologists in practice. There was a shocking revelation showing the dearth of vascular neurologists as compared to our counterparts, cardiologists. The ratio of graduating stroke neurologists to that of cardiologists is ~1:10; however, the disease burden is not proportionate. Why is this? A part of this could be attributed to the amount of exposure we get in acute stroke management during our training as residents, making us comfortable to manage these patients and hence inclined towards either an inpatient or outpatient setting without a formal fellowship. But wait, there is more to it: The panelists gave us an insight into poststroke care and management, which is also equally important. They discussed in detail patient care both in acute and in the post-discharge period, emphasizing that a fellowship is important, as it gives you an opportunity for continuity of care even at the community level.

By |November 19th, 2021|clinical, Conference|Comments Off on AHA Scientific Sessions: “Updates in Stroke: Careers & Future Directions in Vascular Neurology”

Are NIHSS Score and Age More Than Just Numbers?

Meghana Srinivas, MD
@SrinivasMeghana

Bres-Bullrich M, Fridman S, Sposato LA. Relative Effect of Stroke Severity and Age on Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke. Stroke. 2021;52:2846–2848.

In this article by Maria Bres-Bullrich et al., the authors discuss the utilization of prognostic tools in determining functional outcomes in patients with acute ischemic due to an anterior circulation large vessel occlusion (LVO) with or without mechanical thrombectomy (MT). Mechanical thrombectomy (MT) is the standard of care for patients presenting with anterior circulation LVO. However, not all patients who receive MT benefit in a similar way. Stroke severity and age, which are readily available, are strong determinants of outcomes in patients receiving MT in clinical trials, and they heavily influence the decision to perform MT. However, there is a possible discrepancy between observational studies and clinical trials, with the former showing older age group (≥80 years) is associated with lower likelihood of shift to better outcomes and higher rates of death. In real-world practice, the interplay between stroke severity and age, as well as the relative weight of each variable on outcomes, are poorly understood.

By |November 18th, 2021|clinical, outcomes, prognosis|Comments Off on Are NIHSS Score and Age More Than Just Numbers?

CHIP and Stroke: Risk for Cerebrovascular Diseases Dwells in the Bone Marrow

Aurora Semerano, MD
@semerano_aurora

Bhattacharya R, Zekavat SM, Haessler J, Fornage M, Raffield L, Uddin MM, Bick AG, Niroula A, Yu B, Gibson C, et al. Clonal Hematopoiesis Is Associated With Higher Risk of Stroke. Stroke. 2021.

Clonal hematopoiesis of indeterminate potential (CHIP) consists of a clonal expansion of circulating blood cells that arises from somatic mutations in hematopoietic stem cells. This condition usually does not entail abnormal blood cell counts and is common in older individuals, since it has been detected by DNA sequencing in >10% of people aged 70+ years. While carrying a relatively modest risk of developing hematological malignancy, from 2014 onwards CHIP has been unexpectedly and increasingly recognized as an independent, non-traditional risk factor for cardiovascular diseases and atherosclerosis, underlying the important interplay between aging, inflammation, and cardiovascular health. Interestingly, CHIP is determined by mutations in a handful of genes, which are currently under active investigations in experimental models. For example, accelerated atherosclerosis and increased release of inflammatory cytokines have been found in mice that bear TET2-deficient leukocytes. The relationship between CHIP and stroke risk was first reported in 2014 by Jaiswal et al.1 Indeed, by analyzing two cohorts of ~3000 patients, the presence of a somatic mutation was associated with an increased risk of ischemic stroke with a hazard ratio of 2.6 (95% CI, 1.4 to 4.8).

In the article by Bhattacharya et al. recently published in Stroke, the authors aimed at expanding the knowledge about the association between CHIP and risk of cerebrovascular events, taking into account both ischemic and hemorrhagic strokes, as well as stroke etiology. A total of 86,178 individuals from 8 prospective cohorts or biobanks were included. The overall prevalence of CHIP at baseline was 6%. CHIP was associated with an increased risk of total stroke (hazard ratio, 1.14; 95% CI, 1.03–1.27). Unexpectedly, this relationship was primarily driven by a 24% increased odds of hemorrhagic stroke, particularly subarachnoid hemorrhage. Though CHIP was not found to be associated with ischemic stroke overall, in exploratory analyses from one female patient cohort, CHIP was more strongly associated with small vessel disease than with large artery atherosclerosis or cardioembolic etiologies. When analyzing mutations in specific CHIP genes, TET2 showed the strongest association with total stroke and ischemic stroke, whereas DMNT3A and TET2 were each associated with increased risk of hemorrhagic stroke.

By |November 17th, 2021|clinical, Conference|Comments Off on CHIP and Stroke: Risk for Cerebrovascular Diseases Dwells in the Bone Marrow