American Heart Association

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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
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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 |February 14th, 2022|clinical, Conference, health care, policy|Comments Off on Digital Health in Primordial and Primary Stroke Prevention: Feasible Solution During COVID-19 Pandemic?
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World Stroke Congress: “Stroke in Low to Middle Income Countries”

Ericka Samantha Teleg, MD

World Stroke Congress
October 28–29, 2021

Plenary Session: “Stroke in Low to Middle Income Countries”

While the landscape of stroke changes in terms of innovations, pathways and technology, there is a continuing increase of stroke burden in the low to middle income countries (LMICs). This session was moderated by Dr. Norlinah Ibrahim and Dr. Mayowa Owolabi.

Dr. Owolabi opened the discussion by giving an overview of the Lancet Commission in giving evidence-based recommendations that are pragmatic in nature extending to primary, secondary, and tertiary prevention, keeping in mind that these regions bear a burden due to limited resources. He emphasized the Stroke Quadrangle that includes epidemiological surveillance, acute care, rehabilitation, palliative care, health promotion, and disease prevention. He set the stage by reiterating that there is scarcity of funding for primary stroke prevention, particularly in LMICs. There is indeed an absence of an integrative approach. Regional and national differences in policymaking are also a variable. 

By |November 8th, 2021|clinical, Conference, health care|Comments Off on World Stroke Congress: “Stroke in Low to Middle Income Countries”
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Stroke in the COVID-19 Era

Kevin O’Connor, MD

Katsanos AH, Palaiodimou L, Zand R, Yaghi S, Kamel H, Navi BB, Turc G, Benetou V, Sharma VK, Mavridis D, et al. Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Stroke. 2021.

COVID-19 complicates many aspects of clinical care, including care of stroke patients. Katsanos et al. conducted a meta-analysis on the impact of COVID-19 on the provision of stroke care, independent of SARS-CoV-2 infection status. They collected 46 studies capturing data from 129,491 patients across Africa, Asia, Europe, and the Americas comparing common stroke care variables pre- and post-pandemic onset. These included demographic information, vascular risk factors, intravenous thrombolysis (IVT) administration, endovascular thrombectomy (EVT) performance, relevant time metrics, and hospitalization outcomes.

By |October 12th, 2021|clinical, health care, policy|Comments Off on Stroke in the COVID-19 Era
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A Good Reminder: Adherence to Quality Indicators Associated with Decreased 7-Day Mortality

Melanie R. F. Greenway, MD
@MRFGreenwayMD

Haas K, Rücker V, Hermanek P, Misselwitz B, Berger K, Seidel G, Janssen A, Rode S, Burmeister C, Matthis C, et al. Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke. Stroke. 2020;51:3664–3672.

In the age of checklists, quality metrics, and frequent audits, sometimes the importance of these indicators is taken for granted. Instead of serving as a guiding light for quality care, they may be seen as an annoyance, slowing down an already inefficient system. This study reviewing the association between quality indicators (QI) and outcomes is a good reminder of the importance of tending to these quality indicators. 

This study utilized the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutschprachiger Schlaganfall Register), which is a network of nine stroke registers, comprising multiple regions throughout the country. 388,012 patients with acute ischemic stroke admitted to 736 hospitals were reviewed from 2015-2016. Of the hospitals participating, 55.6% of them had stroke unit services. Overall, 7-day in-hospital mortality was 3.4%, and median length of stay was 8 days. 

By |April 20th, 2021|clinical, health care, policy|1 Comment
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The Road Less Traveled? Reassessing Triage Strategies in Prehospitalized Stroke Patients

Yasmin Aziz, MD

Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke. 2020;51:3310–3319.

Patients with acute large vessel occlusions (LVOs) have better outcomes if they are sent to the endovascular suite expeditiously. Yet, many times these patients are taken to the nearest primary stroke center under the “drip and ship” model.

In this study, the authors used geographic information, census data, and stroke center accreditor information to build an origin to destination matrix analyses of patient location to nearest primary stroke center and to nearest intervention center. To do so, four different triage strategies were compared: (1) always going directly to the nearest primary stroke center, (2) always going directly to an endovascular center; (3) using the current AHA algorithm suggesting direct transfer to endovascular center if driving time is less than 30 minutes when LVO is suspected and won’t preclude tPA administration; (4) using a modified algorithm that would allow for additional driving time if an LVO is suspected if thrombolysis isn’t precluded (adding <30 minutes of driving time, <60 minutes of driving time, or not restricting by driving time at all). 

By |April 5th, 2021|clinical, health care|Comments Off on The Road Less Traveled? Reassessing Triage Strategies in Prehospitalized Stroke Patients
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Another Prehospital Model Favoring Liberal Transport to Thrombectomy Center, But Clinical Trials Still Elusive

Walter Valesky, MD

Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke. 2020;51:3310–3319.

With the increasing importance of endovascular therapy in acute ischemic stroke care, triage and emergency transport strategies have taken on renewed importance. Current recommendations advise preferential transport to a comprehensive stroke center (CSC) if a large vessel occlusion (LVO) is suspected based on prehospital screening and when the total transport time is less than 30 minutes. The study summarized here evaluated alternative triage strategies in comparison with the current American Heart Association (AHA) recommendations.1 

A previously utilized decision-tree model referred to in a prior study2 was used to map outcomes of a suspected LVO to either a primary stroke center (PSC) and then transferred for thrombectomy or directly to an intervention center. A base scenario was applied to the model in which emergency medical services (EMS) was activated for a hypothetical patient with a suspected stroke within 4.5 hours of symptom onset with several time assumptions corresponding to “Get With the Guidelines” recommendations. LVO prevalence was estimated at 20% among suspected stroke patients based on prior studies,2-3 and prehospital assessment applied the rapid arterial occlusion evaluation (RACE) with an assumed sensitivity of 84% and specificity of 60% at a cutoff of 5 points. 

By |March 12th, 2021|clinical, health care|Comments Off on Another Prehospital Model Favoring Liberal Transport to Thrombectomy Center, But Clinical Trials Still Elusive
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COVID-19 Pandemic Disrupts Acute Stroke Care

Tyler Owens, DO

Montaner J, Barragán-Prieto A, Pérez-Sánchez S, Escudero-Martínez I, Moniche F, Sánchez-Miura JA, Ruiz-Bayo L, González A. Break in the Stroke Chain of Survival due to COVID-19. Stroke. 2020;51:2307–2314.

How has the COVID-19 pandemic affected our modern systems of acute stroke care? Montaner et al. performed a descriptive analysis before and during the current COVID-19 era, giving a glimpse into how the pandemic can negatively affect acute stroke care. The study was done in a southern region of Spain. Key metrics in the study were taken from pre-hospital and hospital acute care.

Data was collected from a region comprised of 2 stroke units and 2 large hospitals. One of the hospitals served as a thrombectomy referral center and the other as a tele-stroke referral center for several community hospitals. Data for the study was collected from an ongoing stroke registry. The study samples included 41 thrombectomies, 32 tele-stroke consults, and 51 patients treated with thrombolysis therapy. The bulk of the analyses focused on data 15 days prior to the outbreak to 15 days after (March 31, 2020).

By |February 11th, 2021|clinical, health care|Comments Off on COVID-19 Pandemic Disrupts Acute Stroke Care
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Article Commentary: “Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era”

Burton J. Tabaac, MD
@burtontabaac

Diegoli H, Magalhães PSC, Martins SCO, Moro CHC, França PHC, Safanelli J, Nagel, V, Venancio VG, Liberato RB, Longo AL. Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era. Stroke. 2020.

On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic. As of this writing, the global number of cases exceeds 8.1 million. However, despite the rapidly increasing prevalence of COVID-19, many questions remain regarding this unusual and highly lethal disease. The pathogenesis of COVID-19–associated neurologic injury remains to be established. SARS-CoV-2 has been shown to induce a hypercoagulable state, thus increasing the risk of arterial thrombosis with acute ischemic stroke.(1)

From late 2019 to early 2020, COVID-19 started to disrupt the healthcare systems of many nations. From the beginning of the pandemic, it has been a major concern for doctors and public authorities that resources needed to treat other conditions such as stroke are diverted for COVID-19.(2) The authors are keen to note that “patients may be unwilling to go to a hospital for stroke treatment due to fear of becoming contaminated with the disease.” Using a population-based stroke registry, the authors of this original contribution investigated the impact of the onset of the COVID-19 pandemic on stroke admissions in Joinville, Brazil. The authors’ hypotheses were as follows: First, hospital admissions for stroke were reduced after the onset of the COVID-19 pandemic. Next, the reduction occurred only in transient ischemic attacks (TIA) and mild cases. Also, there was a change in the time between stroke onset and hospital admissions. Finally, the number of patients receiving reperfusion therapies (IVT and MT) has decreased.

By |June 19th, 2020|clinical, health care, outcomes, policy|Comments Off on Article Commentary: “Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era”
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Endovascular Thrombectomy With Improved Reperfusion Leads to Long-Term Public Health and Societal Cost Benefits

Melissa Trotman-Lucas, PhD
@TrolucaM

Kunz WG, Almekhlafi MA, Menon BK, Saver JL, Hunink MG, Dippel DWJ, et al. Public Health and Cost Benefits of Successful Reperfusion After Thrombectomy for Stroke. Stroke. 2020;51:899–907.

The number of deaths due to stroke is 10 million per year globally, with a prevalence of 42 million. Large vessel occlusions (LVO) account for a third of all occlusive ischemic strokes and are the largest contributor to the morbidity and mortality associated with ischemic stroke. The evolution and use of endovascular thrombectomy (EVT) for these patients have transformed stroke treatment and care; clinical trials utilizing EVT demonstrated the benefits of this technique during post-stroke recovery, including reduced disability and improved outcome. In multiple countries, EVT has been adopted as the standard of care for LVO and is recommended for use where possible in other countries — limits come from availability of suitably trained staff and equipment.

By |April 17th, 2020|clinical, health care, outcomes|Comments Off on Endovascular Thrombectomy With Improved Reperfusion Leads to Long-Term Public Health and Societal Cost Benefits
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