American Heart Association


Early Rehab – It leads to better outcomes!

Rajbeer Singh Sangha, MD

Liu N, Cadilhac DA, Andrew NE, Li Z, Li J, et al. Randomized Controlled Trial of Early Rehabilitation After Intracerebral Hemorrhage Stroke: Difference in Outcomes Within 6 Months of Stroke. Stroke. 2014

Current evidence suggests that early physical rehabilitation (VER) of stroke survivors in the acute stage may result in better motor recovery, reduced mental, functional and neurological disability, and improved quality of life. The previous studies that have been conducted regarding this topic have analyzed a small proportion of patients with ICH and there still remains a need for a larger phase three trial. According to the authors, the current general consensus that exists is that patients with ICH should be mobilized later than those with ischemic stroke, despite a lack of evidence to support this view. They aimed to compare Very Early Rehabilitation (VER) with standard care in patients with ICH and hypothesized that VER within 48 hours of ICH onset would result in reduced mortality, morbidity, and better quality of life outcomes compared to standard care at 3- and 6- months following stroke.

The study was a prospective, multi-centre, randomized controlled study, with 2 parallel groups followed for 6-months with blinded assessment of outcomes. Both groups received standard care, but participants in the VER group commenced rehabilitation as soon as practical after randomization but within 48 hours of ICH onset. In contrast, the standard care group commenced rehabilitation after 7 days. Out of 326 patients that were eligible, 243 patients were randomized (mean age 59 years; 56% male). At 6-months, patients receiving standard care were more likely to have died (aHR: 4.44, 95%CI: 1.24, 15.87). Further analysis of the morbidity outcomes showed a 6-point difference in the Physical Component Summary score of the SF-36 (95%CI 4.2, 8.7); a 7-point difference for the Mental Component Summary score (95%CI: 4.5, 9.5); a 13-point difference in Modified Barthel Index scores (95%CI: 6.8, 18.3), and a 6-point difference in SAS scores (95%CI: 4.4, 8.3) was reported in favor of the intervention groups.

The findings in this study point strongly towards ICH patients who were randomized to VER more likely to be alive at 6-months than those who received standard care alone. Patients who received VER also had a shorter length of hospital stay and reported significantly greater quality of life, independence with activities of daily living, and improved mental health outcomes at 6-months following stroke compared to those randomized to standard care. These results are in conjunction with previous smaller trials that have been conducted including the VERITAS trial in the UK and the AVERT phase II trial. While the authors could not account for the exact pathophysiological mechanism that lead to the improved outcomes, it should mean a significant change in the dogma towards rehabilitation in centers that wait for a period of 7 days or greater prior to starting. Further trials should focus on the specific techniques that would improve outcomes in a more efficient manner as well as more sensitive scales of measuring outcomes including the Neuro QOL which is a validated self-reported neurological assessment of quality of life.

By |November 19th, 2014|hemorrhage|1 Comment

Spotting the SPOT sign by using a delayed CT angiogram sequence

It is common knowledge amongst the stroke community that a spot sign seen on a CT angiogram predicts hematoma expansion in patients with Intracerebral hemorrhage (ICH).  Size of the hematoma is an independent predictor of poor outcome and all attempts are made to prevent the increase in size by use of hemostatic medications and blood pressure control. The authors of this study hypothesize that addition of a 90 second delayed CT would help capture additional ICH patients with the spot sign and increase the sensitivity for predicting hematoma expansion and poor outcome. Patients with spontaneous ICH were enrolled prospectively between February 2012 and August 2013 and underwent a non-contrast head CT, immediately followed by CTA of the head with a 90 second delayed acquisition through the hematoma volume.

All CTA studies were independently reviewed by two board-certified radiologists and the spot sign was identified as a focus of contrast pooling within the ICH with an attenuation ≥120 HU that was discontinuous from normal or abnormal vasculature adjacent to the ICH and was of any size and morphology. Hematoma expansion was considered significant if the volume increased by 6ml or by 33% from baseline. A multivariate logistic regression model was utilized to analyze data and sensitivity, specificity and positive/negative predictive values were calculated.

A total of 121 patients were enrolled in the study however only 74 had follow up CT scans and were included in the primary analysis. A total of 15 patients had a positive spot sign detected on any CTA and the overall rate of hematoma expansion was 15%. Hematoma expansion was predominantly seen in the spot sign positive group (47% vs. 7%). Accuracy measures for the spot sign on delayed CTA were: sensitivity 55%, specificity 87%, PPV 43%, NPV 92%, accuracy 82%. When the CT scans for all 121 patients were analyzed the spot sign was seen on 36 scans, with 15 detected exclusively on the delayed 90 second imaging. The presence of a spot sign and high blood glucose levels were independent predictors of mortality in the multivariate logistic regression model. Greater than 95% of these patients with a positive spot sign were dead at follow up.
This study re-enforces that spot sign is a predictor of hematoma expansion and poor outcome. The 90 second sequence is cost effective and time efficient however the numbers in the study are really small. The question arises – are we going to try everything to detect a spot sign? The authors conclude that the delayed 90 second sequence may help select patients eligible hemostatic intervention but we need to ask ourselves if it really changes clinical practice. Although the spot sign is predictive of expansion, it is only seen in a small percent of patients with ICH and a delayed CT has a sensitivity of 55% to detect a spot sign.  If a safe hemostatic medication is available and approved, I wonder if we would be so selective in its use.  Let’s reserve our judgement till the  SPOTLIGHT (spot sign selection of intracerebral hemorrhage to guide hemostatic therapy trial)  is on ICH treatment with hemostatic therapy. 
By |October 28th, 2014|hemorrhage|0 Comments

Characteristics of Intracerebral Hemorrhage in Rivaroxaban vs. Warfarin

Abdel Salam Kaleel, MD, MSc

Hagii J, Tomita H, Metoki N, Saito S, Shiroto H, Hitomi H, et al. Characteristics of Intracerebral Hemorrhage During Rivaroxaban Treatment: Comparison With Those During Warfarin. Stroke. 2014

This study compared the clinical characteristics, neuroradiologic findings, and functional outcomes of patients taking rivaroxaban and patients taking warfarin for nonvalvular atrial fibrillation who subsequently developed intracerebral hemorrhages. In particular, it sought to determine which group had more favorable characteristics after ICH. This study was conducted between April 2011 and October 2013 in the Hirosaki Stroke and Rehabilitation Center and included 585 ICH patients, 5 of whom had ICH while taking rivaroxaban, 56 of whom had ICH while taking warfarin, and 524 of whom had ICH on no anticoagulant therapy. ICH was diagnosed by immediate computed tomography (CT) with a follow up scan at day 2
after admission. The hematoma volume, expansion of hematoma, and extent of cerebral microbleeds were determined in surviving patients; Vitamin K was given for reversal of anticoagulation in patients on warfarin, but no reversal was given for patients previously on rivaroxaban. Scales and scores, namely CHADS2, HAS-BLED, and modified Rankin Scales, were determined on each patient. The differences were then computed by Mann-Whitney U test or Fisher’s exact test. 

Interestingly, patients on rivaroxaban had a smaller hematoma volume while none of them had expansion of hematoma or underwent surgical treatment. Those patients who had been taking warfarin on admission experienced expansion of hematoma in 21% and required surgical treatment in 11%. These findings occurred in the setting of rivaroxaban-treated patients having more cerebral microbleeds than the warfarin-treated group. When comparing the patients with mRS of 0 and 1 before admission, none of the patients in the rivaroxaban group had mRS >4 at discharge, but half of the patients taking warfarin did. Additionally, ten of the warfarin-treated patients died whereas none of the rivaroxaban-treated patients did. While the study did have several limitations, including single-center retrospective analysis and small number of study patients, it did provide valuable comparisons and some insight in characteristics of patients who suffered from ICH while taking warfarin or rivaroxaban.
By |August 20th, 2014|hemorrhage|0 Comments