American Heart Association

outcomes

Article Commentary: “Association of Intraventricular Fibrinolysis With Clinical Outcomes in ICH”

Ericka Samantha Teleg, MD

Kuramatsu JB, Gerner ST, Ziai WC, Bardutzky J, Sembill JA, Sprügel MI, Mrochen A, Kölbl K, Ram M, Avadhani R, et al. Association of Intraventricular Fibrinolysis With Clinical Outcomes in ICH: An Individual Participant Data Meta-Analysis. Stroke. 2022.

This meta-analysis examines the utilization of intraventricular fibrinolysis (IVF) and its impact on clinical outcomes in intracerebral hemorrhage. Despite several studies showing intraventricular clot resolution and safety among an intracerebral hemorrhage (ICH) population with a small hematoma volume but larger intraventricular hemorrhage volumes, the primary efficacy analyses for functional outcomes were neutral. Thus, tailoring clinical selection of patients that may benefit from IVF may determine functional benefit.

The statistical method that the authors have utilized to summarize data from several trials and observational data is crucial, as this kind of method used in meta-analysis preserves the clustering of the cohorts of patients from the different studies. This method also allows a large sample to be studied. This is the strength of the data and its results. The Individual Participant Data meta-analysis included 9 studies. The IPD set was compiled and analyzed in an academic center, University Hospital Erlangen in Germany. The eligibility for IPD inclusion included the following: (1) supratentorial primary ICH or IVH with IVH causing acute hydrocephalus treated with an external ventricular drainage (EVD); (2) patients aged >18 years; (3) pre-morbid modified Rankin Scale (mRS) < 3; (4) >10 patients treated with IVF within each study framework; (5) no evidence of early care limitations or death within 48 hours after admission; (6) no evidence of secondary ICH-etiologies; (7) no other competing treatment intervention; (8) use of validated imaging methods; (9) standardized scoring of neurological status; (10) availability of standardized functional outcome assessed by the mRS. 

By |June 22nd, 2022|clinical, hemorrhage, outcomes|Comments Off on Article Commentary: “Association of Intraventricular Fibrinolysis With Clinical Outcomes in ICH”

Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”

Hannah Roeder, MD, MPH

Hahn M, Gröschel S, Hayani E, Brockmann MA, Muthuraman M, Gröschel K, Uphaus T, on behalf of the German Stroke Registry—Endovascular Treatment (GSR-ET) Study Group. Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy. Stroke. 2022.

For working-age stroke patients, returning to work (RTW) is a yardstick for functional recovery and is associated with improved well-being. Patients who suffer large vessel occlusion (LVO) are at greater risk for persistent neurological deficits; however, in the mechanical thrombectomy era, even patients with LVO may have a favorable outcome allowing RTW. Hahn and colleagues used data from the German Stroke Registry Endovascular Treatment (GSR-ET) to explore the likelihood and predictive factors for RTW with particular attention to sex differences.

The investigators included patients in the GSR-ET who were known to be employed prior to their stroke and were less than 65 years of age (the retirement age in Germany), and excluded patients who did not receive thrombectomy or were deceased by day 90. After application of inclusion/exclusion criteria, about one-tenth of patients in the GSR-ET were eligible (606 out of 6635). Of eligible patients, 35.6% (216) were re-employed at 3 months post-stroke.

By |April 25th, 2022|clinical, outcomes, prognosis|Comments Off on Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”

POST-NIHSS and Posterior Circulation Strokes

Kevin O’Connor, MD

Alemseged F, Rocco A, Arba F, Schwabova JP, Wu T, Cavicchia L, Ng F, Ng JL, Zhao H, Williams C, et al. Posterior National Institutes of Health Stroke Scale Improves Prognostic Accuracy in Posterior Circulation Stroke. Stroke. 2021.

The NIH Stroke Scale (NIHSS) is an indispensable part of acute stroke evaluations, but its components focus more on anterior circulation deficits than posterior circulation deficits. Alemseged et al. developed the POST-NIHSS to augment the NIHSS with additional posterior circulation deficits based on retrospective analysis of 202 patients with clinical and radiographic evidence of posterior circulation stroke and NIHSS score <10 who did not undergo mechanical thrombectomy from the Basilar Artery Treatment and Management registry. They then validated their POST-NIHSS with 65 prospectively recruited patients.

Clinical features of posterior circulation strokes may include gait/truncal ataxia, diplopia, ptosis, nystagmus, internuclear ophthalmoplegia, vertical gaze impairment, Horner syndrome, palatal palsy, tongue deviation, and abnormal cough. The retrospective analysis identified gait/truncal ataxia (OR, 3.14 [95% CI, 1.24–7.92], P=0.02), dysphagia (OR, 5.22 [95% CI, 1.63–16.7], P=0.005), and abnormal cough (OR, 8.17 [95% CI, 1.49–44.8], P=0.02) as significantly associated with poor outcome. To the standard NIHSS, the POST-NIHSS adds 3 points for gait/truncal ataxia when assessing item 7 and a new item 12 to assess for abnormal cough (5 points) and dysphagia (4 points). In a ROC analysis for age-adjusted poor outcome, POST-NIHSS performed better than NIHSS (POST-NIHSS AUC, 0.80 [95% CI, 0.73–0.87] versus NIHSS AUC, 0.73 [95% CI, 0.64–0.83]). In a subgroup sensitivity analysis of 156 of the 202 patients with NIHSS 0-5 (77%), POST-NIHSS remained associated with age-adjusted poor outcome (OR, 1.40 [95% CI, 1.14–1.70], P=0.01) while NIHSS was not (OR, 1.12 [95% CI, 0.82–1.56], P=0.46).

By |April 4th, 2022|clinical, outcomes, prognosis|Comments Off on POST-NIHSS and Posterior Circulation Strokes

Mortality and Pediatric Stroke

Kevin O’Connor, MD

Sundelin HEK, Walås A, Söderling J, Bang P, Ludvigsson JF. Long-Term Mortality in Children With Ischemic Stroke: A Nationwide Register-Based Cohort Study. Stroke. 2021.

Having recently explored post-stroke epilepsy in children, Sundelin et al. now examine mortality following pediatric stroke (<18 years of age). They identified children who had an ischemic stroke (n=1,327) along with matched controls (n=13,269) using several registers of the Swedish population (1969-2016). Of the 1,327 pediatric strokes, 343 (25.8%) were perinatal strokes and 984 were (74.2%) ischemic, which also included cerebral venous sinus thrombosis (CVST) as it could not be differentiated from ischemic stroke in the registers.

Pediatric ischemic stroke was associated with increased mortality beyond one week of follow-up from stroke (HR=10.8 [95% CI, 8.1–14.3]). Mortality remained increased past one year (HR=7.7 [95% CI, 5.6–10.7]) and past 20 years (HR=3.9 [95% CI, 2.1–7.1]). The highest risk for mortality was between one week and 6 months (HR=43.3 [95% CI, 17.8–105.3]). Overall mortality risk was elevated for both perinatal stroke (≤28 days; HR=7.0 [95% CI, 3.4–14.7]) and childhood stroke (>28 days of age; HR=11.6 [95% CI, 8.5–15.8]) without a statistically significant difference between the two. Notably, females (HR=16.7 [95% CI, 10.2–27.4]) had a statistically significant (P=0.03) higher mortality risk than males (HR=8.5 [95% CI, 6.0–12.1]).

By |January 20th, 2022|clinical, outcomes, prognosis|Comments Off on Mortality and Pediatric Stroke

Real-World Experience of Mechanical Thrombectomy in Patients With Pre-Stroke Disability

Ammad Mahmood, MBChB
@AMahmoodNeuro

Millán M, Ramos-Pachón A, Dorado L, Bustamante A, Hernández-Pérez M, Rodríg uez-Esparragoza L, Gomis M, Remollo S, Castaño C, Werner M, et al., and on behalf of the Cat-SCR Consortium. Predictors of Functional Outcome After Thrombectomy in Patients With Prestroke Disability in Clinical Practice. Stroke. 2021.

Major clinical trials generally exclude patients with pre-stroke disability, generally defined as pre-stroke modified Rankin scale (mRS) of ≥2 or 3. Accordingly, thrombectomy guidelines [1, 2] state the benefit of mechanical thrombectomy (MT) for patients with pre-stroke disability is less clear, particularly for those aged >80. Patients with pre-stroke disability are routinely considered for MT particularly when other clinical and radiological factors are favorable, such as early presentation or good ASPECTS score. In this registry-based study, patients with mRS of 2 or 3 who underwent MT in the Catalonia stroke network were examined to assess any association between pre-stroke disability and outcomes, as well as aiming to identify factors predictive of favorable outcome for patients with pre-stroke disability. A favorable outcome in this context was defined as a return to baseline mRS at 90 days.

By |December 17th, 2021|clinical, outcomes, prognosis|Comments Off on Real-World Experience of Mechanical Thrombectomy in Patients With Pre-Stroke Disability

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”

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?

Article Commentary: “d-dimer Level as a Predictor of Recurrent Stroke in Patients With Embolic Stroke of Undetermined Source”

Meghana Srinivas, MD
@SrinivasMeghana

Choi KH, Kim JH, Kim JM, Kang KW, Lee C, Kim JT, Choi SM, Park MS, Cho KH. d-dimer Level as a Predictor of Recurrent Stroke in Patients With Embolic Stroke of Undetermined Source. Stroke. 2021;52:2292–2301.

Embolic stroke of underdetermined source is used to identify patients with nonlacunar embolic cryptogenic strokes with a more restrictive inclusion criteria for strokes of cryptogenic origin and complete diagnostic workup in comparison to classic cryptogenic strokes.

Patients with a diagnosis of ESUS at the time of their index stroke carry a high risk of recurrent strokes, which is approximately twice as compared to cryptogenic stroke other than ESUS. Given this incidence, it is important to identify the underlying mechanism and cause of strokes for secondary stroke prevention. Although the most common mechanism in ESUS is embolism with covert atrial fibrillation being the most common cause, recent randomized control trials have shown that non-vitamin antagonist oral anticoagulants (OACs) are not superior to aspirin in preventing recurrence of strokes in patients with ESUS. This can be explained by the heterogeneity among the potential causes of ESUS, which can be covert AF and hidden malignancy to patients with ipsilateral carotid stenosis of less than 50% and aortic arch atherosclerosis. As in the name, it is unknown at least at the time of initial presentation. It is important to identify factors which can predict the risk of recurrent stroke in patients with ESUS and use the right secondary preventative measures.

By |November 3rd, 2021|clinical, outcomes, prognosis|Comments Off on Article Commentary: “d-dimer Level as a Predictor of Recurrent Stroke in Patients With Embolic Stroke of Undetermined Source”

Post-Stroke Epilepsy in Children

Kevin O’Connor, M.D.

Sundelin HEK, Tomson T, Zelano J, Söderling J, Bang P, Ludvigsson JF. Pediatric Ischemic Stroke and Epilepsy: A Nationwide Cohort Study. Stroke. 2021.

Post-stroke epilepsy is a well-known entity, particularly in adults. To explore post-stroke epilepsy in children, Sundelin et al. used the Swedish National Registers to identify 1220 children with ischemic stroke (including cerebral venous sinus thrombosis, which could not be differentiated in the Register) and 12155 comparators between 1969-2016; they excluded patients with previously known epilepsy.

Of the 1220 children with ischemic stroke, 219 (18%) developed post-stroke epilepsy compared to 91 comparators (0.7%). The epilepsy risk was highest in the six months following stroke (HR, 119.4 [95% CI, 48.0–297.4]) and remained elevated even at 20 years post-stroke (HR, 7.9 [95% CI, 3.3–19.0]). The cumulative incidence of post-stroke epilepsy increased with longer follow-up periods: 11.9% at 5 years (95% CI, 10.1%–14.0%), 21.6% (95% CI, 19.0%–24.6%), and 26.4% at 30 years (95% CI, 23.0%–30.1%).

By |November 1st, 2021|clinical, outcomes, prognosis|Comments Off on Post-Stroke Epilepsy in Children

Chasing the D-Dimer Level in Patients With ESUS

Muhammad Rizwan Husain, MD
@RIZWANHUSAINMD

Choi KH, Kim JH, Kim JM, Kang KW, Lee C, Kim JT, Choi SM, Park MS, Cho KH. d-dimer Level as a Predictor of Recurrent Stroke in Patients With Embolic Stroke of Undetermined Source. Stroke. 2021;52:2292–2301.

D-dimer levels are known to be a marker for underlying hypercoagulable state in several studies reporting raised D-dimer levels in patients with cardioembolic stroke, underling malignancy, and venous thromboembolism. However, the role of D-dimer levels to predict recurrent stroke in patients with ESUS (Embolic Stroke of Undetermined Source) is unknown.

The authors in this study evaluated the role of plasma D-dimer levels to help predict recurrent stroke (ischemic or hemorrhagic) within 1 year in patients with ESUS, as well as to evaluate possible etiologies of recurrent strokes based on D-dimer levels.

By |October 25th, 2021|clinical, outcomes, prognosis|Comments Off on Chasing the D-Dimer Level in Patients With ESUS