American Heart Association

prognosis

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.

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.

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.

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%).

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.

Does Concurrent COVID-19 Infection Affect Functional Outcomes of Patients With Acute Ischemic Stroke?

Mona Al Banna, MB BCh, Msc(Res)
@DrMonaAlBanna

Martí-Fàbregas J, Guisado-Alonso D, Delgado-Mederos R, Martínez-Domeño A, Prats-Sánchez L, Guasch-Jiménez M, Cardona P, Núñez-Guillén A, Requena M, Rubiera M, et al. Impact of COVID-19 Infection on the Outcome of Patients With Ischemic Stroke. Stroke. 2021.

Various studies are showing that neurologic complications, including stroke, occur frequently in COVID-19 patients. In addition, the COVID-19 pandemic has compromised the delivery of well-established time-sensitive therapies and system delivery in stroke care. The authors of this study set out to determine whether patients with stroke and COVID-19 had worse functional outcomes compared to patients without COVID-19 and, if so, evaluate whether this was attributable to direct effects of the virus itself or due to logistical difficulties of providing care during a global pandemic.

The authors conduced a prospective multicentered cohort study of 19 hospitals in Catalonia, Spain, from mid-March to May 15, 2020. Patients were eligible if they had an acute ischemic stroke with a previous modified Rankin Scale (mRS) of 0-3. Patients were then classified according to their SARS-CoV-2 PCR status. The authors then collected various data variables, including demographic data, vascular risk factor profiles, pre-admission medications, NIHSS on admission and at 72 hours, imaging data, reperfusion therapies (and, if applicable, TICI scores), time metrics (e.g., door to needle, door to groin), stroke etiology and functional outcome at 3 months.  

Pooled Risk-Benefit Analysis of Long-Term Antiplatelet Therapies for Non-Cardioembolic Transient Ischemic Attack or Stroke

Dixon Yang, MD

Hilkens NA, Algra A, Diener HC, Bath PM, Csiba L, Hacke W, Kappelle LJ, Koudstaal PJ, Leys D, Mas J-L, et al. Balancing Benefits and Risks of Long-Term Antiplatelet Therapy in Noncardioembolic Transient Ischemic Attack or Stroke. Stroke. 2021.

Aspirin monotherapy, aspirin with dipyridamole, and clopidogrel alone are the first-line antithrombotic therapies for long-term secondary prevention of non-cardioembolic stroke and transient ischemic attack (TIA). In clinical practice, we often consider an individual patient’s bleeding risks against potential benefits of reduced ischemic events from these single antiplatelet agents. Assessing risk-benefit by stratification of bleeding risk may help guide clinical decision-making. Therefore, Hilkens et al. sought to investigate the net benefit of antiplatelet treatment according to an individual’s bleeding risk through pooled analysis of six randomized control trials.

The authors pooled individual patient data from CAPRIE, ESPS-2, MATCH, CHARISMA, ESPRIT, and PRoFESS, which investigated antiplatelet therapy in the subacute or chronic phase after non-cardioembolic stroke or TIA. The authors stratified patients into quintiles by their individually calculated S2TOP-BLEED score, derived from sex, smoking, modified Rankin Scale, prior stroke, hypertension, body mass index, age, and diabetes. For each quintile, the authors determined the annual rate of major bleeding and recurrent ischemic events of: 1) aspirin monotherapy; 2) aspirin-clopidogrel versus monotherapy; 3) aspirin-dipyridamole versus clopidogrel; and 4) aspirin versus clopidogrel. In the second, third, and fourth comparisons, the authors calculated net benefit.

Article Commentary: “Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: MaRISS”

Dixon Yang, MD

Romano JG, Gardner H, Campo-Bustillo I, Khan Y, Tai S, Riley N, Smith EE, Sacco RL, Khatri P, Alger HM, et al, on behalf of the MaRISS Investigators. Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: MaRISS. Stroke. 2021;52:1995–2004.

Acute ischemic stroke commonly presents with mild or improving symptoms,1 often defined as minor stroke with NIHSS ≤ 5. Many of these patients are not treated with acute thrombolytic therapy due to exclusion from the landmark NINDS recombinant tissue-type plasminogen activator efficacy trials.2 Despite perceived minor symptoms, many of those hospitalized may be unable to walk independently or return directly to home at discharge.3 Effects of thrombolysis and long-term outcomes in minor stroke are still not well understood. Thus, Romano and colleagues sought to describe multidimensional long-term outcomes in patients with mild ischemic stroke symptoms from MaRISS (Mild and Rapidly Improving Stroke Study).

This prospective observational study recruited sites who participated in Get With The Guidelines-Stroke, had more than 300 annual stroke discharges, and reflected regional and national representation of hospital centers. Eligible MaRISS participants presented within 4.5 hours from stroke symptoms onset, had a brain CT excluding non-ischemic causes, and initial NIHSS of 0-5. Those with pre-morbid disability of mRS ≥2 or with complete resolution of symptoms on initial evaluation were excluded. The primary outcome was an mRS score of 0-1 at 90 days post-event. Secondary outcomes included Barthel Index 95-100 versus <95, Stroke Impact Scale-16 (SIS-16) ≥88.2 versus <88.2, and European Quality of Life 5D-5L 1 versus <1 and its visual analogue scale ≥90 versus <90.

Baseline CT-Perfusion Deficit Performs Well in Basilar Artery Stroke Prognostication

Csilla Manoczki, MD

Fabritius MP, Tiedt S, Puhr-Westerheide D, Grosu S, Maurus S, Schwarze V, Rübenthaler J, Stueckelschweiger L, Ricke J, Liebig T, et al. Computed Tomography Perfusion Deficit Volumes Predict Functional Outcome in Patients With Basilar Artery Occlusion. Stroke. 2021;52:2016–2023.

Automated CT/MRI perfusion imaging has become the gold standard for therapeutic decision-making of anterior circulation ischemic strokes presenting in the extended time window. However, there is no validated imaging selection criteria available for the less frequent, but more challenging cases of posterior circulation infarcts.

In this study, Fabritius et al. investigated the predictive value of various CT imaging parameters in a cohort of patients who had presented with acute ischemic stroke secondary to basilar artery occlusion and received modern endovascular treatment (with or without prior intravenous thrombolysis). Forty-nine eligible patients were identified retrospectively in the German Stroke Registry between June 2015 and December 2019. The standardized imaging protocol consisted of non-contrast CT, single phase CT-angiogram and whole-brain CT perfusion studies.

ISC 2021 Session: Prognostication and Early Withdrawal of Care in Ischemic Stroke and ICH

Melanie R. F. Greenway, MD
@MRFGreenwayMD

International Stroke Conference 2021
March 17–19, 2021
Session: Prognostication and Early Withdrawal of Care in Ischemic Stroke and ICH (116)
Moderators: Aneesh Singhal, MD, and James Meschia, MD
Presenters: Gustavo Saposnik, MD, MPH, PhD, FRCPC; H B Van Der Worp, MD; Claire Creutzfeldt, MD; J Claude Hemphill III, MD, MAS; Wendy Ziai, MD, MPH

Moderated by Dr. Aneesh Singhal from Massachusetts General Hospital and Dr. James Meschia from Mayo Clinic, this session on prognostication in ischemic stroke and intracranial hemorrhage was informative, interactive, and diverse. Topics ranged from accurate prognostication to coaching physicians on important care discussions with patients and families. A must-watch session for those who were unable to watch it live, in my opinion.

Dr. Gustavo Saposnik of St. Michael’s Hospital and the University of Toronto started the session by (painfully) reminding us that poker players and meteorologists are much more accurate in predicting outcomes than physicians. With routine feedback, they are able to refine their practice with data less prone to outcome bias. From there, he took us on a tour of the many validated risk scores available, and their limitations, and encouraged the audience to use risk scores to supplement prognostication rather than “eyeballing” the assessment.