American Heart Association

prognosis

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.

Long-Term Sex Differences After TIA Presentation: An Opportunity for Diagnosis and Treatment

Walter Valesky, MD

Purroy F, Vicente-Pascual M, Arque G, Baraldes-Rovira M, Begue R, Gallego Y, Gil MI, Gil-Villar MP, Mauri G, Quilez A, et al.  Sex-Related Differences in Clinical Features, Neuroimaging, and Long-Term Prognosis After Transient Ischemic Attack. Stroke. 2021;52:424–433.

Stroke affects more women than men. This gender preponderance has been attributed to longevity of women, putting them at higher risk of stroke. The gender differences are poorly reported in the literature for transient ischemic attack (TIA). The few studies that have addressed the gender differences in TIA have mainly focused on presentation nuances between men and women, initial management, and stroke recurrence rates of up to 1 year.1-2 Purroy et al. attempt to give greater insight into this issue by following a cohort of patients diagnosed with TIA for up to 10 years.

The authors analyzed data on 723 consecutive patients with TIA presenting to the emergency department after exclusion of mimics. These patients were admitted to the neurology service with a median ABCD2 score of 5. TIA was defined as transient neurologic deficits lasting less than 24 hours. Approximately 40% of these patients underwent imaging that was diffusion-weighted imaging (DWI) positive on MRI within 7 days of symptom onset. The diagnostic evaluation for stroke was notable in that extra- and intracranial ultrasound was utilized for vascular imaging rather than CTA or MRA. The primary outcome was recurrent ischemic stroke defined by new neurological symptoms associated with changes on neuroimaging. 

ESO-WSO 2020: Prognosis After Acute Stroke Interventions

Aurora Semerano, MD
@semerano_aurora

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020
Session: Scientific Communications 16: Prognosis After Acute Stroke Interventions

Revascularization therapies, including intravenous thrombolysis and endovascular thrombectomy, have shown to reduce mortality and disability after stroke in randomized clinical trials, as well as in the real world. However, even when the revascularization treatment is effective, a significant amount of patients experiences poor outcome. Investigating the mechanisms and the predictors of poor prognosis despite acute stroke interventions was the goal of the 8 lectures of this interesting session, chaired by Prof. Mike Charma from Canada and Prof. Else C. Sandset from Norway.

Dr. Chen Chen, from China, illustrated her work aimed at determining patient characteristics of Asian and non-Asian patients with acute ischemic stroke included in the ENCHANTED study: Compared to non-Asian patients, Asian patients were at increased risk of hemorrhagic transformation and neurologic deterioration during hospitalization after thrombolysis treatment, potentially suggesting that distinctive monitoring for complications is needed in subgroups of patients after acute stroke intervention.

Normal-Appearing White Matter – It’s Not What It Looks Like

Charlotte Zerna, MD, MSc
@CharlotteZerna

Sagnier S, Catheline G, Dilharreguy B, Linck P-A, Coupé P, Munsch F, et al. Normal-Appearing White Matter Integrity Is a Predictor of Outcome After Ischemic Stroke. Stroke. 2020;51:449–456.

The relationship between normal-appearing white matter (NAWM) integrity and specific brain functions has been reported during aging and in patients with cerebral small vessel disease, suggesting that it might be a relevant area of cerebral plasticity. In this study, the authors wanted to evaluate the predictive value of NAWM integrity on different domains of post-stroke recovery.

Through the Brain Before Stroke study undertaken by the Bordeaux University Hospital, eligible patients (>18 years, ischemic supratentorial stroke diagnoses within 24 to 72 hours after symptom onset, NIHSS between 1-25, in the absence of pre-stroke dementia and pre-stroke disability (mRS ≥1)) were prospectively and consecutively recruited between June 2012 and February 2015.

Clinical and Radiographic Predictors of Mortality After Intracerebral Hemorrhage

Elizabeth M. Aradine, DO

Fallenius M, Skrifvars MB, Reinikainen M, Bendel S, Curtze S, Sibolt G, et al. Spontaneous Intracerebral Hemorrhage: Factors Predicting Long-Term Mortality After Intensive Care. Stroke. 2019;50:2336-2343.

High mortality from a large spontaneous intracerebral hemorrhage (ICH) is somewhat intuitive, but whether this holds true months after the event is not well known. The authors sought to better elucidate this in “Spontaneous Intracerebral Hemorrhage: Factors Predicting Long-Term Mortality After Intensive Care.” This multicenter retrospective study included all adults admitted to the ICU in Finland from 2003 to 2013 with spontaneous ICH. Demographics and clinical data including age, admission GCS, anticoagulation use, and chronic medical comorbidities were recorded. A CT scan was required to evaluate the hemorrhage location and were categorized as supratentorial superficial, supratentorial deep, brainstem, and cerebellum. The volume of hemorrhage was calculated using the ABC/2 formula, which incorporates length, width, and shape of hemorrhage, as well as CT slice thickness and number of slices where hemorrhage is present. Three models (clinical, radiographic, and combined clinical and radiographic) were used to evaluate the predictability of mortality from ICH. Patients were followed for 12 months.

New Scoring System Proposed to Better Predict Outcomes for Ruptured Aneurysm Microsurgery

Kara Jo Swafford, MD

Ban VS, El Ahmadieh TY, Aoun SG, Plitt AR, Lyon KA, Eddleman C, et al. Prediction of Outcomes for Ruptured Aneurysm Surgery: The Southwestern Aneurysm Severity Index. Stroke. 2019;50:595–601.

Aneurysmal subarachnoid hemorrhage (SAH) accounts for 80% of nontraumatic SAH and is associated with high morbidity and mortality. Severity grading scales have been created, including the Hunt and Hess scale, which predict outcomes independent of treatment. Prognosis following microsurgical intervention not only depends on clinical presentation, but also aneurysm anatomy and comorbidities. The Southwestern Aneurysm Severity Index (SASI) was created to risk stratify patients with ruptured aneurysms for microsurgical treatment. SASI components include clinical features, imaging findings, aneurysm characteristics and re-operation.