prognosis

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.

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.

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.

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.

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.