prognosis

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.

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.

Kevin S. Attenhofer, MD
@KAttenhofer

Ferrigno M, Bricout N, Leys D, Estrade L, Cordonnier C, Personnic T, et al. Intravenous Recombinant Tissue-Type Plasminogen Activator: Influence on Outcome in Anterior Circulation Ischemic Stroke Treated by Mechanical Thrombectomy. Stroke. 2018

2015 was a big year for stroke. For the first time in 20 years, stroke practitioners demonstrated an effective tool in the treatment of acute ischemic stroke. Mechanical thrombectomy (MT) quickly became standard practice. While MT was proposed as an adjunctive therapy for stroke in addition to IV-rtPA (IVT), many of the 2015 trials, as well as the subsequent imaging based trials (DAWN, DEFUSE 3), included patients who did not receive IVT.

The benefit of MT was similar in patients who received IVT and MT compared to MT alone in some trials. This has led some to suggest that MT alone could be a treatment option which maximizes potential benefit while minimizing some of the risks associated with IVT (such as hemorrhage). In fact, I’ve seen non-neurology physicians advocate for MT to replace IVT entirely. Still, others argue that IVT facilitates MT (higher rate of successful recanalization, shorter procedures, and shorter time to recanalization) as well as dissolving distal clots. To date, no randomized controlled trial has compared combination IVT/MT versus MT alone. A recent meta-analysis of the 2015 thrombectomy trials seems to support the latter view: that IVT and MT are complimentary.

Kevin S. Attenhofer, MD

Hilkens NA, Li L, Rothwell PM, Algra A, Greving JP. External Validation of Risk Scores for Major Bleeding in a Population-Based Cohort of Transient Ischemic Attack and Ischemic Stroke Patients. Stroke. 2018

You can’t discuss stroke prevention without talking about antiplatelet drugs. Drugs like Aspirin and Clopidigrel are frequently used by stroke neurologists as the secondary prevention treatment of choice for patients with TIA and non-cardioembolic ischemic strokes. However, we must remember that bleeding is a clinically important and potentially life-threatening side effect of these agents. Reliably predicting who is most likely to bleed would dramatically inform the clinician’s decision-making process and likely result in improved patient outcomes.

To that end, the S₂TOP-BLEED score was derived from patient data from six randomized trials (CAPRIE, ESPS-2, MATCH, CHARISMA, ESPRIT, and PRoFESS). It is a 28-point score that incorporates readily available patient characteristics: Sex, Smoking history, Type of antiplatelet, Outcome (mRS), Prior stroke, Blood pressure, Low BMI, Elderly, Ethnicity, Diabetes. It was validated in the PERFORM trial (Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin Terutroban in Patients with a History of Ischemic Stroke or Transient Ischemic Attack Study). In this paper, Hilkens et al. externally validate the S₂TOP-BLEED score in observational data from a real-world setting.

Neal S. Parikh, MD 
@NealSParikhMD

Tu W, Liu Q, Cao J, Zhao S, Zeng X, Deng A. γ-Glutamyl Transferase as a Risk Factor for All-Cause or Cardiovascular Disease Mortality Among 5912 Ischemic Stroke. Stroke. 2017

In light of an increasing interest in and understanding of the association between liver disease and cerebrovascular disease, Wen-Jun Tu and colleagues sought to explore the association between serum γ-glutamyl transferase (GGT) and post-stroke mortality.

In their well-designed and well-powered prospective, multicenter cohort observational study, the authors enrolled 5,912 patients within 24 hours of acute ischemic stroke. The study was conducted in China. They excluded patients with known hepatobiliary disease and alcohol abuse. Serum GGT level at baseline was the exposure of interest, and patients were followed for a median of 1 year with regular telephone interviews and review of death certificates. The primary outcome was all-cause mortality, and cardiovascular death (including fatal stroke) was separately adjudicated. Men and women were analyzed differently because normative values for GGT are sex-specific.