American Heart Association

prognosis

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.

Outcomes of Anticoagulation for Venous Thrombosis, a Meta-Analysis

Gurmeen Kaur, MBBS
@kaurgurmeen

Aguiar de Souza D, Neto LL, Canhão P, Ferro JM. Recanalization in Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis. Stroke. 2018

With the advent of the endovascular era for ischemic strokes, the role for endovascular therapy for cerebral venous thrombosis (CVT) has been approached with growing interest. However, anticoagulation continues to be the mainstay of treatment for CVT.

In this interesting meta-analysis, de Sousa et al reviewed recanalization rates, clinical outcomes and recurrence rates in patients with CVT.

A total of 468 studies were screened, of which 19 were identified after excluding those studies which had pediatric patients, in which >10% of individuals had endovascular treatment and in whom anticoagulation was not used as part of the post-operative treatment plan.

By |October 1st, 2018|clinical, prognosis|0 Comments

IV-tPA and Mechanical Thrombectomy – A Winning Team

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.

Does tPA Really Save Lives?

Kevin S. Attenhofer, MD

Muruet W, Rudd A, Wolfe C, and Douiri A. Long-Term Survival After Intravenous Thrombolysis for Ischemic Stoke: A Propensity Score-Matched Cohort with up to 10-Year Follow-Up. Stroke. 2018

Although tissue plasminogen activator (tPA) has been approved in the United States for treatment of acute ischemic stroke since the mid-90s, there persists a sharp divide between neurologists and the emergency medicine community regarding the safety and efficacy of tPA. Imbalances between the treatment and control groups in the NINDS tPA study, criticisms of the subjective nature of functional outcome scores, and allegations of conflicts of interest have all contributed to the lingering controversy surrounding tPA. I have personally encountered significant resistance and hostility to IV tPA from other providers over 20 years after its approval. In this article, Muruet et al. add to a growing volume of literature that should help the community neurologist assuage the concerns of fellow providers.

Predicting Blood in the Real World

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.