treatment

Tolga D Dittrich, MD
@to_dittrich

Wagner B, Lorscheider J, Wiencierz A, Blackham K, Psychogios M, Bolliger D, De Marchis GM, Engelter ST, Lyrer P, Wright PR, et al. Endovascular Treatment for Acute Ischemic Stroke With or Without General Anesthesia: A Matched Comparison. Stroke. 2022.

Endovascular treatment (EVT) effectively treats acute ischemic stroke and has gained increasing importance over the last few years. An important peri-procedural question is the choice of anesthesia type, especially whether conscious sedation (CS) is preferable to general anesthesia (GA). The current recommendation is that this decision should be made individually based on patient characteristics (e.g., aspiration risk) and technical feasibility.¹ Based on data from the Swiss Stroke Registry, Wagner and colleagues investigated the influence of anesthesia type on functional outcome at three months in patients receiving EVT for anterior circulation stroke.

Thomas Raphael Meinel, MD
@TotoMynell

Kim BC, Youn YC, Jeong JH, Han HJ, Kim JH, Lee J-H, Park KH, Park KW, Kim E-J, Oh MS, et al. Cilostazol Versus Aspirin on White Matter Changes in Cerebral Small Vessel Disease: A Randomized Controlled Trial. Stroke. 2021.

Small-vessel disease, including manifest stroke, but more frequently covert lesions, is a silent pandemic contributing considerably to dementia, frailty, gait problems and mood disorders worldwide.¹ The imaging spectrum of small-vessel disease includes white matter hyperintensities (WMH), lacunes, acute small subcortical infarcts, cerebral microbleeds and dilated perivascular spaces.²

It is thus of utmost importance that Kim et al. undertook the work to perform a multicenter, double-blind, randomized controlled trial³ on whether cilostazol slow release (200 mg) as compared to aspirin (100 mg) might be able to slow down WMH progression over the follow-up duration of two years. For this trial, Korean patients aged 50-85 with (45%) and without (55%) manifest stroke were recruited from memory clinics or neurology outpatient clinics referred for memory problems, gait disturbances, personality changes or secondary prevention after a small subcortical infarction or TIA between 2013 and 2016. They had to have at least moderately severe WMH and at least one lacune. Exclusion criteria included contraindications to antiplatelets, significant atherosclerosis or cardioembolic heart disease amongst others. The methods included sophisticated brain imaging and neurocognitive assessments.

Vignan Yogendrakumar, MD MSc
@VYogendrakumar

Bala F, Casetta I, Nannoni S, Herlihy D, Goyal M, Fainardi E, Michel P, Thornton J, Power S, Saia V, et al. Sex-Related Differences in Outcomes After Endovascular Treatment of Patients With Late-Window Stroke. Stroke. 2022.

To date, differences in clinical outcomes between males and females undergoing endovascular therapy (EVT) within the early time window have not been observed. Outcome data in the late window (> 6 hours from symptom onset) stratified by sex remains limited. To that effect, Bala and colleagues sought to use data from the SOLSTICE Consortium to investigate potential differences in outcomes between males and females undergoing EVT in the late window.

The SOLSTICE Consortium is an individual-patient level analysis of data from select registries and clinical trials. Patient selection for EVT in the late window was based on collateral or perfusion imaging. Outcomes evaluated in this analysis include functional independence (mRS ≤ 2), mRS shift, mortality at 90 days, and symptomatic intracranial hemorrhage.

Wern Yew Ding, MBChB

Li ZX, Xiong Y, Gu HQ, Fisher M, Xian Y, Johnston SC, Wang YJ. P2Y12 Inhibitors Plus Aspirin Versus Aspirin Alone in Patients With Minor Stroke or High-Risk Transient Ischemic Attack. Stroke. 2021;52:2250–2257.

Patients with ischemic stroke or transient ischaemic attack (TIA) are at risk of further events. Previously, these patients were treated with single antiplatelet therapy. However, contemporary guidelines recommend that dual-antiplatelet therapy (DAPT) may be considered in the acute phase: the duration of treatment depending on stroke severity. Several studies have investigated the use of different DAPT regimens in patients with minor stroke or high-risk TIA.

In this study by Li and colleagues, the authors undertook a systematic review and meta-analysis of 4 randomized controlled trials that included a total of 21493 patients with acute minor stroke (NIHSS score ≤3/≤5) or high-risk TIA (ABCD² ≥4/≥6) who were randomized to receive either DAPT or aspirin alone within 24 hours of symptom onset. Three of the 4 studies used clopidogrel while the remaining study investigated the use of ticagrelor. The authors reported that DAPT reduced the risk of stroke recurrence by 24%. However, there was no statistical difference in all-cause mortality between the groups, and those on DAPT were exposed to a 2.2-fold greater risk of moderate or severe bleeding.

Praveen Hariharan, MD

Sanz-Cuesta BE, Saver JL. Lipid-Lowering Therapy and Hemorrhagic Stroke Risk: Comparative Meta-Analysis of Statins and PCSK9 Inhibitors. Stroke. 2021.

Since the birth of statins in the late 20^th century, statins have become an integral part of cardiovascular disease management. However, several studies showing increased risk of hemorrhagic stroke with statin use have raised concerns, and the risk is currently being evaluated with ongoing randomized clinical trials. PCSK9 (proprotein convertase subtilisin kexin 9) inhibitors are the most potent novel antihyperlipidemic medications and could serve as potential alternatives to statins.

In this study, Drs. Sanz-Cuesta and Saver investigated the hemorrhagic stroke rates of PCSK9 inhibitors by undertaking a meta-analysis of data available from randomized clinical trials (RCTs) comparing low or high dose statins with each other or controls, and low and high dose PCSK9 inhibitors with each other or controls. Assuming a gradient risk based on the history of ischemic or hemorrhagic stroke and medication dosing, RCTs were planned to be grouped into 4 subcategories: 1) all patients/any dose; 2) all patients/high dose; 3) history of ischemic stroke/any dose; and 4) history of hemorrhagic stroke/any dose.