treatment

Yan Hou, MD, PhD

Bornstein NM, Saver JL, Diener HC, Gorelick PB, Shuaib A, Solberg Y, et al.. Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow. A Randomized, Sham-Controlled Trial. Stroke. 2019;50:00-00.

Preclinical studies have demonstrated that sphenopalatine ganglion (SPG) stimulation is a potent method to enhance collateral flow and reduce infarct size in stroke animal models. The ImpACT-24A Investigators performed a sham-controlled, randomized trial to test the efficacy and safety of SPG stimulation as a potential therapy for patients with acute anterior circulation ischemic stroke who are not eligible for reperfusion therapy.

A total of 253 patients with acute anterior circulation ischemic stroke with moderate deficit (median NIHSS of 11) within 24 hours of onset not treated with tPA or thrombectomy either received SPG (n=153) or sham (n=100) stimulation. The primary efficacy outcome is mRS improvement beyond expectation at 90 days, which was defined as an mRS score one or more points better than expected based on a prognostic model. Although SPG stimulation only showed a 9.7% higher rates of mRS improvement beyond expectations in the intention to treat population (SPG vs. sham: 49.7% vs. 40%, odd ratio 1.48, p=0.13); there was a 23% higher rate of mRS improvement beyond expectations in the subgroup of patients with confirmed cortical involvement (SPG vs. sham: 50% vs. 27%, odd ratio 2.7, p=0.03). The different beneficial effects of SPG stimulation between patients with cortical infarcts and deep subcortical infarcts was considered due to more robust collateral arterial networks in superficial leptomeningeal arteries supplying the cortical layers. SPG stimulation was not associated with any increase in serious adverse events, symptomatic intracranial hemorrhage, or mortality. Only two serious adverse events were considered possibly related to the implantation (one epistaxis and one torn extraction).

Raffaele Ornello, MD

Janssen PM, Venema E, Dippel DWJ. Effect of workflow improvements in endovascular stroke treatment: A systematic review and meta-analysis. Stroke. 2019;50:665–674.

Acting fast is of key importance to ensure the success of endovascular treatment (EVT) for ischemic stroke. While the available evidence already showed that workflow interventions improve the time to treatment with intravenous rtPA, the effect of workflow interventions on EVT is less clear. In their systematic review and meta-analysis, the authors included 51 studies referring to workflow interventions in EVT, including anesthetic management, pre-hospital management, in-hospital transfer management, teamwork, and feedback. Overall, each single intervention resulted in a significant improvement of time to EVT, with a mean value of 26 minutes and up to 64 minutes for feedback interventions.

Although limited by the large contribution of retrospective data and by the low availability of pre-hospital management data, the published systematic review and meta-analysis underlines the importance and effectiveness of planning adequate EVT workflow intervention in clinical practice to improve the treatment time of ischemic stroke and patient outcomes.

Lina Palaiodimou, MD

Neilson LE, Rogers LR, Sundararajan S. Evaluation and Treatment of a Patient with Recurrent Stroke in the Setting of Active Malignancy. Stroke. 2018

This article by Neilson et al. reports a case of a 75-year-old female patient presenting with multiple ischemic lesions with temporal dispersion and localization in multiple arterial territories. The patient was newly diagnosed with lung cancer, more specifically mucinous adenocarcinoma, found randomly in MRI of cervical spine, which was performed as part of differential diagnosis of transient left arm weakness and numbness. Smoking was reported as a predisposing factor for lung cancer, as well as ischemic stroke.

Kat Dakay, DO

Baek J-H, Kim BM, Heo JH, Nam HS, Kim YD, Park H, et al. Number of Stent Retriever Passes Associated With Futile Recanalization in Acute Stroke. Stroke. 2018

Mechanical thrombectomy has been recognized as the standard of care in acute ischemic stroke due to proximal large vessel occlusion. However, despite best efforts, it is not always successful: According to the authors, about 20-30% of clots are refractory to stent retriever thrombectomy. However, even if the vessel is eventually recanalized, the patient may still not necessarily have a favorable outcome, often termed “futile recanalization”; rates of futile recanalization vary widely depending on the definition used. Additionally, there are risks to a long and complex thrombectomy procedure in cases with refractory clots. In this article, the authors examine the number of stent retriever attempts, or passes, as a marker for futile recanalization.

In this multicenter, retrospective study [1], patients with a proximal anterior circulation large vessel occlusion treated with stent retriever thrombectomy were included. Additionally, patients needed to have an NIHSS of 4 or greater and be treated within 10 hours of last known well. The number of stent retriever passes required to achieve successful recanalization of TICI 2b or 3 was measured. A total of 467 patients were included in the study, with a median age of 67.3 years, median NIHSS of 15, and median ASPECTS of 8. The median number of stent retriever passes was 2, although rates ranged from 1 to 7.

Alejandro Fuerte, MD

Levine SR, Weingast SZ, Weedon J, Stefanov DG, Katz P, Hurley D, et al. To Treat or Not to Treat? Exploring Factors Influencing Intravenous Thrombolysis Treatment Decisions for Minor Stroke. Stroke. 2018

The activase/alteplase package insert from the Food and Drug Administration was updated in February 2015. Despite this, controversy continues over the criteria for the use of this drug in minor stroke, defined as National Institutes of Health Stroke Scale (NIHSS) score 1 to 5. In this article, Levine et al explore clinical factors influencing alteplase treatment decisions for patients with ictus minor.

This is a descriptive study. A committee of stroke experts identified the key factors in making decisions about the use of alteplase. The most prominent factors on the basis of which the study was developed were the following: all patient-dependent: National Institutes of Health Stroke Scale (NIHSS), NIHSS area of primary deficit, baseline functional status, previous ischemic stroke (IS), previous intracerebral hemorrhage (ICH), recent anticoagulation, and temporal pattern of symptoms in first hour of care. A fractional factorial design was used to provide unconfounded estimates of the effect of the 7 main factors, plus first-order interactions for the NIHSS. A joint statistical analysis was then applied.