treatment

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.

Robert W. Regenhardt, MD, PhD

Gory B, Piotin M, Haussen DC, Steglich-Arnholm H, Holtmannspötter M, Labreuche J, et al. Thrombectomy in Acute Stroke With Tandem Occlusions From Dissection Versus Atherosclerotic Cause. Stroke. 2017

The revolution of acute stroke care, with the 2015 trials demonstrating superiority of endovascular thrombectomy (ET) compared to tPA alone and the subsequent DAWN and DEFUSE 3 trials extending its time window, has raised many questions about which patients will experience net benefit from this powerful therapy. Certainly, some vessel occlusions are more amenable to ET than others, but should the presence of technically difficult occlusions, with perhaps higher procedural risks, limit eligibility? Though poorly represented, patients with anterior circulation tandem lesions, involving both the cervical internal carotid artery (ICA) and an intracranial artery, experienced similar benefits as those with isolated intracranial occlusions in the HERMES meta-analysis. It is unclear if the etiology of tandem lesions predicts outcomes, if etiology should influence the decision to undergo ET, or if it should influence the procedural approach.

The two most common etiologies of tandem lesions are carotid atherosclerosis and carotid dissection. Treatment typically occurs in two phases: management of the cervical ICA lesion by stenting, angioplasty, both, or medical treatment alone, and management of the intracranial occluded vessel by stent retriever or direct aspiration first pass technique. The order of these phases remains controversial, with some centers starting with the intracranial lesion as stent retrievers only require a small microcatheter for deployment. Stenting versus angioplasty of the cervical ICA can be debated based on adequacy of collaterals, risk of reperfusion injury, risk of immediate dual antiplatelet therapy, and other individualized factors.

Shashank Shekhar, MD, MS
@Artofstroke

Smith CJ, Hulme S, Vail A, Heal C, Parry-Jones AR, Scarth S, et al. SCIL-STROKE (Subcutaneous Interleukin-1 Receptor Antagonist in Ischemic Stroke): A Randomized Controlled Phase 2 Trial. Stroke. 2018

Multiple preclinical and clinical research is suggesting the definite role of inflammation in the brain after ischemic stroke. The inflammation could be both detrimental and helpful based on the stages of the post-stroke pathogenesis. I always explain this to my stroke patients by giving an example of injury to, e.g., a finger. I ask them, When you hurt your finger, what happens to it? It starts hurting, swells and turns colors due to inflammation. Similarly, in the brain after stroke, the brain goes through the similar process; unlike pain medicine for fingers, we don’t have medicine which helps with inflammation in the brain, but with time, the body tends to heal most of the inflammation. Explaining to them in lay terms helps them understand the process better. In this study, investigators from the SCIL-Stroke phase II trial are investigating if blocking interleukin IL-1 results in the lowering IL-6 levels and if this could be associated with a better clinical outcome. This project is in line with the previously published work by Dr. Albers’ group, where they addressed a similar question but without a placebo control arm.