Treatment of atrial fibrillation (AF) in the elderly population has always been challenging. Fragile age, multiple comorbidities, and fall risk put them as a red flag whenever a decision to anticoagulate them is made. Edoxaban is a direct oral factor Xa inhibitor. Studies have been done comparing low dose Edoxaban with warfarin and have found Edoxaban once-daily regimens noninferior to warfarin with respect to the prevention of stroke or systemic embolism and have been associated with significantly lower rates of bleeding and death from cardiovascular causes.1
The Edoxaban Low-Dose for EldeR CARE AF patients (ELDERCARE-AF) study is a phase 3, randomized, double-blind, placebo-controlled, parallel-group, multicenter study comparing the safety and efficacy of once-daily edoxaban 15 mg versus placebo in Japanese patients with NVAF ≥80 years of age who are considered ineligible for standard oral anticoagulant therapy.2
By strokeblog|October 9th, 2020|clinical, treatment|Comments Off on Chaos About Treatment of Chaotic Heartbeat in Elderly Patients
The successful endovascular treatment (EVT) trials for
large vessel occlusion (LVO) strokes have excluded patients with basilar artery
occlusion (BAO). Recently, the results of the Basilar Artery International
Collaboration Study (BASICS) were presented at the European Stroke Organization
(ESO-WSO) virtual platform. The results, even though underpowered to show
significant benefits of EVT <6 hours of BAO, were effective in patients with
moderate to severe deficits (NIHSS > 10). The trial results have shifted the
spotlight to the distinction in the neuro-anatomy of posterior-circulation
vessels and collateral circulation in this part of the brain, etio-pathological
mechanisms involved in large vessel disease in the posterior circulation, as
well as appropriate patient selection based on symptom severity and time window
from symptom onset. In this blog, I will discuss a retrospective study from
South Korea relevant to this topic that was published in the July issue of Stroke.
In this study, the authors present data from 81 patients with acute BAO treated with EVT using manual aspiration or stent retriever at their institute in South Korea over a period of eight years from 2012 to 2019. Posterior circulation collaterals were graded using the Basilar Artery on CT Angiogram (BATMAN) score and posterior circulation collateral score (PC-CS). Both these scoring systems have a maximum possible score of 10 points. 64% of these patients achieved TICI 2b or 3 recanalization within a median time of 5.5 hours from symptom onset, and 37% of patients had good functional outcomes defined by a 3-month modified Rankin scale ≤ 2. When compared to patients with poor outcomes, the ones with favorable outcomes had lower baseline NIHSS (15 vs 7.5, p<0.01), a greater proportion of distal BAO (20% vs 63%, p<0.01), and better posterior circulation collateral scores (5 vs 6, p<0.01). The authors also compared these groups on a timeline of < 3hrs, 3-6 hrs, 6-12 hrs, and >12 hrs from symptom onset. Interestingly, the time to recanalization from symptom onset was not significantly different between the groups. Receptor operating characteristic (ROC) curve analysis for collateral scores yielded the highest area under the curve with a cut-off score of 6 for both BATMAN and PC-CS. Using these cut-offs, multivariate analysis revealed that NIHSS score <15 (odds ratio 8.49, P=0.004), PC-CS ≥6 (odds ratio 3.79, P=0.042), and distal BAO (odds ratio 3.67, P=0.035) were independent predictors of good clinical outcomes.
Figure 1. Schematic illustration of collateral scores.
By strokeblog|August 26th, 2020|clinical, treatment|Comments Off on A Collateral Dialogue: Addressing Neuroanatomy of Posterior Circulation in Basilar Artery Occlusion
The goal of current therapeutic
strategies for acute ischemic stroke with large vessel occlusion (LVO) is
recanalization of the occlusion before irreversible damage has occurred. In
this large multicenter, prospective, randomized, open-label trial with blinded
outcome assessment, Dr. Jianmin Liu and his team
aimed to answer the question of whether mechanical thrombectomy (MT) alone
(thrombectomy alone group) would be non-inferior to combined treatment of IV-tPA
and MT (combined group) in patients with LVO.
This trial included patients ³ 18 years of age who presented to 41 pre-selected academic
medical centers in China within 4.5 hours of symptom onset, had National
Institutes of Health Stroke Scale (NIHSS) ³ 2 with imaging showing an LVO (intracranial segment of ICA, M1 or
proximal M2 only). Any patients who did not meet American Heart Association/American
Stroke Association guidelines for alteplase or MT were not included in the
trial. The standard dose of tPA at 0.9 mg/kg was used, and the first-line
strategy for MT was stent-retriever. Statistically, the trial was designed to
provide 80% power (at a two-sided alpha level of 0.05) to determine a
non-inferiority margin of 0.8. 656 patients were randomized in 1:1 fashion by a
web-based system with 327 patients in the thrombectomy alone group and 329
patients in the combined group. The patient enrollment period was 17 months
(February 23, 2018, to July 2, 2019). The baseline characteristics of patients
were similar in both the groups with a median age of 69 years, median NIHSS
score of 17, and median ASPECTS value of 9. The median duration from stroke
onset to randomization was 167 minutes in the thrombectomy alone group and 177
minutes in combined group with time from randomization to groin puncture being
31 minutes and 36 minutes, respectively.
By strokeblog|May 15th, 2020|clinical, Conference, treatment|Comments Off on Endovascular Thrombectomy With or Without Intravenous Alteplase: ESO-WSO Large Clinical Trials Webinar
I was happy to see
that although the ESO-WSO 2020 annual meeting was postponed, we still had the
opportunity to virtually hear the results of some recent large clinical trials.
One of the five trials presented was the Basilar Artery International
Collaboration Study (BASICS) presented by Dr. Wouter Schonewille from The
Netherlands. Posterior circulation occlusions have been largely excluded from
the main endovascular randomized control trials, so these results were highly
anticipated.
Many of us are
familiar with the devastating effects of a basilar artery occlusion (BAO), and
from a personal experience, some of these cases have been very challenging
without having the guidance of large trials as we do with anterior circulation
occlusions. The clinical presentations, stroke severity, and collateral
patterns are inherently different. This trial was an international,
multicenter, controlled trial with randomized treatment-group assignments
investigating the efficacy and safety of endovascular therapy (EVT) plus best
medical management (BMM) versus BMM alone <6 hours of estimated time of BAO.
Patients were randomly assigned (1:1 ratio) to EVT+BMM or BMM alone and
stratified according to: randomizing center, use of IVT, and NIHSS (<20 vs >20).
The enrollment period was from 2011 through 2019. Patients were excluded with
intracranial hemorrhage, extensive brainstem ischemia, or cerebellar mass
effect/acute hydrocephalus. The calculated sample size was 300 patients
assuming favorable outcome in 46% with EVT+BMM and 30% with BMM. Primary
outcome was mRS <3 at 90 days. Secondary outcome measures included
clinical outcomes (mRS 0-2 at 90 days and mRS distribution) and imaging
outcomes (posterior circulation ASPECTS score at 24 hours and basilar artery
patency at 24 hours).
With the COVID-19 pandemic taking more than 50,000 lives in
the United States, emergency medical services are being forced to change their
triage policies in order to ensure safety of both the patients and the health
care personnel involved.
Stroke and STEMI triage systems are among the first to be
affected, especially because there is some evidence for the increased incidence
of acute ischemic strokes in COVID-19 patients, secondary to the
hypercoagulability.
The Society of Vascular and Interventional Neurology has
issued a guidance statement highlighting practices that all institutes should
be incorporating into their routine stroke workflow — pre-, intra- and post-mechanical
thrombectomy. These guidelines serve as pointers that can be used to modify our
existing protocols. Because we are going to continue to see the effect of COVID-19
through the summer, especially in highly impacted states like New York,
Massachusetts and Illinois, and there is also a potential second wave predicted
for fall and winter 2020, it is prudent that all centers adopt these best
practice guidelines in their daily stroke triage and workflow.
By strokeblog|April 29th, 2020|clinical, treatment|Comments Off on Article Commentary: “Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams”
Cervical artery dissection (CAD) has an annual incidence of
about 2.9% per 100,000, though that seems to be under-reported, as many
patients usually do not present for evaluation or undergo routine vessel
imaging for local symptoms like pain or headache. At the same time, even though
CAD accounts for about 1-2% of total ischemic strokes, it can be the cause of
up to 25% of strokes in the young population.
The Cervical Artery Dissection in Stroke Study (CADISS) is
the only prospective randomized clinical trial to date that evaluated if there
was a reduction in subsequent stroke in patients treated with either
antiplatelet or anticoagulation. It also looked at the presence of arterial
recanalization between the two groups.
By strokeblog|April 24th, 2020|clinical, treatment|Comments Off on Article Commentary: “Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection”
Efficacy and safety of endovascular treatment (EVT) in
anterior circulation strokes is clearly validated; however, such evidence is
still lacking in vertebrobasilar occlusions. Liu et al. aimed to demonstrate
safety and efficacy of EVT in posterior circulation strokes. To achieve this
goal, the authors performed a multicenter, randomized, open-label trial in
patients within 8 h of vertebrobasilar occlusion (basilar or V4 segment of
vertebral artery). Patients were allocated to receive either EVT plus standard
medical therapy or standard medical therapy alone. Given endovascular
procedure, stent-retriever was the most employed technique, but
thromboaspiration, intra-arterial thrombolysis, balloon angioplasty or stenting
were also permitted. Primary outcome was mRS 0-3 at 90 days, assessed on an
intention-to-treat basis. Primary safety outcome was mortality at 90 days.
Secondary safety endpoints included symptomatic intracranial hemorrhage,
device-related complications and other severe events rates. Each participating
center had to have completed at least 5 mechanical thrombectomy procedures with
stent retriever devices in the preceding year. The primary data analysis was
done on the intention-to-treat population. In addition, secondary prespecified
analyses were performed in the per-protocol population and in the as-treated
population.
By strokeblog|April 3rd, 2020|clinical, treatment|Comments Off on Mechanical Thrombectomy in Vertebrobasilar Occlusion: Still Looking for Evidence
A
conversation with Houman
Khosravani, MD, PhD, Assistant Professor, Division of Neurology, Department
of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada.
Twitter: @neuroccm
Interviewed
by Victor J. Del Brutto, MD,
Assistant Professor, Stroke Division, Department of Neurology, University of
Miami Miller School of Medicine, Florida. Twitter: @vdelbrutto
Dr. Del Brutto: First of all, I would like to thank you and
your team for putting together these thoughtful recommendations on how to
evaluate patients with suspected stroke during the Coronavirus Disease 2019
(COVID-19) pandemic. As a stroke neurologist, I share the global feeling of
uncertainty that this pandemic has caused and look forward to modifying my
institution practices in order to maximize patients’ outcomes, their safety,
and the safety of the professionals involved in their care. In your article,
you mention that stroke patients are at an increased risk of suboptimal
outcomes during the COVID-19 pandemic. Could you please comment on the factors
that may influence patient outcomes?
Dr. Khosravani: During the COVID-19 pandemic,
patients are affected at several junctions in stroke care, including during the
hyperacute phase. For example, paramedics responding to a stroke call, in some
jurisdictions, will begin the screening process prior to arrival and then again
on scene. When screening is positive, pre-notification to the hospital should
occur, and this triggers a protected code stroke (PCS). Patients being brought
directly to the ED will require additional screening. The necessary use of PPE,
with a Safety Lead observing, will add some delays to the front-end processes,
but these are essential to keeping providers safe. It is very plausible that,
for example, door-to-needle/door-to-groin puncture times will be impacted.
Similarly, at the point-of-care, a COVID-19–suspected patient going to imaging
will result in having special precautions used in the scanner or
neuroangiography suite, which will add additional time (for cleaning as well);
this impacts scenarios with back-to-back code strokes as well.
By strokeblog|April 1st, 2020|clinical, health care, treatment|Comments Off on Author Interview: Dr. Houman Khosravani, MD, PhD, on “Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic”
Thrombus is a dynamic structure with constantly
changing size, morphology and location over time, to variable extent in each
patient, before recanalization occurs. Recently, there is interest in
understanding dynamic clot features, especially regarding thrombus movement —
defined as change in the occlusion site — between initial (typically CT
angiogram) and follow-up vascular imaging (usually catheter angiogram for
mechanical thrombectomy). Whether thrombus migration before recanalization is
of any clinical or functional significance remains under investigation. The
thrombus migration was studied in the past.1 It underlies a clinical
phenomenon called “spectacular shrinking deficit,” in which a patient with
major hemispheric syndrome shows rapid (over minutes to hours) and dramatic
improvement or disappearance of most clinical deficits.1 Use of
regular “vascular imaging” now allows investigating the concept in reverse
order, i.e., the incidence thrombus migration and correlate it with clinical
change or functional outcome. Different factors determine the dynamic behavior
of the clot, including source of thrombus (etiology of stroke), composition of
the thrombus, initial thrombus location within arterial tree (for example,
proximal vs distal occlusion), angioarchitecture around the thrombus and use of
intravenous thrombolysis (IVT).1-4
By strokeblog|February 10th, 2020|clinical, treatment|Comments Off on Thrombus Migration in Large Vessel Occlusion: Is it Good or Bad?
Dr. Drouard-de Rousiers et al. performed a retrospective
analysis of all patients over 90 years old who received endovascular therapy in
the Endovascular Treatment in Ischemic (ETIS) registry from 2013-2018.
The study is based on observational data retrospectively
gathered from multiple sites, all devices were third generation, clinical and
radiographic data were evaluated on admission, and CT or MRI was performed
between 12 and 72 hours to track hemorrhagic transformation. The patients with
successful reperfusion had OR 3.26 of having lower 90-day mRS mainly driven by
decreased mortality. The caveat to this benefit is that procedural
complications were 16.5% including vessel perforations and dissections.
The July 2022 issue of Stroke is now available online! Check out the issue for the latest Original Contributions, as well as a Focused Update on Intracerebral Hemorrhage, Topical Reviews, Comments and Opinions, Advances in Stroke, and more. #AHAJournalshttps://t.co/RiuMyt05zMhttps://t.co/yV6LAMyma8
