American Heart Association

ESOC 2022 Official Welcome and Large Clinical Trials

Andy Lim, MBA, FACEM, GAICD
@ALim0211

ESOC 2022 Amphithéâtre, Centre de Congrès de Lyon, Wednesday, 4 May 2022, 10:30 – 12:30 CEST

Here we are, officially welcomed to the 8th European Stroke Organisation Conference! Results of nine large trials were released this morning, and social media is already buzzing with excitement from these results. Here are the key findings for those who might have missed out.

Three tenecteplase trial results were released today. The AcT trial, a Canadian trial of 1600 patients with acute stroke, demonstrated that tenecteplase was noninferior (5% margin) to alteplase in acute ischaemic stroke with comparable functional outcomes and no significant safety issues. NOR-TEST 2A, a Norwegian trial of 1036 stroke patients up to 4.5 hrs inclusive of wake-up stroke, could not show that tenecteplase is non-inferior. Tenecteplase yielded worse safety and functional outcome compared with alteplase. Dose chosen was 0.4mg/kg, and part B intends to test the reduced dose of 0.25mg/kg. The Australian TASTE-A trial of 104 patients demonstrated significantly smaller CT perfusion lesions in patients treated with tenecteplase compared to alteplase, indicating earlier reperfusion, with no safety concerns.

Six additional studies were presented:
• The Paramedic Norwegian Acute Stroke Prehospital Project demonstrated significantly better functional outcome in an intervention group that trained paramedics in the use of NIHSS in the pre-hospital setting at the cost of longer on-scene time.
• SPRINT showed that a structured SMS message, education video, workbook, and telephone follow-up improved lifestyle and medication adherence.
• ATTICUS, stopped early for futility, showed us that apixaban not superior to ASA with switch to apixaban in case of AF in prevention new ischaemic lesions during 12 months follow-up of an enriched embolic stroke of undetermined source population.
• SETPOINT2 taught us that early versus late tracheostomy in ventilated stroke patients did not lead to better functional outcome at six months.
• AMETIS revealed similar rates of functional independence and major periprocedural complications when comparing procedural sedation versus GA in endovascular management of stroke.
• Finally, the Chinese ATTENTION trial demonstrated significantly improved functional outcome and secondary efficacy outcomes, as well as lower overall disability and mortality, when EVT was compared with best medical management in acute basilar artery occlusion within <12hrs from the estimated time (defined as the sudden onset of stroke symptoms consistent with acute basilar occlusion, excluding previous minor prodromal symptoms, or time the patient was last known to be well).

This sets the 8th ESOC off to a great start this Wednesday 4th May in Lyon, France!

By |May 5th, 2022|Conference|Comments Off on ESOC 2022 Official Welcome and Large Clinical Trials

Article Commentary: “Early Deterioration, Hematoma Expansion, and Outcomes in Deep Versus Lobar Intracerebral Hemorrhage”

Karissa C Arthur, MD
@KCArthurMD

Kuohn LR, Witsch J, Steiner T, Sheth KN, Kamel H, Navi BB, Merkler AE, Murthy SB, Mayer SA. Early Deterioration, Hematoma Expansion, and Outcomes in Deep Versus Lobar Intracerebral Hemorrhage: The FAST Trial. Stroke. 2022.

Intracranial hemorrhage (ICH) accounts for more than two-thirds of mortality from all stroke subtypes. ICH can be deep or lobar, and it is unclear if these subtypes differ in complications such as hematoma expansion (HE) or early neurologic deterioration (END). It is important to identify these differences as it may lead to different monitoring and treatment approaches. The authors hypothesized that HE and poor functional outcomes would occur more frequently in deep ICH, and END would be more common in patients with lobar hemorrhage.

The authors performed a secondary analysis using data from the FAST trial (Factor VII for Acute Hemorrhagic Stroke), a large, randomized trial with serial neuroimaging and blind volume measurements to assess for differences in HE, END, and functional outcomes between deep and lobar ICH. There were several exclusion criteria of the FAST trial, including GCS of 5 or less, known anticoagulant use or coagulopathy, known thrombotic disease within 30 days, and several others. CT imaging was done within 3 hours of symptom onset, at 24 hours, and 72 hours, and was evaluated by two individual blinded neuroradiologists. HE included hematoma expansion > 33% or 6 mL from baseline in 24 hours. END was defined as GCS decrease by 2 points or increase in NIHSS by at least 4 within 24 hours. Modified Rankin Scale (mRS) was used to assess functional outcome.

Graphic abstract
By |May 4th, 2022|clinical|Comments Off on Article Commentary: “Early Deterioration, Hematoma Expansion, and Outcomes in Deep Versus Lobar Intracerebral Hemorrhage”

Long-Term Consequences of Stroke-Heart Syndrome

Praveen Hariharan, MD

Buckley BJR, Harrison SL, Hill A, Underhill P, Lane DA, Lip GYH. Stroke-Heart Syndrome: Incidence and Clinical Outcomes of Cardiac Complications Following Stroke. Stroke. 2022.

Over the last two decades, an increasing body of evidence has recognized various cardiovascular complications following ischemic stroke collectively known as the stroke-heart syndrome. Ischemic stroke can cause impaired autonomic cardiac reflexes, repolarization abnormalities, myocardial injury and cardiomyopathy resulting in myocardial infarction, cardiac arrhythmias including atrial fibrillation, new-onset or exacerbation of heart failure, recurrent stroke, poor functional outcomes, and increased mortality. Many studies have explored the short-term consequences, but there is a paucity of data on long-term clinical outcomes.

In this study, the authors have utilized retrospective observational data obtained from a global federated health research network called TriNetX. Patients with an incident acute ischemic stroke from 2002-2021 with at least 5 years follow up were included. Ischemic stroke patients with newly diagnosed cardiovascular complications within 4 weeks post-stroke were 1:1 propensity score-matched (for baseline demographics and comorbidities) with ischemic stroke patients without cardiovascular complications for comparison of 5-year MACE (major adverse cardiovascular events) outcomes.

By |May 2nd, 2022|clinical|Comments Off on Long-Term Consequences of Stroke-Heart Syndrome

Childhood Ischemic Stroke and SARS-CoV-2

Kevin O’Connor, MD

Beslow LA, Agner SC, Santoro JD, Ram D, Wilson JL, Harrar D, Appavu B, Fraser SM, Rossor T, Torres MD, et al. International Prevalence and Mechanisms of SARS-CoV-2 in Childhood Arterial Ischemic Stroke During the COVID-19 Pandemic. Stroke. 2022.

Over the last two years, data have shown an increased risk of ischemic stroke in the setting of SARS-CoV-2 infection. Beslow et al. explored the relationship between SARS-CoV-2 and childhood (age 29 days to 18 years) ischemic stroke based on data from multiple sites across 21 countries.

The sites reported 373 acute ischemic strokes from June to December 2020 during the same time that they recorded 7,231 pediatric SARS-CoV-2 hospitalizations. Of 335 (89.8%) childhood ischemic strokes that underwent testing for SARS-CoV-2, 23 (6.9%) were positive for the virus, and clinical information was available for 22 cases. The overall risk of childhood ischemic stroke in children hospitalized for SARS-CoV-2 was low at 0.32% (95% binomial exact CI, 0.20%-0.48%), but this may include children in whom the infection was found incidentally.

By |April 27th, 2022|clinical|Comments Off on Childhood Ischemic Stroke and SARS-CoV-2

Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”

Hannah Roeder, MD, MPH

Hahn M, Gröschel S, Hayani E, Brockmann MA, Muthuraman M, Gröschel K, Uphaus T, on behalf of the German Stroke Registry—Endovascular Treatment (GSR-ET) Study Group. Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy. Stroke. 2022.

For working-age stroke patients, returning to work (RTW) is a yardstick for functional recovery and is associated with improved well-being. Patients who suffer large vessel occlusion (LVO) are at greater risk for persistent neurological deficits; however, in the mechanical thrombectomy era, even patients with LVO may have a favorable outcome allowing RTW. Hahn and colleagues used data from the German Stroke Registry Endovascular Treatment (GSR-ET) to explore the likelihood and predictive factors for RTW with particular attention to sex differences.

The investigators included patients in the GSR-ET who were known to be employed prior to their stroke and were less than 65 years of age (the retirement age in Germany), and excluded patients who did not receive thrombectomy or were deceased by day 90. After application of inclusion/exclusion criteria, about one-tenth of patients in the GSR-ET were eligible (606 out of 6635). Of eligible patients, 35.6% (216) were re-employed at 3 months post-stroke.

By |April 25th, 2022|clinical, outcomes, prognosis|Comments Off on Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”

Endovascular Treatment for Ischemic Stroke: Do We Need General Anesthesia?

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.

By |April 20th, 2022|clinical, treatment|Comments Off on Endovascular Treatment for Ischemic Stroke: Do We Need General Anesthesia?

Article Commentary: “Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke”

Dixon Yang, MD

Dicpinigaitis AJ, Gandhi CD, Pisapia J, Muh CR, Cooper JB, Tobias M, Mohan A, Nuoman R, Overby P, Santarelli J, et al. Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke. Stroke. 2022.

Pediatric acute ischemic stroke (AIS) is an uncommon and poorly understood clinical entity, but its absolute incidence has been increasing and may represent significant cause of disability. In 2019, the American Heart Association Stroke Council and Council of Cardiovascular and Stroke Nursing issued a statement suggesting emergent therapies and endovascular therapies be limited to consideration of children with persistent neurologic deficits (pediatric NIHSS >/= 6), radiographically confirmed large vessel occlusion, and those with a large body habitus due to technical considerations and risks with exposure to radiation and contrast.

In absence of high-quality data and trials, optimal management for pediatric acute ischemic stroke remains unclear. Therefore, Dicpinigaitis and authors performed a large cross-sectional analysis using an administrative inpatient care registry in the United States from the Healthcare Cost and Utilization Project to characterize patient profiles and clinical course of endovascular therapy (EVT) in pediatric patients for AIS.

By |April 18th, 2022|clinical|Comments Off on Article Commentary: “Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke”

Optimal Timing of Carotid Revascularization

Kevin O’Connor, MD

Cui CL, Dakour-Aridi H, Lu JJ, Yei KS, Schermerhorn ML, Malas MB. In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis. Stroke. 2022;53:100-107.

When a patient presents with a symptomatic carotid lesion, what is the optimal time to revascularize and with what procedure? Cui et al. explored this in their retrospective cohort study comparing outcomes among carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) who underwent their respective procedures urgently (0-2 days from latest symptoms), early (3-14 days), or late (15-180 days). From 2016-2019, there were 2006 urgent revascularizations (CEA, n=1112; TCAR, n=144; TFCAS, n=750), 7423 early revascularizations (CEA, n=5126; TCAR, n=929; TFCAS, n=1369), and 9214 late revascularizations (CEA, n=6060; TCAR, n=1536; TFCAS, n=1618). Analysis compared outcomes between TCAR and CEA and between TFCAS and CEA for each timeframe.

By |April 15th, 2022|clinical|Comments Off on Optimal Timing of Carotid Revascularization

AST-004 Treatment Reduces Brain Infarct Volume in a Nonhuman Primate Ischemic Stroke Model

Kristina Shkirkova, BSc
@KShkirkova

Liston TE, Hama A, Boltze J, Poe RB, Natsume T, Hayashi I, Takamatsu H, Korinek WS, Lechleiter JD. Adenosine A1R/A3R (Adenosine A1 and A3 Receptor) Agonist AST-004 Reduces Brain Infarction in a Nonhuman Primate Model of Stroke. Stroke. 2022;53:238-248. 

Adenosine A1 and A3 receptors (A1R and A3R) are involved in supply of energy, oxygen, and nutrients to the brain. Under pathological conditions of brain injury, these receptors may play an important role in functional balance and neuroprotection.1 Studies in mice have shown that activation of A1R and A3R with agonists results in reduction of cerebral lesion volume in ischemic stroke models. Adenosine A1 and A3 receptors are viable therapeutic targets for stroke treatment; however, there remains a need to establish appropriate dosing and timing of A1R/A3R agonist treatment that could be translated for its use in clinical studies.

By |April 13th, 2022|basic sciences|Comments Off on AST-004 Treatment Reduces Brain Infarct Volume in a Nonhuman Primate Ischemic Stroke Model

Sex-Specific Risk Factors: Complications of Pregnancy Can Increase Risk of Stroke

Arooshi Kumar, MD
@ArooshiK

Liang C, Chung HF, Dobson AJ, Mishra GD. Infertility, Miscarriage, Stillbirth, and the Risk of Stroke Among Women: A Systematic Review and Meta-Analysis. Stroke. 2022;53:328–337.

It is well established that stroke is a leading cause of mortality and disability around the world. It is more recently accepted that sex-related differences exist for stroke prevalence and outcomes, and that females might carry additional risk factors transcending the traditional vascular risk factors. To that end, pregnancy and childbirth mark a uniquely special experience for females. A growing body of evidence suggests that pregnancy and complications of pregnancy are associated with long-term risk of stroke.1-2 Liang et al. published a comprehensive systematic review on the association between infertility, miscarriage, stillbirth, and stroke.

By |April 11th, 2022|clinical, health care, policy|Comments Off on Sex-Specific Risk Factors: Complications of Pregnancy Can Increase Risk of Stroke