American Heart Association

Article Commentary: “Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage”

Ericka Samantha Teleg, MD

Bako AT, Pan A, Potter T, Tannous J, Johnson C, Baig E, Meeks J, Woo D, Vahidy FS. Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage. Stroke. 2022.

This cross-sectional study highlights the importance of keeping track of nationwide changes in the intracerebral hemorrhage landscape based on demographic and geographic differences across the United States. While some regions globally do not have such resources to organize and structure the source of this database, this article provides a good template to do so because this is done at the national level.

The source for the data is the Nationwide Inpatient Sample (NIS), the largest publicly available all-payer in-hospital database in the United States. It represents over 90% of U.S. hospitalizations. The trend weights for pre-2012 NIS data were used to provide estimates comparable across pre- and post-2012 sample. The exclusion includes hospitalizations with concurrent diagnosis that is due to secondary intracerebral hemorrhage.

By |February 18th, 2022|clinical, Conference|Comments Off on Article Commentary: “Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage”

ISC 2022 Session: Technology and Health in the Stroke Field

Sishir Mannava, MD
@sishmannMD

International Stroke Conference 2022
February 9–11, 2022

Learning Studio Session: Speakers Panel on “Technology and Health in the Stroke Field”
Moderators: Dr. Nicole Gonzales and Dr. Lauren Fournier
Speakers: Dr. James Grotta, Dr. Sunil Sheth, Dr. Amanda Jagolino, Dr. Eliza Miller, Dr. Jennifer Rasmussen Winkler, Dr. Alicia Zha

The panel discussed many aspects of technology and health in the stroke field and what it has brought to us post-pandemic. In regard to telemedicine/telestroke care, some major advantages that the panel discussed are: increased outreach to communities that wouldn’t have received the care, including specific sub-populations of patients such as those who live very far away, postpartum care, and care for disabled patients who are unable to travel. Dr. Sheth highlighted that acute telestroke care isn’t the only advantage, the future hope is that we can use telestroke care consultation more for preventative stroke that may have a major impact on overall health care. 

By |February 15th, 2022|clinical, Conference|Comments Off on ISC 2022 Session: Technology and Health in the Stroke Field

ISC 2022 Session: ‘Cocktails Anyone?’ Intravenous Thrombolysis Symposium

Yasmin Aziz, MD

International Stroke Conference 2022
February 9–11, 2022
Session: ‘Cocktails Anyone?’ Intravenous Thrombolysis Symposium

The 2022 International Stroke Conference moderated debates kicked off on Wednesday morning, February 9, with an ode to everyone’s favorite cocktail in New Orleans: thrombolytics.

Dr. Maarten Lansberg was the first to speak, arguing that any patient who meets extended window criteria for alteplase, whether by DWI-FLAIR mismatch or by CTP mismatch, should be eligible to receive treatment. After citing data from WAKE-UP and EXTEND, Dr. Laansberg presented evidence from two large meta-analyses showing favorable functional 90-day outcomes, in patients selected by MRI or by CTP, when treated with alteplase over placebo.1, 2 He concluded by stating that while the AHA/ASA guidelines cite only DWI-FLAIR mismatch with unclear last known normal time for alteplase administration, the Australian stroke guidelines mention either a DWI-FLAIR mismatch or a CTP mismatch for extended window administration. His conclusion was that all patients ineligible for thrombectomy presenting within 12 hours of last known normal time should be considered for extended window alteplase if a mismatch in either modality is found.

By |February 15th, 2022|clinical, Conference|Comments Off on ISC 2022 Session: ‘Cocktails Anyone?’ Intravenous Thrombolysis Symposium

Article Commentary: “Magnitude of Blood Pressure Change After Endovascular Therapy and Outcomes: Insight From the BP-TARGET Trial”

Sishir Mannava, MD
@sishmannMD

Anadani M, Maïer B, Escalard S, Labreuche J, de Havenon A, Sabben C, Lapergue B, Gory B, Richard S, Sibon I, et al. Magnitude of Blood Pressure Change After Endovascular Therapy and Outcomes: Insight From the BP-TARGET Trial. Stroke. 2022.

Blood pressure (BP) control after endovascular therapy (EVT) for large vessel occlusion is an oft-debated topic. Many stroke providers, although aware of the potential harm of reperfusion injury, do not know how aggressive to be with BP lowering. The risk with acute lowering of BP is also the risk of hypoperfusion and placing the penumbra at risk of worsening ischemic damage. The authors of this work conducted a post-hoc analysis of the BP TARGET trial (recently published and showing neutral results from intensive BP lowering in patients with successful reperfusion after EVT) to assess the association between change in systolic blood pressure at different time intervals with clinical and radiographic outcomes.

This was a secondary observational post-hoc analysis of the original BP TARGET trial, which enrolled patients with anterior circulation large vessel occlusion stroke and had acute ischemic stroke with successful reperfusion with EVT but had SBP > 130 mmHg at end of procedure (considered the baseline SBP). Patients in the BP TARGET trial were randomized 1:1 to intensive SBP treatment to be achieved within 1 hour of randomization (target 100-129 mmHg) or standard SBP treatment (130-185mmHg). BP was measured every 15 minutes for 2 hours after randomization, then every 30 minutes for 6 hours and then every hour for the remaining 16 hours. The authors defined ΔSBP as baseline SBP minus the mean of achieved SBP levels during 3 periods post-reperfusion: 15 to 60 minutes (ΔSBP15–60M), 1 to 6 hours (ΔSBP1–6H), and 6 to 24 hours (ΔSBP6–24H).

By |February 14th, 2022|clinical, Conference|Comments Off on Article Commentary: “Magnitude of Blood Pressure Change After Endovascular Therapy and Outcomes: Insight From the BP-TARGET Trial”

Digital Health in Primordial and Primary Stroke Prevention: Feasible Solution During COVID-19 Pandemic?

Fransisca Indraswari, MD

Feigin VL, Owolabi M, Hankey GJ, Pandian J, Martins SC. Digital Health in Primordial and Primary Stroke Prevention: A Systematic Review. Stroke. 2022.

The COVID-19 pandemic has shifted healthcare towards digital devices to compensate for less physical interaction, without compromising on the quality of patient care. Stroke care has typically been focused on secondary prevention and acute management, i.e., thrombolysis and endovascular, while there are not many studies on primary prevention. Primordial stroke prevention refers to the activities to avoid development of risk factors for stroke, whereas primary stroke prevention refers to activities to treat or reduce exposure to risk factors for stroke. Feigin et al. have provided a systematic literature review on how primary and primordial stroke prevention can be achieved through technology. The unprecedented growth of smartphone or other digital technologies is being used in almost every area of healthcare, offering a unique opportunity to improve primordial and primary stroke prevention at the individual level. The aim of the study is to provide current knowledge, challenges and opportunities of digital health in primordial and primary stroke prevention.

By |February 14th, 2022|clinical, Conference, health care, policy|Comments Off on Digital Health in Primordial and Primary Stroke Prevention: Feasible Solution During COVID-19 Pandemic?

Article Commentary: “Emergency Medical Service Time Intervals for Patients With Suspected Stroke in the United States”

Tolga D. Dittrich, MD
@to_dittrich

Cash RE, Boggs KM, Richards CT, Camargo Jr CA, Zachrison KS. Emergency Medical Service Time Intervals for Patients With Suspected Stroke in the United States. Stroke. 2022.

In acute stroke care, time is arguably the most critical outcome-determining factor. In addition to early recognition of stroke symptoms, prompt transport to a qualified hospital by emergency medical services (EMS) is essential to ensure optimal care. Cash and colleagues evaluated EMS time intervals for adults with suspected stroke in the United States between 2018 and 2019 and examined differences by geographic location.

Approximately 410,000 call-outs were considered, of which the vast majority of transports (98%) were ground-based. A comparison of ground-based and air-bound transports revealed that the time between dispatch and hospital arrival was considerably longer for air-bound transports (ground-based vs. air-bound (median, IQR): 35 min [27-45] vs. 56 min [43-70]), demonstrating disparity to the disadvantage of rural and border regions. In each transport group, 10% of the patients had pre-hospital times outside the target recommendations (≥58 minutes in the ground-based transport group, ≥86 minutes in the air-bound transport group).1

By |February 10th, 2022|clinical, Conference|Comments Off on Article Commentary: “Emergency Medical Service Time Intervals for Patients With Suspected Stroke in the United States”

DOACs: The Way Forward for Treating CVT

Ayush Agarwal, DM
@drayushagarwal

Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, Henninger N, Elnazeir M, Liberman AL, Moncrieffe K, et al. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study. Stroke. 2022.

Cerebral venous sinus thrombosis (CVT) is an uncommon cause of stroke and commonly afflicts a relatively younger population. Anticoagulation is the treatment of choice. Warfarin has formed this backbone with a gradual shift towards the newer direct oral anticoagulants (DOACs) of late (based on the ease of administration and lack of therapeutic monitoring). However, the query exists whether these patients can safely and effectively be treated with DOACs?

Large scale randomized controlled trials are difficult to conduct on CVT patients because of low incidence (RESPECT-CVT had only 120 patients), and data from other relevant sources (recent studies on DOAC use in venous thromboembolism and non-valvular atrial fibrillation) is encouraging. Therefore, Yaghi et al. conducted this multicenter study to find the real-world data comparing the efficacy and safety outcomes in patients with CVT treated with DOACs and warfarin over a 6-year period. Efficacy was measured clinically by a recurrence of venous thrombosis and radiographically by recanalization rates. Safety was calculated based on the occurrence of bleeding manifestations (major and minor).

By |February 10th, 2022|clinical, Conference, treatment|Comments Off on DOACs: The Way Forward for Treating CVT

Regulatory T Cells in Females Provide Endogenous Neuroprotection, But Increase Secondary Neurodegeneration in Males in Neonatal Encephalopathy in Mice

Kristina Shkirkova, BSc

Beckmann L, Obst S, Labusek N, Abberger H, Köster C, Klein-Hitpass L, Schumann S, Kleinschnitz C, Hermann DM, Felderhoff-Müser U, et al. Regulatory T Cells Contribute to Sexual Dimorphism in Neonatal Hypoxic-Ischemic Brain Injury. Stroke. 2022.

Regulatory T cells (Tregs) are specialized T cells that have an ability to suppress immune response. Recent evidence suggests a sexual dimorphism in the role Tregs play after brain injury.

In the study recently published in Stroke by Beckmann et al., experimental administration of hypoxia-ischemia to neonatal mice by ligation of the right common carotid artery, as a model of neonatal encephalopathy, resulted in increased cerebral Tregs infiltration into the brain. Flow cytometry revealed that females experienced significantly higher frequency and total amount of Treg infiltration than males 24 hours after the induced hypoxia-ischemia in the brain but not in the peripheral tissue. To further investigate the functional contribution of Tegs in both sexes, a special agent, DTX, was used to deplete the number of Tregs in mice. As a result of Treg depletion, a more significant injury was observed in female cortex and hippocampus, while in males, the injury was decreased in these areas. Depletion of Tregs also resulted in functional deficits only in females in early forelimb coordination test as well as long-term exploratory activity. In the hippocampus, Treg depletion increased microglial response, endothelial activation, and leukocyte accumulation in female compared to non-depleted females. Females were also observed to have increased basil lamina disruption following Treg depletion, while for males, Treg depletion provided vascular protection. These differences between sexes were not explained by levels of female hormone estradiol, as there was not a difference observed in serum estradiol levels between males and females. Independent of sex hormones, female Tregs were immunosuppressive on effector T cell compared with male, with Myc Targets, mTORC1 signaling and oxidative phosphorylation pathways showing prominence in gene set enrichment analysis.

By |February 4th, 2022|basic sciences, pathogenesis|Comments Off on Regulatory T Cells in Females Provide Endogenous Neuroprotection, But Increase Secondary Neurodegeneration in Males in Neonatal Encephalopathy in Mice

Carotid Intervention in Women: To Treat or Not to Treat?

Nurose Karim, MD

Rockman C, Caso V, Schneider PA. Carotid Interventions for Women: The Hazards and Benefits. Stroke. 2022.

Atherosclerotic carotid artery disease (CAD) is responsible for near 10-15% of strokes. Their prevalence increases with age, and there are racial and gender differences. The incidence is highest in Native American people followed by white. African American males and Asian females have the lowest prevalence. The estimated >50% sclerotic CAD prevalence in Caucasian males is 2.3% in their 60s, which increases to 6.0% in 70s and 7.5% in 80s. The corresponding prevalence in women is 2.0%, 3.6% and 5.0% in their 60s, 70s and 80s, respectively. Active smoking, diabetes and hypertension are strongly associated with increased carotid intima and media thickness and carotid plaque. Other cardiovascular risk factors include metabolic syndrome and hypertriglyceridemia. The age-related changes in the intima progresses faster in women after age 60 secondary to menopause, which causes stiffer arteries and hypertension.

It is a well-known fact that the ipsilateral stroke risk increases with the degree of stenosis which is independent of gender. The outcome of stroke and CAD is worse in women due to several reasons including disease pathophysiology, role of estrogen and other sex hormones, access to care, seeking medical attention, provider bias, and socioeconomic status. Women tend to present with uncommon symptoms including incontinence, nausea, loss of consciousness, and difficulty swallowing, which may lead to delay in diagnosis and treatment. The cerebral ischemic response is also thought to be different in men vs women.

By |February 3rd, 2022|clinical|Comments Off on Carotid Intervention in Women: To Treat or Not to Treat?

Article Commentary: “Health Screening Program to Enhance Enrollment of Women and Minorities in CREST-2”

Karissa Arthur, MD

Lal BK, Meschia JF, Jones M, Aronow HD, Lackey A, Lake R, Howard G, Brott TG. Health Screening Program to Enhance Enrollment of Women and Minorities in CREST-2. Stroke. 2022.

Enrollment of women and minorities into trials related to carotid disease is low, despite efforts to bolster recruitment of these groups. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) therefore sought to improve recruitment of women and minorities via a screening program. Life Line Screening (LLS) is a nationwide private health screening organization which helps to identify adults at risk for serious vascular diseases via screening events in local communities across the United States. The investigators developed a partnership (CREST-LLS partnership) in order to enhance identification of asymptomatic carotid stenosis among women and minorities.

For the CREST-LLS partnership, all LLS screening events occurring within a 50-mile radius of a CREST-2 center were identified for participation over the course of one year. Each event evaluates 25-100 participants who are recruited via targeted emails, local television and radio channels, newspapers, and direct mail. Cost to the participant was variable and depended on pre-arranged sponsorships, union health plans, and the assessments selected by participants. Available assessments included blood pressure measurements, ankle-brachial measurements, ECG, and blood lipid levels. If participants were over 50 with at least 2 vascular risk factors, carotid artery duplex ultrasound was performed by trained and certified vascular ultrasound technologists. If ultrasound peak systolic velocity was greater than or equal to 230 cm/s, participants were suspected of having high-grade carotid stenosis. These participants were provided the findings and informed about the opportunity to be evaluated at the nearest CREST-2 clinical center. Their consent to be contacted by study coordinators was also requested by non-medical staff.

By |February 2nd, 2022|clinical|Comments Off on Article Commentary: “Health Screening Program to Enhance Enrollment of Women and Minorities in CREST-2”