Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis

BACKGROUND

Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use.

METHODS AND RESULTS

A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration.

CONCLUSIONS

Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

Calcium Antagonists in the Management of Patients with Aneurysmal Subarachnoid Hemorrhage: A Review

Cerebral arterial vasospasm and infarction is the leading cause of death and disability among patients who reach a major medical center after aneurysmal subarachnoid hemorrhage (SAH). Recent evidence suggests that two calcium antagonists, nimodipine or nicardipine, may be useful in preventing this important complication of SAH. This paper reviews the current status of these two calcium antagonists in the management of SAH.

Cytokines, brain proteins, and growth factors in acute stroke patients: A pilot study

BACKGROUND

Immunomodulation and cell signaling involve several cytokines, proteins, and other mediators released in response to the trauma, inflammation, or other insults to the central nervous system. This pilot study is part of the registry designed to evaluate the temporal trends among these molecules after an acute ischemic stroke (AIS) in patients.

METHODS

Twelve AIS patients were enrolled within 24 hours of the symptoms onset. Two sets of plasma samples were collected: First at admission and second at 24 hours after admission. Cytokines/chemokines and other inflammatory molecules were measured using multiplex assay kit.

RESULTS

An increased trend in IL-6 (22 vs. 34 pg/ml), IL-8/CXCL8 (87 vs. 98 pg/ml), MMP-9 (16225 vs. 18450 pg/ml), and GMF-β (999 vs. 3739 pg/ml) levels was observed overtime after an AIS. Patients ≤60 years had lower levels of plasma MCP-1/CCL2 (50-647 vs. 150-1159 pg/ml), IL-6 (9-25 vs. 20-68 pg/ml), and IL-8 (30- 143 vs. 72-630 pg/ml), when compared with patients >60 years old.

CONCLUSION

Cytokines/chemokines and other inflammatory mediators play an important role in the pathogenesis of stroke in addition to mediating poststroke inflammation. Further research is needed to evaluate and characterize the cumulative trends of these mediators for the clinical prognosis or as surrogate biomarkers.

The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults

OBJECTIVE

To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates.

METHODS

We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality.

RESULTS

We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality.

CONCLUSIONS

The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.

Transient global amnesia does not increase the risk of subsequent ischemic stroke: a propensity score-matched analysis

INTRODUCTION

Data regarding the risk of cerebrovascular events following transient global amnesia (TGA) remain controversial. While some neuroradiological studies suggest an underlying cerebrovascular etiology, results from the clinical studies have been largely conflicting. We, therefore, aimed to evaluate the risk of ischemic stroke in a large, nationally representative sample of patients with TGA.

METHODS

We utilized the Nationwide Readmissions Database 2010-2015 to identify all hospitalizations with the primary discharge diagnosis of TGA. We selected a 2% random sample of all elective admissions to be included as controls. A propensity score-matched analysis was performed to match patients with TGA and the controls. The primary outcome was readmission due to ischemic stroke up to 1 year following discharge from the index hospitalization, assessed using the Kaplan-Meier survival analysis in the propensity-matched groups.

RESULTS

There were 24,803 weighted hospitalizations due to TGA (mean ± SD age: 65.6 ± 10.4 years, female: 54.9%) and 699,644 corresponding controls. At baseline, patients with TGA were significantly older, more likely to be male, and had a higher prevalence of hypertension, hyperlipidemia, coronary artery disease, cerebrovascular disease, and migraine, as compared to the controls. However, after propensity score matching, we obtained 21,202 cases and 21,293 well-matched corresponding controls, and the risk of readmission due to ischemic stroke in patients with TGA was not different compared to the control group (HR: 1.13, 95% CI 0.62-2.05, P 0.686) during the mean (SD) follow-up period of 192.2 (102.4) days.

CONCLUSIONS

After adjustment for demographics and cerebrovascular risk factors, TGA is not associated with an increased risk of subsequent ischemic stroke.

Abstract P428: The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults

Introduction: The intracerebral hemorrhage (ICH) score is a widely used scoring system for predicting mortality in patients with ICH. This score has been validated for use in adults of all ages with ICH, but not specifically for use in populations of young adults (age 18-45). We aimed to determine the validity of the ICH score when applied to young adults with ICH.

Methods: This was a retrospective analysis of all patients aged 18-45 with spontaneous ICH consecutively admitted to our institution from 2009-2019. We calculated the ICH score for each patient, recording the individual subcomponents, and analyzed the scores for prediction of mortality at 30 days. We also analyzed the individual subcomponents of the score for effect on mortality.

Results: We identified 156 patients (mean age 35 +/- 7.8; 67 were female, 103 were white) to include in our study. The 30-day mortality rate was 15% (n=24); these patients had a mean age of 34.9 +/- 7.8, compared to survivors who had mean age 35.4 +/- 7.8 (p=0.797). ICH scores were predictive of mortality (p=0.036 for trend); however, the actual mortality rates in our population were substantially lower than those predicted by the ICH score. Specifically, patients in our population with scores of 1, 2, or 3 had 30-day mortality rates of 0%, 3%, and 41%, compared to the current ICH score mortality predictions of 13%, 26%, and 72%, respectively. Scores of 4 and 5 in our population were more closely aligned to current ICH predictions (85% and 100% compared to 97% and 100%, respectively). Of the ICH score subcomponents, ICH volume >30mL (p=0.007) and Glasgow Coma Scale (GCS) scores of 3 or 4 (p=0.014) were the strongest predictors of mortality at 30 days.

Conclusion: The ICH score is predictive of mortality for adults of all ages, but the specific mortality rates associated with this scoring system vary considerably when applied to young adults (age 18-45). This over-estimation should be taken into consideration when applying the predictions of the ICH score to young adults with ICH; additionally, special attention should be given to ICH volume >30mL and very low GCS scores, as these were the strongest predictors of early mortality.

Cerebrovascular manifestations of tumors of the heart

Primary tumors of the heart, most commonly myxoma, are an uncommon cause of ischemic stroke and intracranial aneurysms. The tumors may occur in any age group but are most frequently detected in middle-aged persons with an atypical or cryptogenic stroke. While some patients will have a history of cardiac or constitutional symptoms, in many cases ischemic stroke will be the initial manifestation of the cardiac mass. Myxomas are the most common cardiac tumors, and valvular fibroelastoma is also a potential cardiac cause of stroke. Among patients with stroke, the most common location for a myxoma is the left atrium. Elevations of inflammatory markers provide clue for a myxoma. Cardiac imaging is the most definitive diagnostic study. Treatment centers on surgical removal of the cardiac mass may be curative.

Management of Ischemic Stroke Following Left Ventricular Assist Device

BACKGROUND

Acute ischemic stroke is a common complication and an important source of morbidity and mortality in patients with left ventricular assist devices. There are no standardized protocols to guide management of ischemic stroke among patients with left ventricular assist device. We evaluated our experience treating patients who had an acute ischemic stroke following left ventricular assist device placement.

METHODS

We retrospectively reviewed all patients who underwent left ventricular assist device placement from 2010-2019 and identified patients who had acute ischemic stroke following left ventricular assist device placement.

RESULTS

Of 216 patients having left ventricular assist device placement (mean±SD age 52.9±16.2 years, women 26.9%), 19 (8.8%) had acute ischemic stroke (mean±SD age 55.8±12.0 years, women 36.8%). Median (interquartile range) time to ischemic stroke following left ventricular assist device placement was 96 (29-461) days. At the time of the ischemic stroke, 16/19 (84.2%) patients were taking both antiplatelet and anticoagulation therapy, 1/19 (5.3%) patient was receiving only anticoagulants, 1/19 (5.3%) patient was taking aspirin and dipyridamole, and 1/19 (5.3%) patient was not taking antithrombic agents. INR was subtherapeutic (INR<2.0) in 7/17 (41.2%) patients. No patient was eligible to receive thrombolytic therapy, while 5/19 (26.3%) underwent mechanical thrombectomy. Anticoagulation was continued in the acute stroke phase in 11/19 (57.9%) patients and temporarily held in 8/19 (42.1%) patients. Hemorrhagic transformation of the ischemic stroke occurred in 6/19 (31.6%) patients. Anticoagulation therapy was continued following ischemic stroke in 4/6 (66.7%) patients with hemorrhagic transformation.

CONCLUSIONS

While thrombolytic therapy is frequently contraindicated in the management of acute ischemic stroke following left ventricular assist device, mechanical thrombectomy remains a valid option in eligible patients. Anticoagulation is often continued through the acute phase of ischemic stroke secondary to concerns for LVAD thrombosis. The risks and benefits of continuing anticoagulation must be weighed carefully, especially in patients with large infarct volume, as hemorrhagic transformation remains a common complication.

Detection and Quantification of Symptomatic Atherosclerotic Plaques With High-Resolution Imaging in Cryptogenic Stroke

BACKGROUND AND PURPOSE

High-resolution vessel wall imaging (HR-VWI) is a powerful tool in diagnosing intracranial vasculopathies not detected on routine imaging. We hypothesized that 7T HR-VWI may detect the presence of atherosclerotic plaques in patients with intracranial atherosclerosis disease initially misdiagnosed as cryptogenic strokes.

METHODS

Patients diagnosed as cryptogenic stroke but suspected of having an intracranial arteriopathy by routine imaging were prospectively imaged with HR-VWI. If intracranial atherosclerotic plaques were identified, they were classified as culprit or nonculprit based on the likelihood of causing the index stroke. Plaque characteristics, such as contrast enhancement, degree of stenosis, and morphology, were analyzed. Contrast enhancement was determined objectively after normalization with the pituitary stalk. A cutoff value for plaque-to-pituitary stalk contrast enhancement ratio (CR) was determined for optimal prediction of the presence of a culprit plaque. A revised stroke cause was adjudicated based on clinical and HR-VWI findings.

RESULTS

A total of 344 cryptogenic strokes were analyzed, and 38 eligible patients were imaged with 7T HR-VWI. Intracranial atherosclerosis disease was adjudicated as the final stroke cause in 25 patients. A total of 153 intracranial plaques in 374 arterial segments were identified. Culprit plaques (n=36) had higher CR and had concentric morphology when compared with nonculprit plaques (P≤0.001). CR ≥53 had 78% sensitivity for detecting culprit plaques and a 90% negative predictive value. CR ≥53 (P=0.008), stenosis ≥50% (P<0.001), and concentric morphology (P=0.030) were independent predictors of culprit plaques.

CONCLUSIONS

7T HR-VWI allows identification of underlying intracranial atherosclerosis disease in a subset of stroke patients with suspected underlying vasculopathy but otherwise classified as cryptogenic. Plaque analysis in this population demonstrated that culprit plaques had more contrast enhancement (CR ≥53), caused a higher degree of stenosis, and had a concentric morphology.

Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States

INTRODUCTION

A diagnosis of transient ischemic attack (TIA) must be followed by prompt investigation and rapid initiation of measures to prevent stroke. Prior studies evaluating the risk of stroke after TIA were conducted in the emergency room or clinic settings. Experience of patients admitted to the hospital after a TIA is not well known. We sought to assess the early risk of ischemic stroke after inpatient hospitalization for TIA.

METHODS

We used the 2010-2015 Nationwide Readmissions Database to identify all hospitalizations with the primary discharge diagnosis of TIA and investigated the incidence of ischemic stroke readmissions within 90 days of discharge from the index hospitalization.

RESULTS

Of 639,569 index TIA admissions discharged alive (mean ± SD age 70.4 ± 14.4 years, 58.7% female), 9,131 (1.4%) were readmitted due to ischemic stroke within 90 days. Male sex, head/neck vessel atherosclerosis, hypertension, diabetes, atrial flutter/fibrillation, previous history of TIA/stroke, illicit drug use, and higher Charlson Comorbidity Index score were independently associated with readmissions due to ischemic stroke. Ischemic stroke readmissions were associated with excess mortality, discharge disposition other than to home, and elevated cost.

CONCLUSIONS

Patients hospitalized for TIA have a lower risk of ischemic stroke compared to that reported in the studies based on the emergency room and/or outpatient clinic evaluation. Among these patients, those with cardiovascular comorbidities remain at a higher risk of readmission due to ischemic stroke despite undergoing an inpatient evaluation and should therefore be the target for future preventive strategies.

Differential Risk Factors and Outcomes of Ischemic Stroke due to Cervical Artery Dissection in Young Adults

INTRODUCTION

Cervical artery dissection (CeAD) is a major cause of ischemic stroke in young adults. Our understanding of the specific risk factors and clinical course of CeAD is still evolving. In this study, we evaluated the differential risk factors and outcomes of CeAD-related strokes among young adults.

METHODS

The study population consisted of young patients 15-45 years of age consecutively admitted with acute ischemic stroke to our comprehensive stroke center between January 1, 2010, and November 30, 2016. Diagnosis of CeAD was based on clinical and radiological findings. Univariate and multivariable logistic regression analyses were used to assess the risk factors and clinical outcomes associated with CeAD-related strokes.

RESULTS

Of the total 333 patients with acute ischemic stroke included in the study (mean ± SD age: 36.4 ± 7.1 years; women 50.8%), CeAD was identified in 79 (23.7%) patients. As compared to stroke due to other etiologies, patients with CeAD were younger in age, more likely to have history of migraine and recent neck manipulation and were less likely to have hypertension, diabetes, and previous history of stroke. Clinical outcomes of CeAD were comparable to strokes due to other etiologies. Within the CeAD group, higher initial stroke severity and history of tobacco use were associated with higher modified Rankin Scale score at follow-up.

CONCLUSIONS

While history of migraine and neck manipulation are significantly associated with CeAD, most of the traditional vascular risk factors for stroke are less prevalent in this group when compared to strokes due to other etiologies. For CeAD-related strokes, higher initial stroke severity and history of tobacco use may be associated with higher stroke-related disability, but overall, patients with CeAD have similar outcomes as compared to strokes due to other etiologies.

Training in Neurology: Feedback from Graduates About the Psychiatry Component of Residency Training

OBJECTIVE

To obtain feedback from early career adult and pediatric neurologists about the psychiatry component of residency training.

METHODS

A survey was developed and administered electronically to 4 cohorts of recently certified American Board of Psychiatry and Neurology diplomates.

RESULTS

The response rate was 16% (431/2,677) and included 330 adult neurologists and 101 pediatric neurologists. Fewer than half of the respondents described themselves as extremely or quite satisfied with their psychiatry training whereas 26% of the adult neurologists and 33% of the pediatric neurologists felt slightly or not at all prepared for this component of practice. Four themes were identified in the respondents' suggestions for improving psychiatry training: provide more outpatient experience; provide more time/teaching in psychiatry; provide more experience with both pharmacologic and nonpharmacologic psychiatric treatments; and provide more exposure to patients with conditions likely to be encountered in neurology/child neurology practice.

CONCLUSION

These recent graduates of adult and pediatric neurology residency programs felt underprepared for the psychiatric issues they encountered in their patients. They suggested a number of strategies for better alignment of psychiatry training with the likely demands of practice. A model curriculum recently developed by the American Academy of Neurology's Consortium of Neurology Program Directors and the American Association of Directors of Psychiatric Residency Training also provides guidance for both neurology and psychiatry program directors.

Abstract TP220: Differential Risk Factors and Outcomes of Ischemic Stroke Due to Cervical Artery

Introduction: Cervical artery dissection (CeAD) is a major cause of acute ischemic stroke (AIS) in young adults. Its pathophysiology is distinct from the other etiologies of AIS and is determined by both genetic and environmental factors. In this study, we sought to determine the risk factors for and outcomes of AIS due to CeAD in young adults, in the era of increasing utilization of neuroimaging and neuro-intervention procedures.

Methods: We retrospectively reviewed all cases of AIS between 15-45 years of age admitted to our comprehensive stroke center between January 2010 - November 2016. Risk factors and outcomes were compared between patients with and without CeAD using univariate analysis. Multivariable generalized linear and logistic regression models were used to adjust for confounding variables.

Results: Of the total 333 patients with AIS included in the study (mean±SD age: 36.4±7.1 years; females 50.8%), CeAD was identified in 84 (25.2%) patients. When compared to the non-CeAD group, patients with CeAD were younger in age and more likely to have a history of migraine and recent chiropractic neck manipulation (p<0.05). Risk factors including hypertension, diabetes, hyperlipidemia and obesity were more prevalent in the non-CeAD group (p<0.05). Patients with CeAD had shorter hospital stay by an average of 1.8 days (95% CI=0.3-3.4, p<0.05), however, this difference was not statistically significant after adjustment for initial NIHSS score, age, gender, and comorbidities. Patients with CeAD were more likely to have worse functional outcome at discharge, defined as modified Rankin scale score (mRS) ≥3, independent of the above confounding variables (adjusted odds ratio 3.6, 95% CI=1.6-8.1). The in-hospital mortality rate, discharge disposition, mRS score and recurrence rates at follow-up (mean time 4.2 months) were similar between the two groups.

Conclusions: While history of migraine and recent chiropractic neck manipulation are significantly associated with CeAD; most of the traditional vascular risk factors are less prevalent in this group. In comparison with AIS due to other etiologies, patients with CeAD have worse functional outcomes at the time of discharge but similar outcomes at follow up, which suggests a propensity for better recovery.

Abstract WP252: Secular Trends for Etiologies of Acute Ischemic Stroke in Young Adults

Introduction: Because acute ischemic stroke (AIS) in young adults is not rare, understanding trends in etiology may help decisions about evaluation and secondary stroke prevention. This study describes probable causes of AIS in a cohort of young adults and identifies changes in etiologies and diagnostic studies compared to 20 years ago.

Methods: We retrospectively reviewed all patients aged 15-45 admitted to our comprehensive stroke center between 1/2010-11/2016 with AIS. Diagnostic studies and stroke etiologies for each patient were reviewed. We then compared our results to a historic sample of young patients who presented to our center in 1977-1993 using univariate chi-squared comparison for each etiology.

Results: We identified 333 young adults, 169 (50.8%) were women. The mean age was 36.4±7.1 years. Vessel imaging was performed in 305 (91.3%) cases vs. 68.9% in the historic sample. Of these, 247 (81.0%) had magnetic resonance angiography (MRA). Transthoracic echocardiography (TTE) was performed in 101 (30.3%) and transesophageal echocardiography (TEE) was performed in 171 (51.4%) cases compared to 67.1% who underwent TTE in the historic sample. Etiologic comparisons to the historic sample yielded significant decline in small vessel disease ( P = .029) and a major increase in stroke of other identified cause ( P = .024). Other TOAST etiologies illustrated in Figure 1. The most common etiology for stroke in our sample was arterial dissection 84 (25.2%), whereas this was found in only 6.0% of patients in the historic sample ( P< .001).

Conclusions: Using the TOAST classification, the most common subtype in young adults was stroke of other identified cause; a rate that reflects a marked increase in the diagnosis of dissection. Despite advancement in diagnostic studies, cryptogenic stroke remains a common category in young adults.

National Institutes of Health StrokeNet Training Core

Background and Purpose- The National Institutes of Health (NIH) StrokeNet provides a nationwide infrastructure to advance stroke research. Capitalizing on this unique opportunity, the NIH StrokeNet Training Core (NSTC) was established with the overarching goal of enhancing the professional development of a diverse spectrum of professionals who are embedded in the stroke clinical trials network of the NIH StrokeNet. Methods- This special report provides a descriptive account of the rationale, organization, and activities of the NSTC since its inception in 2013. Current processes and their evolution over time for facilitating training of NIH StrokeNet trainees have been highlighted. Data collected for monitoring training are summarized. Outcomes data (publications and grants) collected by NSTC was supplemented by publicly available resources. Results- The NSTC comprises of cross-network faculty, trainees, and education coordinators. It helps in the development and monitoring of training programs and organizes educational and career development activities. Trainees are provided directed guidance towards their mandated research projects, including opportunities to present at the International Stroke Conference. The committee has focused on developing sustainable models of peer-to-peer interaction and cross-institutional mentorships. A total of 124 professionals (43.7% female, 10.5% underrepresented minorities) have completed training between 2013 and 2018, of whom 55% were clinical vascular neurologists. Of the total, 85% transitioned to a formal academic position and 95% were involved in stroke research post-training. Altogether, 1659 indexed publications have been authored or co-authored by NIH StrokeNet Trainees, of which 58% were published during or after their training years. Based on data from 109 trainees, 33% had submitted 72 grant proposals as principal or co-principal investigators of which 22.2% proposals have been funded. Conclusions- NSTC has provided a foundation to foster nationwide training in stroke research. Our data demonstrate strong contribution of trainees towards academic scholarship. Continued innovation in educational methodologies is required to adapt to unique training opportunities such as the NIH StrokeNet.

Recurrent Hemispheric Stroke Syndromes in Symptomatic Atherosclerotic Internal Carotid Artery Occlusions: The Carotid Occlusion Surgery Study Randomized Trial

BACKGROUND

There are limited data on outcomes of extracranial-intracranial (EC-IC) bypass in patients with recurrent hemispheric syndromes due to atherosclerotic internal carotid artery occlusion (AICAO).

OBJECTIVE

To compare clinical outcomes and efficacy of EC-IC bypass surgery in patients with and without recurrent hemispheric syndromes associated with AICAO in the Carotid Occlusion Surgery Study (COSS).

METHODS

In patients enrolled in the COSS trial, we compared baseline characteristics and clinical outcomes for participants with (rHEMI+) and without recurrent hemispheric ischemia (rHEMI−) prior to randomization into surgical vs medical groups. The primary outcome was all stroke and death from randomization through 30 d and ipsilateral ischemic stroke within 2 yr.

RESULTS

Of 195 randomized participants, 100 were rHEMI+ (50 in each group). Baseline characteristics between rHEMI+ and rHEMI− participants were similar except rHEMI+ were more likely to have had previous stroke prior to randomization (61% vs 20%, P &lt; .01) and to have TIA as the entry event (59% vs 21%, P &lt; .01). All primary endpoints were ipsilateral ischemic strokes. There were no significant differences in occurrence of the primary endpoint between nonsurgical and surgical participants in rHEMI+ (26.3% vs 22.4%, P = .660) and rHEMI− (18.9% vs 19.5%, P = .943). For nonsurgical participants, there was no significant difference in the primary endpoint for rHEMI+ vs rHEMI− patients (P = .410)

CONCLUSION

Patients with recurrent hemispheric stroke syndromes enrolled in the COSS trial did not show benefit from EC-IC bypass compared to medical treatment. Early aggressive risk factor measures should be prioritized to reduce recurrent strokes in these patients.

Bradycardia and Asystole in Patients Undergoing Symptomatic Chronically Occluded Internal Carotid Artery Recanalization

BACKGROUND

Reports have emerged describing the successful endovascular recanalization of the chronically occluded internal carotid artery (COICA). The impact this restoration of flow has on the sensitive carotid sinus baroreceptors has not been previously described. In this manuscript, we present the largest COICA surgical series to date, with a specific focus on perioperative heart rate abnormalities.

METHODS

Patient demographics were obtained, and the COICAs were radiographically classified based on the anatomic distribution of the stenosis and collateral flow. Thirty-six patients had a total of 37 COICA revascularization procedures.

RESULTS

A total of 23 patients had intraprocedural bradycardia during balloon angioplasty. Three patients went into transient asystole during the procedure, and 2 of these patients had symptomatic bradycardia with ischemic cerebral changes, 1 of which required permanent pacemaking. All other patients had immediate resolution of their bradycardia, asystole, and neurologic symptoms immediately following balloon deflation and pharmaceutical management. There was a statistically significant difference in the observed proportion of bradycardic patients among COICA classifications (P = 0.014). There was no statistically significant difference in mean age between patients with bradycardia and those without (aged 63.36 vs. 67.71 years, P = 0.2265).

CONCLUSIONS

Bradycardia associated with angioplasty of the carotid bulb was observed in the majority of patients receiving COICA revascularization. A small percentage of these patients were symptomatic. Our results suggest that carotid sinus baroreceptors remain active while residing in a complete arterial occlusion, and close monitoring is necessary during balloon angioplasty of the proximal COICA.

Secular Increases in Spontaneous Subarachnoid Hemorrhage during Pregnancy: A Nationwide Sample Analysis

IMPORTANCE

Understanding of the epidemiology, outcomes, and management of spontaneous subarachnoid hemorrhage (sSAH) during pregnancy is limited. Small, single center series suggest a slight increase in morbidity and mortality.

OBJECTIVE

To determine if incidence of sSAH in pregnancy is increasing nationally and also to study the outcomes for this patient population.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis was performed utilizing the Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project for the years 2002-2014 for sSAH hospitalizations. The NIS is a large administrative database designed to produce nationally weighted estimates. Female patients age 15-49 with sSAH were identified using the International Classification of Diseases, 9th Revision, Clinical Modification code 430. Pregnancy and maternal diagnosis were identified using pregnancy related ICD codes validated by previous studies. The Cochran-Armitage trend test and parametric tests were utilized to analyze temporal trends and group comparisons. Main Outcomes and Measures: National trend for incidence of sSAH in pregnancy, age, and race/ethnicity as well as associated risk factors and outcomes.

RESULTS

During the time period, there were 73,692 admissions for sSAH in women age 15-49 years, of which 3978 (5.4%) occurred during pregnancy. The proportion of sSAH during pregnancy hospitalizations increased from 4.16 % to 6.33% (P-_Trend < .001) during the 12 years of the study. African-American women (8.19%) and Hispanic (7.11%) had higher rates of sSAH during pregnancy than whites (3.83%). In the NIS data, the incidence of sSAH increased from 5.4/100,000 deliveries (2002) to 8.5/100,000 deliveries (2014; P-_Trend < .0001). The greatest increase in sSAH was noted to be among pregnant African-American women from (13.4 [2002]) to (16.39 [2014]/100,000 births). Mortality was lower in pregnant women (7.69% versus 17.37%, P < .0001). Pregnant women had a higher likelihood of being discharged to home (69.78% versus 53.66%, P < .0001) and lower likelihood of discharge to long term facility (22.4% versus 28.7%, P < .0001) than nonpregnant women after sSAH hospitalization.

CONCLUSIONS AND RELEVANCE

There is an upward trend in the incidence of sSAH occurring during pregnancy. There was disproportionate increase in incidence of sSAH in the African American and younger mothers. Outcomes were better for both pregnant and nonpregnant women treated at teaching hospitals and in pregnant women in general as compared to nonpregnant women.

Diagnosis and Treatment of Primary Central Nervous System Angiitis

PURPOSE OF REVIEW

Primary central nervous system angiitis (PCNSA) is a rare disease. Varying clinical pictures coupled with lack of sensitive and specific diagnostic tests lead to challenges in management of these patients. This unfortunately may lead to both under- or over-diagnosis and unnecessary treatment. It is important to recognize the different conditions that may mimic the clinical and radiologic presentation. We present a contemporary literature review that should update physicians who encounter this patient population.

RECENT FINDINGS

Recent additions to the literature in form of case reports and single-center series show that digital subtraction angiography was the most widely used test to diagnose PCNSA. It is also important to note that brain biopsy is still considered "gold standard" and should be pursued as it not only has information that establishes the diagnosis but also may help in ruling out the diagnosis from mimics. In around 39% of suspected cases, an alternate diagnosis was eventually confirmed highlighting the importance of a comprehensive work-up. For treatment, almost all the literature supports the use of glucocorticoids as the initial treatment and if the patient has a relapse or develops steroid toxicity then the second most commonly used agent was cyclophosphamide. There are increasing reports of benefits with other agents such as methotrexate, azathioprine, mycophenolate, infliximab, and etanercept. The diagnosis and management of PCNSA continues to be a challenge. Formation of prospective patient registries with continued immunologic research for novel targets and immunomodulatory modalities may hold promise for future care of these patients.

Mechanical Thrombectomy: Emerging Technologies and Techniques

BACKGROUND

The treatment of acute ischemic stroke due to large vessel occlusion (LVO) has revolutionized in the last decade. We sought to compile the most relevant literature published about the evolution in treating this disabling and fatal disease.

METHODS

A literature review of recent studies describing early treatment options like intravenous tissue plasminogen activator to the latest mechanical thrombectomy (MT) techniques was performed. We described in a chronological order the evolution of LVO treatment.

RESULTS

Recanalization rates with newer techniques and MT devices approach a 90% of effectiveness. Timely interventions have also resulted in better clinical outcomes with approximately 50% of patient achieving functional independence at 90 days. At least 14 new third generation thrombectomy devices are currently being evaluated in in vitro and clinical studies.

CONCLUSIONS

The treatment of LVO with MT is feasible and safe. MT is standard of care in treating acute ischemic stroke due to LVO.

Cerebral Microbleeds are an Independent Predictor of Hemorrhagic Transformation Following Intravenous Alteplase Administration in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Intravenous alteplase (rt-PA) increases the risk of hemorrhagic transformation of acute ischemic stroke. The objective of our study was to evaluate clinical, laboratory, and imaging predictors on forecasting the risk of hemorrhagic transformation following treatment with rt-PA. We also evaluated the factors associated with cerebral microbleeds that increase the risk of hemorrhagic transformation.

METHODS

Consecutive patients with acute ischemic stroke admitted between January 1, 2009 and December 31, 2013 were included in the study if they received IV rt-PA, had magnetic resonance imaging (MRI) of the brain on admission, and computed tomography or MRI of the brain at 24 (18-36) hours later to evaluate for the presence of hemorrhagic transformation. The clinical data, lipid levels, platelet count, MRI, and computed tomography images were retrospectively reviewed.

RESULTS

The study included 366 patients, with mean age 67 ± 15 years; 46% were women and 88% were white. The median National Institutes of Health Stroke Scale (NIHSS) score was 6 (interquartile range 3-15). Hemorrhagic transformation was observed in 87 (23.8%) patients and cerebral microbleeds were noted in 95 (25.9%). Patients with hemorrhagic transformation tended to be older, nonwhite, have atrial fibrillation, higher baseline NIHSS score, lower cholesterol and triglyceride levels, and cerebral microbleeds and nonlacunar infarcts. Patients with cerebral microbleeds were more likely to be older, have hypertension, hyperlipidemia, previous history of stroke, and prior use of antithrombotics. On multivariate analysis race, NIHSS score, nonlacunar infarct, and presence of cerebral microbleeds were independently associated with hemorrhagic transformation following treatment with rt-PA.

CONCLUSIONS

Presence of cerebral microbleeds is an independent predictor of hemorrhagic transformation of acute ischemic stroke following treatment with rt-PA.

Abstract TP305: Geographical Dispersion of Patients Referred to a Comprehensive Stroke Center in a Rural Setting

Introduction: Most patients with stroke in Iowa are initially seen in small community hospitals and are subsequently transferred to another institution with a higher level of care. The Iowa Stroke Registry (ISR) was developed to assess the system of stroke care in the state. Community hospitals in the state are supported by the comprehensive stroke center (CSC) through consultation for acute stroke treatment. The objective for this project was to analyze the geographical dispersion of transfers to the CSC to begin an evaluation of the system of stroke care in the state.

Method: We analyzed the prospectively collected data in the Iowa Stroke Registry (ISR). The ISR has collected data from 32 hospitals: comprehensive (1), primary (15), and stroke capable hospitals in Iowa beginning in 2010. To date over 23, 000 patients have been enrolled. Information from this analysis included the CSC data only collected in a national database and imported ino the ISR from 2015-April, 2017 that included zip code data. During that time period 2576 patients were direct admissions or transfers to the CSC. Distances were based on the number of miles between the patients’ and CSC zip code.

Results: Approximately 80% of all stroke patients at the CSC were transferred from a community hospital. Patients originated in 78 of the 99 counties in Iowa. The median distance was 63 miles. Of the transfers from local hospitals, 86% were within 90 miles with the largest group 60-89 miles from the CSC. Of all patients transferred for ischemic stroke approximately 30% received treatment with intravenous alteplase at the outside hospital.

Conclusion: In conclusion, these data suggest a high degree of geographical dispersion for stroke patients transferred to a CSC in a rural state. This analysis of the system of stroke care in Iowa indicates the CSC provided support to multiple community hospitals for acute stroke treatment. Further analysis of the system of stroke care is needed to better understand patient transfers including mode of transfer and reason for transfer.

Intracerebral hemorrhage after IV tPA for stroke as early symptom of ANCA-associated vasculitis

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rare diseases characterized by a necrotizing small-vessel vasculitis and circulating ANCA that comprise granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (EGPA). Acute ischemic stroke (AIS) can be a manifestation of central nervous system (CNS) involvement in these diseases. Furthermore, intracerebral hemorrhage (ICH) is a potential complication of these necrotizing vasculitides. We describe a case of AAV who presented with acute ischemic stroke and developed multiple ICHs after administration of IV tPA. We propose that patients with AAV are more prone to develop hemorrhage in the presence of IV tPA and discuss the possible underlying pathogenesis. We suggest that AAV should be considered a contraindication for administration of IV tPA.

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ANCA-associated vasculitides (AAV) can present with acute ischemic stroke.

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Intracerebral hemorrhage is a potential complication of AAV.

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IV tPA can increase risk of ICH in patients with AAV.

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AAV could be a relative contraindication for administration of IV tPA.

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial

BACKGROUND

Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.

METHODS

In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134.

FINDINGS

Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar.

INTERPRETATION

In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status.

FUNDING

National Institute of Neurological Disorders and Stroke.

Abstract WP52: White Matter Hyperintensity, Cerebral Microbleeds and Risk of Hemorrhagic Transformation with Intravenous rt-PA

Background and Purpose: Intravenous rt-PA is associated with risk of hemorrhagic transformation. We sought to determine if the degree of white matter hyperintensity on Fluid Attenuated Inversion Recovery (FLAIR) and the presence of cerebral microbleeds (MB) on Gradient Recalled Echo (GRE) sequences on MRI was associated with increased risk of hemorrhagic transformation following intravenous rt-PA.

Methods: Acute ischemic stroke patients admitted to University of Iowa Hospitals and Clinics between 1/1/2009 and 12/31/2013 were included in the study if - i) received intravenous rt-PA ii) had MRI brain with Diffusion Weighted Imaging (DWI), GRE and FLAIR sequence within the first 48 hours of stroke onset, and iii) had CT head or MRI at 20-36hr post rt-PA to evaluate for hemorrhagic transformation. White matter hyperintensity on FLAIR was evaluated based on Fazekas scale from 0-4. A score of 0 and 1 on Fazekas scale was combined to form group 1 and a score 3 and 4 was combined to form group 2 for analysis. MB were evaluated on GRE. Presence of MB was categorized as group 1 (1-5 MB) and 2 (6 or more MB). CT or MRI head performed at 20-36 hours after rt-PA was evaluated for hemorrhagic transformation. If present it was classified as group 1 (HI 1 and 2) and 2 (PH 1 and 2).

Results: A total of 402 patients met the study criteria among 607 patients. Mean age was 67±14 years. Among them 45% were women and 88% whites. FLAIR deep white matter hyperintensity was graded on Fazekas as 0 - 26%, 1-51%, 2-12% and 3-11%. FLAIR periventricular white matter hyperintensity was graded as 0 - 10%, 1-49%, 2-25% and 3- 16%. MB were present in 26% of the study population with only 3 patients in group 2. Hemorrhagic transformation was seen in 24% of the patients with 66% of these having petechial hemorrhage. Deep white matter (p=0.47) and periventricular (p=0.73) white matter hyperintensity was not significantly associated with hemorrhagic transformation. However, presence of MB was significantly associated with hemorrhagic transformation (p=0.006, OR = 2.03, CI 1.215-3.392).

Conclusion: Microbleeds increases the risk of hemorrhagic transformation following administration of intravenous rt-PA. However, white matter hyperintensity did not result in increased risk of hemorrhagic transformation after rt-PA.

Helicopter transportation in the era of thrombectomy: The next frontier for acute stroke treatment and research

Purpose

Many patients suffer a stroke at a significant distance from a specialized center capable of delivering endovascular therapy. As a result, they require rapid transport by helicopter emergency medical services, sometimes while receiving a recombinant tissue plasminogen activator infusion (drip and ship). Despite its critical role in the new era of reperfusion, helicopter emergency medical services remains a poorly evaluated aspect of stroke care.

Method

Comprehensive narrative review of all published articles of helicopter emergency medical services related to acute stroke care in the inter-hospital and pre-hospital settings, including technical aspects and physical environment implications.

Findings

Helicopter emergency medical services transports are conducted during a critical early time period when specific interventions and ancillary care practices may have a significant influence on outcomes. We have limited knowledge of the potential impact of the unusual physical factors generated by the helicopter on the ischemic brain, which affects our ability to establish rational guidelines for ancillary care and the delivery of specific interventions.

Discussion

Unlike the pre-hospital and hospital settings where stroke interventions are delivered, the inter-hospital helicopter emergency medical services transfer setting remains a "black box" for acute stroke care and research. This gap is particularly relevant for many patients living in rural areas, or in congested urban areas, that depend on helicopter emergency medical services for rapid access to a tertiary stroke center.

Conclusion

Addressing the helicopter emergency medical services stroke gap in clinical trials and acute care delivery would homogenize capabilities through all care settings, thus minimizing potential disparities in research access and outcomes based on geographical location.

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

BACKGROUND

Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease.

METHODS

In this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction.

RESULTS

By 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003).

CONCLUSIONS

In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.).

Abstract TP168: Risk of Stroke and Hemorrhage in Patients Treated With Warfarin Versus Dabigatran Requiring Surgery

Introduction: Patients with atrial fibrillation (AF) cease anticoagulants prior to surgery to minimize bleeding risk. Patients requiring emergency surgery may be particularly vulnerable to bleeding if anticoagulants remain in the blood. This may be especially problematic with dabigatran (DAB) use given its lack of reversal agent.

Objective: This study compares stroke or bleeding risk in patients with AF taking DAB or warfarin (WARF) that undergo elective, urgent, or emergent inpatient surgery.

Methods: Medicare inpatient claims were used to identify patients with AF who underwent elective (n=20,535) and urgent or emergent (n=24,665) surgery from 11/2010 -12/2012, and had received DAB or WARF within 90 days prior to admission. Outcomes included stroke and major bleeding within 30 days of surgery, and blood units used during the admission. Other patient characteristics included demographics, operation type, and comorbid conditions. Risk adjusted differences in outcomes between patients taking DAB or WARF were estimated within admission category using multivariable regression.

Results: DAB was used by 5,495 (12%) of patients prior to admission. Overall, 1.0% of patients had stroke within 30 days of surgery, 1.2% had a major bleeding event, and patients received an average 0.12 units of blood. Stroke and bleeding rates did not differ for patients taking WARF or DAB, overall or within admission category. Among elective admissions, blood units used also did not differ between WARF or DAB patients. Among urgent and emergent admissions, patients taking DAB used significantly fewer blood units than patients taking WARF (0.09 vs 0.18, respectively; p<.001). Results were consistent after controlling for other patient factors in multivariable models.

Conclusions: Stroke and bleeding risk in patients taking either DAB or WARF were comparable, while patients taking DAB required significantly fewer blood units than patients taking WARF when undergoing emergency surgery. The lack of a reversal agent for DAB does not appear to increase the risk of complications even for emergency surgery.

Effect of helicopter transport on neurological outcomes in a mouse model of embolic stroke with reperfusion: AIR-MICE pilot study

BACKGROUND

Patients often suffer a stroke at a significant distance from a center capable of delivering endovascular therapy, thus requiring rapid transport by helicopter emergency medical services while receiving a recombinant tissue plasminogen activator infusion that was initiated locally. But little is known about how a helicopter flight may impact the safety and efficacy of recombinant tissue plasminogen activator-induced reperfusion and patient outcomes.

AIM

To establish a new animal method to address with fidelity the safety and overall effect of helicopter emergency medical services during thrombolysis.

METHODS

Prospective randomized open blinded end-point study of an actual helicopter flight exposure. Adult C57BL/6 male mice were treated with a 10 mg/kg recombinant tissue plasminogen activator infusion two-hours after an embolic middle cerebral artery occlusion. Mice were randomized in pairs to simultaneously receive the infusion during a local helicopter flight or in a ground hangar.

RESULTS

Eighteen mice (nine pairs) were analyzed. The paired t-test analysis showed nonsignificant smaller infarction volumes in the helicopter-assigned animals (mean pair difference 33 mm(3) , P = 0·33). The amount of hemorrhagic transformation between the helicopter and ground groups was 4·08 vs. 4·56 μl, respectively (paired t-test, P = 0·45).

CONCLUSIONS

This study shows that helicopter emergency medical services do not have an inherent adverse effect on outcome in a mouse model of ischemic stroke with reperfusion. These results endorse the safety of the practice of using helicopter emergency medical services in stroke patients. The observed potential synergistic effect of helicopter-induced factors, such as vibration and changes in altitude, with reperfusion merits further exploration in animal experimental models and in stroke patients.

IV thrombolysis for treatment of patients with stroke upon awakening: Yes? No?

Current guidelines recommend IV administration of recombinant tissue plasminogen activator (rtPA) to carefully selected patients who can be treated within 4.5 hours of ischemic stroke onset. Patients whose neurologic symptoms are discovered upon awakening (wake-up stroke) generally are not given rtPA because of the uncertainty about the time of stroke onset. This group of patients may be relatively large. Preliminary reports suggest that patients with wake-up stroke who can be treated within 4.5 hours of discovery may respond similarly to patients with an established time of stroke onset. Clinical trials, which are selecting patients to treat primarily based on imaging surrogates, are under way. Pending the results of these trials, data about the utility of clinical or imaging findings that would identify those patients who could be treated and information about the safety and efficacy of IV rtPA in this situation are not available.

Association between neurologic improvement with decline in blood pressure and recanalization in stroke

IMPORTANCE

Patients with stroke often have a decline in blood pressure after thrombolysis. Neurologic improvement could result from recanalization or better collateral flow despite persistent occlusion. We hypothesized that neurologic improvement with concurrent decline in blood pressure may be a clinical sign of recanalization after intravenous tissue plasminogen activator.

OBSERVATIONS

Patients treated with intravenous tissue plasminogen activator at Suburban Hospital, Bethesda, Maryland, and MedStar Washington Hospital Center, Washington, DC, from 1999 to 2009 were included in the study if they had pretreatment and 24-hour magnetic resonance angiographic scans, National Institutes of Health Stroke Scale scores at those times, and proximal middle cerebral artery occlusion demonstrated prior to treatment. The recanalization status on 24-hour magnetic resonance angiography was classified as none, partial, or complete. Seventeen patients met study criteria. On 24-hour magnetic resonance angiography, 3 patients had no recanalization, 8 had partial recanalization, and 6 had complete recanalization. At 24 hours after thrombolysis, neurologic improvement with concurrent decline in systolic blood pressure of 20 mm Hg or greater was seen in 4 patients with partial recanalization, 4 patients with complete recanalization, and none of the patients with no recanalization.

CONCLUSIONS AND RELEVANCE

Neurologic improvement with concurrent decline in systolic blood pressure of 20 mm Hg or greater after intravenous tissue plasminogen activator may be a clinical sign of recanalization. This observation needs confirmation in a larger cohort.

Abstract T P235: Assessing the Impact of Rotorcrafts in a Model of Induced Cerebral Embolism (AIR-MICE)

Objective: Stroke is a time-dependent emergency that often requires emergent helicopter evacuation, a critical early setting for which little is known about the positive or deleterious effect of altitude change, noise, acceleration and vibration. While many of these factors could worsen ischemic injury, the low frequency vibrations might augment clot lysis and enhance rtPA treatment. The objective of this study is to measure the feasibility, safety and potential effect of helicopter transport during thrombolysis in an animal model.

Methodology: Prospective, randomized, open intervention and blinded end-point pilot study that combines a controlled experimental model with a real life helicopter flight exposure. Subjects were adult C57BL/6 male mice that simultaneously underwent an embolic middle cerebral artery occlusion (eMCAO) in pairs. Each pair of mice were randomized to receive 10 mg/kg of rtPA at two hours after eMCAO either during a one hour local flight in a MI2 turbine helicopter, or to simultaneously receive the same rtPA infusion while waiting in an airport hangar. Mice were sacrificed at 24 h. Primary outcome measure was infarct volume. Secondary outcome was neurological scores.

Results: Eighteen mice (9 pairs) were analyzed. Lower infarction volumes were seen in the helicopter assigned group in 6/9 pairs. The mean infarction volumes were 246.6 mm 3 (SD 154) for ground group and 213.6 mm 3 (SD 170) for the helicopter group. A paired t-test analysis showed lesser infarction volumes in the helicopter group (mean difference 33 mm 3 , p=0.33), a difference that was not influenced when adjusting for ambient temperature and atmospheric pressure. The neurological scores were similar in the ground and helicopter groups (1.28 vs. 1.22, p=0.88).

Conclusion: Randomized trials of the effect of helicopter transport in a mouse model of eMCAO are feasible, and desirable to test the effect of neuroprotective therapies in this unique setting. These results endorse the safety of aerial transport, which might be associated with lower infarction volumes. The potential synergist effect of vibration in the rotorcraft with reperfusion needs to be explored further.

The safety of aeroplane travel in patients with symptomatic carotid occlusion

OBJECTIVE

Patients with carotid stenosis or occlusion may be at increased risk for stroke during air travel. Records from the Carotid Occlusion Surgery Study (COSS), a randomised trial of surgical revascularisation for complete carotid artery occlusion and haemodynamic ischaemia, were examined for evidence of stroke related to air travel.

METHODS

COSS subjects who travelled by aeroplane to a regional Positron Emission Tomography (PET) centre for a screening of cerebrovascular haemodynamic evaluation were identified. Maximum altitude and total flight time were estimated based on the distance between origin and destination. Ischaemic events were determined by a structured telephone interview within 24 h of travel. Patient demographics, comorbidities, oxygen extraction fraction (OEF) data and 24 h interview responses were recorded.

RESULTS

Seventy-seven patients with symptomatic carotid occlusion travelled by aeroplane to a single PET centre (174 flights). Fifty-two (67.5%) were men and 25 (32.5%) were women. The average age was 58.7±1.4 years. Twenty-seven patients (35.1%) demonstrated evidence of ipsilateral haemodynamic cerebral ischaemia as measured by PET OEF, while 50 (64.9%) had normal OEF. Patients flew an average distance of 418.9±25.9 miles for 107.1±4.7 min per trip. No patient reported symptoms of a transient ischaemic attack or stroke during or within 24 h after aeroplane travel (95% CI 0% to 2.0%).

CONCLUSIONS

The risk of stroke as a consequence of air travel is low, even in a cohort of patients at high risk for future stroke owing to haemodynamic impairment. These patients with symptomatic carotid occlusion should not be discouraged from air travel.

Reassessing the link between herpes zoster ophthalmicus and stroke

This editorial will assess a proposed link between herpes zoster ophthalmicus and subsequent stoke. Herpes zoster (also called shingles) is caused by varicella-zoster virus (VZV), one of the 9 human herpesviruses. When children contract their primary VZV infection, virus often travels to the trigeminal ganglia and establishes latency. Upon reactivation in late adulthood, the same virus travels anterograde to cause herpes zoster ophthalmicus. In some people, the virus also traffics from the same trigeminal ganglion along afferent fibers around the carotid artery and its branches. Subsequently VZV-induced inflammation within the affected cerebral arteries leads to occlusion and stroke. In one retrospective analysis of people with herpes zoster ophthalmicus, there was a 4.5 fold higher risk of stroke than in a control group. Two other studies found a less compelling association.

Lower stroke risk with lower blood pressure in hemodynamic cerebral ischemia

OBJECTIVE

To determine whether strict blood pressure (BP) control is the best medical management for patients with symptomatic carotid artery occlusion and hemodynamic cerebral ischemia.

METHODS

In this prospective observational cohort study, we analyzed data from 91 participants in the nonsurgical group of the Carotid Occlusion Surgery Study (COSS) who had recent symptomatic internal carotid artery occlusion and hemodynamic cerebral ischemia manifested by ipsilateral increased oxygen extraction fraction. The target BP goal in COSS was ≤130/85 mm Hg. We compared the occurrence of ipsilateral ischemic stroke during follow-up in the 41 participants with mean BP ≤130/85 mm Hg to the remaining 50 with higher BP.

RESULTS

Of 16 total ipsilateral ischemic strokes that occurred during follow-up, 3 occurred in the 41 participants with mean follow-up BP of ≤130/85 mm Hg, compared to 13 in the remaining 50 participants with mean follow-up BP >130/85 mm Hg (hazard ratio 3.742, 95% confidence interval 1.065-13.152, log-rank p = 0.027).

CONCLUSION

BPs ≤130/85 mm Hg were associated with lower subsequent stroke risk in these patients.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that control of hypertension ≤130/85 mm Hg is associated with a reduced risk of subsequent ipsilateral ischemic stroke in patients with recently symptomatic carotid occlusion and hemodynamic cerebral ischemia (increased oxygen extraction fraction).

Cerebral vasculitis

The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.