Acute ischemic stroke

Timing of recanalization after intravenous thrombolysis and functional outcomes after acute ischemic stroke

Authors: Yeo LL, Paliwal P, Teoh HL, Seet RC, Chan BP, Liang S, Venketasubramanian N, Rathakrishnan R, Ahmad A, Ng KW, Loh PK, Ong JJ, Wakerley BR, Chong VF, Bathla G, Sharma VK.

BACKGROUND: Recanalization of occluded intracranial arteries remains the aim of intravenous (IV) tissue plasminogen activator (tPA) therapy in acute ischemic stroke (AIS).
OBJECTIVE: To examine the timing and impact of recanalization on functional outcomes in AIS.
DESIGN: A longitudinal cohort of consecutive IV tPA–treated patients with AIS from January 2007 through December 2010. Data were collected for demography, risk factors, stroke subtypes, blood pressure, and National Institutes of Health Stroke Scale scores. Early recanalization (ER) was identified by transcranial Doppler monitoring during the first 2 hours of treatment. Recanalization was reevaluated at 24 hours by computed tomographic angiography (CTA). Patients with ER and patent index artery at 24 hours on CTA were labeled as having persistent recanalization (PR). Recanalization at 24 hours on CTA regardless of transcranial Doppler status was labeled as CTR. Favorable outcome was defined as a modified Rankin Scale score of 0 to 1 at 3 months.

Interarm blood pressure difference and mortality in patients with acute ischemic stroke

Authors: Kim J, Song TJ, Song D, Lee HS, Nam CM, Nam HS, Kim YD, Heo JH.

OBJECTIVE: The objective of this study was to assess the prognostic value of interarm difference of blood pressure (IAD) measured in acute ischemic stroke and to investigate its association with systemic atherosclerosis.
METHODS: This was a hospital-based retrospective observational study. Survival data and systolic/diastolic IAD were collected in patients with acute ischemic stroke. Systemic atherosclerosis was determined based on coronary CT angiography, transesophageal echocardiography, ankle-brachial index examination, and cerebral angiography covering both intracranial and extracranial cerebral arteries.
RESULTS: Of 834 patients, 10.3% had a systolic IAD ≥10 mm Hg, and 6.0% had a diastolic IAD ≥10 mm Hg. During a mean follow-up period of 2.96 ± 0.95 years, 92 patients died (including 68 cardiovascular deaths). In multivariate Cox regression adjusted for cardiovascular risk factors and initial stroke severity, the presence of systolic IAD ≥10 mm Hg was associated with increased risk of all-cause mortality (hazard ratio 1.97, 95% confidence interval 1.16-3.35) and cardiovascular mortality (HR 2.49, 95% CI 1.39-4.46). Patients with diastolic IAD ≥10 mm Hg also had increased risk of all-cause mortality (HR 3.43, 95% CI 1.94-6.08) and cardiovascular mortality (HR 3.51, 95% CI 1.83-6.74). The presence of systolic or diastolic IAD ≥10 mm Hg was associated with peripheral artery disease in the lower limbs, but not with atherosclerosis in the cerebral artery, coronary artery, or the aorta.
CONCLUSIONS: The presence of interarm systolic or diastolic blood pressure difference ≥10 mm Hg is a strong independent prognostic marker in acute ischemic stroke.

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atheros

Authors: Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF; American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups.

PURPOSE: Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.
METHODS: Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.
RESULTS: Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Guidelines for the Early Management of Patients With Ischemic Stroke

Authors: Harold P. Adams Jr, MD, Chair; Robert J. Adams, MD; Thomas Brott, MD; Gregory J. del Zoppo, MD; Anthony Furlan, MD; Larry B. Goldstein, MD; Robert L. Grubb, MD; Randall Higashida, MD; Chelsea Kidwell, MD; Thomas G. Kwiatkowski, MD; John R. Marler, MD; George J. Hademenos, PhD.

In 1994, a panel appointed by the Stroke Council of the American Heart Association authored guidelines for the management of patients with acute ischemic stroke.1 After the approval of the use of intravenous recombinant tissue plasminogen activator (rtPA) for treatment of acute ischemic stroke by the Food and Drug Administration, the guidelines were supplemented by a series of recommendations 2 years later.2 Several promising interventions for the treatment of acute ischemic stroke have subsequently been tested in clinical trials, and other components of acute management have been evaluated since the previous guidelines were published. These new data have prompted the present revision of the prior guideline statement.

The goal of these guidelines is to provide updated recommendations that can be used by primary care physicians, emergency medicine physicians, neurologists, and other physicians who provide acute stroke care from admission to an emergency department through the first 24 to 48 hours of hospitalization by addressing the diagnosis and emergent treatment of the acute ischemic stroke in addition to the management of its acute and subacute neurological and medical complications.

The association between cerebral atherosclerosis and arterial stiffness in acute ischemic stroke

Authors: Kim J, Cha MJ, Lee DH, Lee HS, Nam CM, Nam HS, Kim YD, Heo JH.

OBJECTIVES: Arterial stiffness is associated with cardiovascular risk factors and atherosclerosis. Measurement of pulse wave velocity (PWV) is one of the most representative and noninvasive techniques for assessing arterial stiffness. We investigated the association of cerebral atherosclerosis with brachial-ankle PWV (baPWV) in acute ischemic stroke patients. If present, we sought to determine whether the relationship differed between atherosclerosis in the intracranial artery and atherosclerosis in the extracranial artery.

METHODS: We included 801 patients with acute ischemic stroke who had undergone angiographic study and baPWV measurement between January 2007 and May 2010. Patients with cerebral artery atherosclerosis were categorized into those with intracranial atherosclerosis, those with extracranial atherosclerosis and those with both intracranial and extracranial atherosclerosis. We determined factors that were associated with baPWV.

RESULTS: Univariate and multivariate analyses showed that high baPWV was significantly associated with older age, lower body mass index, higher brachial systolic pressure, and diabetes mellitus. Increased baPWV was associated with the presence of atherosclerosis (≥50% stenosis) in the intracranial cerebral artery as well as in both the intracranial and extracranial arteries, but not with atherosclerosis in the extracranial cerebral artery. The burden of intracranial cerebral atherosclerosis, which was assessed based on the number of arteries with atherosclerosis, was also closely associated with baPWV.

CONCLUSION: Arterial stiffness was associated with the presence and burden of intracranial cerebral atherosclerosis in stroke patients, but was not associated with the extracranial cerebral atherosclerosis. These findings suggest a potential pathophysiological association between increased arterial stiffness and intracranial cerebral atherosclerosis.

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