Effect of a Coordinated Community and Chronic Care Model Team Intervention vs Usual Care on Systolic Blood Pressure in Patients With Stroke or Transient Ischemic Attack: The SUCCEED Randomized Clinical Trial.

Importance: Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. Objective: To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). Design, Setting, and Participants: This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. Interventions: Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. Main Outcomes and Measures: The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. Results: Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. Conclusions and Relevance: This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT01763203.

The Frequency of Substantial Salvageable Penumbra in Thrombectomy-ineligible Patients with Acute Stroke.

BACKGROUND AND PURPOSE: Endovascular therapy (ET) has become the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, many LVO or medium vessel occlusion (MVO) patients are ineligible for ET, including some who harbor salvageable tissues. To develop complementary therapies for these patients, it is important to delineate their prevalence, clinical features, and outcomes. METHODS: In a prospectively maintained database, we reviewed consecutive AIS patients between December 2015 and September 2016. Based on the first multimodal computed tomography or magnetic resonance imaging, patients were categorized as having substantial penumbra if perfusion lesion volume (Tmax >6 seconds) exceeded ischemic core volume (relative cerebral blood flow <30% on CT perfusion or apparent diffusion coefficient <620 on diffusion weighted image) by ≥20%. RESULTS: Among 174 consecutive AIS patients presenting within 24 hours of last known well time, 29 (17%) had LVO or MVO and substantial penumbra, but were deemed ET ineligible. Among these patients, mean age was 81 (±13), 45% were female, and median National Institute of Health Stroke Scale score was 11 (interquartile range [IQR]: 5-19). The most common reasons for not pursuing ET were: distal occlusion (28%), mild neurologic deficit (16%), and temporally advanced core injury (16%). Ischemic core volume was 20 mL (±31), penumbral volume was 54 mL (±63), and mismatch ratio median was 5.6 (IQR: 2-infinite). Severe disability or death at discharge (modified Rankin scale: 4-6) occurred in 72% of the patients. CONCLUSION: Even in the modern stent retriever era, 1 in 6 AIS patients presents with substantial penumbra judged not appropriate for ET. This population may benefit from the development of alternative therapies, including collateral enhancement, neuroprotection, and thrombectomy devices deployable in distal arteries.

Antiplatelet Regimen for Patients With Breakthrough Strokes While on Aspirin: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Optimal antiplatelet therapy after an ischemic stroke or transient ischemic attack while on aspirin is uncertain. We, therefore, conducted a systematic review and meta-analysis. METHODS: We searched PubMed (1966 to August 2016) and bibliographies of relevant published original studies to identify randomized trials and cohort studies reporting patients who were on aspirin at the time of an index ischemic stroke or transient ischemic attack and reported hazard ratio for major adverse cardiovascular events or recurrent stroke associated with a switch to or addition of another antiplatelet agent versus maintaining aspirin monotherapy. Estimates were combined using a random effects model. RESULTS: Five studies with 8723 patients with ischemic stroke or transient ischemic attack were identified. Clopidogrel was used in 4 cohorts, and ticagrelor was used in 1 cohort. Pooling results showed that addition of or a switch to another antiplatelet agent, versus aspirin monotherapy, was associated with reduced risks of major adverse cardiovascular events (hazard ratio, 0.68; 95% confidence interval, 0.54-0.85) and recurrent stroke (hazard ratio, 0.70; 95% confidence interval, 0.54-0.92). Each of the strategies of addition of and switching another antiplatelet agent showed benefit versus continued aspirin monotherapy, and studies with regimen initiation in the first days after index event showed more homogenous evidence of benefit. CONCLUSIONS: Among patients who experience an ischemic stroke or transient ischemic attack while on aspirin monotherapy, the addition of or a switch to another antiplatelet agent, especially in the first days after index event, is associated with fewer future vascular events, including stroke.

Primary angiitis of the central nervous system presenting as unilateral optic neuritis.

A middle-aged woman who experienced recurrent episodes of unilateral vision loss and eye pain. On presentation, magnetic resonance imaging (MRI) demonstrated left optic nerve enhancement with patchy hyperintensities in the white matter of both frontal lobes and ill-defined enhancement in a lenticulostriate distribution. Ophthalmologic examination revealed left optic disc edema with a macular scar consistent with neuroretinitis. Her subsequent clinical course was notable for 2 episodes of painful vision loss, without associated neurologic symptoms, which resolved with intravenous and oral steroids. More than 1 year after her initial presentation, the patient developed right facial weakness and slurred speech, and shortly thereafter suffered a fatal intracerebral hemorrhage. Histopathology on autopsy confirmed a diagnosis of primary angiitis of the central nervous system (PACNS). This is an unusual case of PACNS presenting with recurrent unilateral optic neuritis. The vascular enhancement pattern on MRI suggesting inflamed cerebral blood vessels is a rarely described pattern, which likely reflects intracerebral extension of the ocular pathology. The combination of neuroretinitis and perivascular MRI enhancement pattern may represent a subtype of PACNS.

Drip, Ship, and Grip, then Slice and Dice: Comprehensive Stroke Center Management of Cervical and Intracranial Emboli.

BACKGROUND AND PURPOSE: Tandem acute thrombotic emboli in the cervical and intracranial arteries are an unusual cause of stroke presenting unique management challenges. In regional systems of acute stroke care anchored by Comprehensive Stroke Centers (CSC), combined fibrinolytic, endovascular, and open surgical intervention is a new therapeutic option. SUMMARY OF CASE: A 28-year-old male underwent retinal surgery, including post-operative neck compression and the next day presented to a primary stroke center with aphasia and right hemiplegia. Intravenous tissue plasminogen activator therapy was initiated and the patient was transferred to a CSC for higher level of care (drip and ship). Imaging at the CSC demonstrated tandem thrombi: a near occlusive lesion at the origin of the left cervical internal carotid artery and a total occlusion of the M1 segment of the left middle cerebral artery. Endovascular thrombectomy with the Solitaire stent retriever resulted in intracranial recanalization (grip). Immediately after the endovascular procedure, open carotid thrombectomy was performed to achieve cervical carotid revascularization without systemic heparinization (slice). Both cervical carotid and intracranial thrombi were processed for proteomic analysis via mass spectrometry (dice). CONCLUSION: Combined fibrinolytic, endovascular, and open surgical intervention can yield revascularization and good clinical outcome in cases of tandem lesions.

The forgotten pectoralis minor syndrome: 100 operations for pectoralis minor syndrome alone or accompanied by neurogenic thoracic outlet syndrome.

BACKGROUND: Since 2005 when we became aware of pectoralis minor syndrome (PMS), more than 75% of patients diagnosed with neurogenic thoracic outlet syndrome (NTOS) also have neurogenic PMS (NPMS), and about 30% have only NPMS, without NTOS. METHODS: Diagnosis was made based on history, physical examination, pectoralis minor (PM), and scalene muscle blocks with lidocaine. Pectoralis minor tenotomy was performed as an outpatient procedure under local anesthesia with heavy sedation through a 5-7 cm transaxillary incision. RESULTS: The clinical picture included pain or tenderness in the anterior chest wall and axilla, together with physical findings of tenderness over the pectoralis minor tendon. Other symptoms were extremity pain, weakness, and paresthesia, similar to symptoms of NTOS. In 76 patients, 100 operations were performed: 48 for NPMS combined with NTOS and 52 for NPMS-alone. Features distinguishing the PM-alone group were fewer and milder occipital headaches, less neck pain, and fewer positive physical findings. Preoperatively, 85% of the of the PM-alone group were still employed compared to only 57% of the combined group (p=0.01). Success rates with 1-3-year follow-up for the PM-alone group were 90% good-excellent, 2% fair, and 8% failed; for the combined group success rates were 35% good-excellent, 19% fair, and 46% failed. All but one of the failures was immediate, only one was late. The only complication was 3 wound infections. Most patients returned to work within a few days. In the combined PMS/TOS group, most of the failed patients subsequently had thoracic outlet operations. CONCLUSION: PMS commonly accompanies NTOS and frequently exists alone. Its recognition is important as many patients with suspected NTOS can be treated successfully with a simple, essentially risk-free PM tenotomy. Should this fail, thoracic outlet decompression can always be performed at a later date.

Diagnosis of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a nonspecific label. When employing it, one should define the type of TOS as arterial TOS, venous TOS, or neurogenic TOS. Each type has different symptoms and physical findings by which the three types can easily be identified. Neurogenic TOS (NTOS) is by far the most common, comprising well over 90% of all TOS patients. Arterial TOS is the least common accounting for no more than 1%. Many patients are erroneously diagnosed as "vascular" TOS, a nonspecific misnomer, whereas they really have NTOS. The Adson Test of noting a radial pulse deficit in provocative positions has been shown to be of no clinical value and should not be relied upon to make the diagnosis of any of the three types. The test is normal in most patients with NTOS and at the same time can be positive in many control volunteers. Arterial TOS is caused by emboli arising from subclavian artery stenosis or aneurysms. Symptoms are those of arterial ischemia and x-rays almost always disclose a cervical rib or anomalous first rib. Venous TOS presents with arm swelling, cyanosis, and pain due to subclavian vein obstruction, with or without thrombosis. Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesia, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds.

Pectoralis minor obstruction of the axillary vein: report of six patients.

PURPOSE: Although the usual site of nonthrombotic venous obstruction of the upper extremity is the subclavian vein, other sites may be the cause of such obstruction. This study describes the diagnosis and treatment of six patients with partial axillary vein obstruction by the pectoralis minor muscle, a condition that can mimic subclavian vein obstruction. METHODS: A chart review of patients undergoing pectoralis minor tenotomies (PMT) between 2004 and 2006 revealed six patients (3 men and 3 women), aged 17 to 39, who underwent seven PMT procedures for symptoms of arm swelling, cyanosis, and pain or tightness. Diagnosis was suggested by history and physical examination and was confirmed by dynamic venography. Patients with paresthesia suggesting associated neurogenic pectoralis minor compression were given a pectoralis minor muscle block. As an outpatient, PMT was initially performed with an infraclavicular approach but later through the transaxillary route. Follow-up was by phone interview in five patients and a physical examination in one. RESULTS: Venography demonstrated axillary vein compression under the pectoralis minor, which was more significant than the minor degree of subclavian vein compression seen on the same venogram. Follow-up was 1.5 years to 10 years in three patients and 3 months in the other three. All six patients experienced good-to-excellent relief of all symptoms. There were no surgical complications. CONCLUSION: Axillary venous obstruction by the pectoralis minor must be distinguished from subclavian vein obstruction, which presents with similar symptoms. PMT is a simple, risk-free, outpatient procedure that has produced uniformly good results.