Inflammatory Biomarkers and Intracranial Hemorrhage after Endovascular Thrombectomy.

BACKGROUND: Intracranial hemorrhage after endovascular thrombectomy is associated with poorer prognosis compared with those who do not develop the complication. Our study aims to determine predictors of post-EVT hemorrhage - more specifically, inflammatory biomarkers present in baseline serology. METHODS: We performed a retrospective review of consecutive patients treated with EVT for acute large vessel ischemic stroke. The primary outcome of the study is the presence of ICH on the post-EVT scan. We used four definitions: the SITS-MOST criteria, the NINDS criteria, asymptomatic hemorrhage, and overall hemorrhage. We identified nonredundant predictors of outcome using backward elimination based on Akaike Information Criteria. We then assessed prediction accuracy using area under the receiver operating curve. Then we implemented variable importance ranking from logistic regression models using the drop in Naegelkerke R2 with the exclusion of each predictor. RESULTS: Our study demonstrates a 6.3% SITS (16/252) and 10.0% NINDS (25/252) sICH rate, as well as a 19.4% asymptomatic (49/252) and 29.4% (74/252) overall hemorrhage rate. Serologic markers that demonstrated association with post-EVT hemorrhage were: low lymphocyte count (SITS), high neutrophil count (NINDS, overall hemorrhage), low platelet to lymphocyte ratio (NINDS), and low total WBC (NINDS, asymptomatic hemorrhage). CONCLUSION: Higher neutrophil counts, low WBC counts, low lymphocyte counts, and low platelet to lymphoycyte ratio were baseline serology biomarkers that were associated with post-EVT hemorrhage. Our findings, particularly the association of diabetes mellitus and high neutrophil, support experimental data on the role of thromboinflammation in hemorrhagic transformation of large vessel occlusions.

Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic.

Background and Purpose- Hyperacute assessment and management of patients with stroke, termed code stroke, is a time-sensitive and high-stakes clinical scenario. In the context of the current coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 virus, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery for those needing admission and to triage care appropriately for those who may be presenting with neurological symptoms but have an alternative diagnosis. Methods- Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Results- A protected code stroke algorithm was developed. Features specific to prenotification and clinical status of the patient were used to define precode screening. These include primary infectious symptoms, clinical, and examination features. A focused framework was then developed with regard to a protected code stroke. We outline the specifics of personal protective equipment use and considerations thereof including aspects of crisis resource management impacting team role designation and human performance factors during a protected code stroke. Conclusions- We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for key considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice.

Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care.

BACKGROUND AND PURPOSE: Management of stroke patients in the acute setting is a high-stakes task with several challenges including the need for rapid assessment and treatment, maintenance of high-performing team dynamics, management of cognitive load affecting providers, and factors impacting team communication. Crisis resource management (CRM) provides a framework to tackle these challenges and is well established in other resuscitative disciplines. The current Coronavirus Disease 2019 (COVID-19) pandemic has exposed a potential quality gap in emergency preparedness and the ability to adapt to emergency scenarios in real time. METHODS: Available resources in the literature in other disciplines and expert consensus were used to identify key elements of CRM as they apply to acute stroke management. RESULTS: We outline essential ingredients of CRM as a means to mitigate nontechnical challenges providers face during acute stroke care. These strategies include situational awareness, triage and prioritization, mitigation of cognitive load, team member role clarity, communication, and debriefing. Incorporation of CRM along with simulation is an established tool in other resuscitative disciplines and can be incorporated into acute stroke care. CONCLUSIONS: As stroke care processes evolve during these trying times, the importance of consistent, safe, and efficacious care facilitated by CRM principles offers a unique avenue to alleviate human factors and support high-performing teams.

Combined Therapeutics: Future Opportunities for Co-therapy with Thrombectomy.

Stroke is an urgent public health issue with millions of patients worldwide living with its devastating effects. The advent of thrombolysis and endovascular thrombectomy has transformed the hyperacute care of these patients. However, a significant proportion of patients receiving these therapies still goes on to have unfavorable outcomes and many more remain ineligible for these therapies based on our current guidelines. The future of stroke care will depend on an expansion of the scope of thrombolysis and endovascular thrombectomy to patients outside traditional time windows, more distal occlusions, and large vessel occlusions with mild clinical deficits, for whom clinical trial results have not proven therapeutic efficacy. Novel cytoprotective therapies targeting the ischemic cascade and reperfusion injury therapy, in combination with our existing treatment modalities, should be explored to further improve outcomes for these patients with acute ischemic stroke. In this review, we will review the current status of thrombolysis and thrombectomy, suggest additional data that is needed to enhance these therapies, and discuss how cytoprotection might be combined with thrombectomy.

The proximal balloon occlusion together with direct thrombus aspiration (protect plus) technique: Experience at a tertiary comprehensive stroke center.

BACKGROUND: Timely restoration of cerebral blood flow using reperfusion therapy is the most effective maneuver for salvaging penumbra. We re-evaluated the previously described PROTECT (PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy) Plus technique at a tertiary comprehensive stroke center. METHODS: We retrospectively analyzed all patients who underwent mechanical thrombectomy with stentrievers between May 2011 and April 2020. Patients were divided between those who underwent PROTECT Plus and those who did not (proximal balloon occlusion with stent retriever only). We compared the groups in terms of reperfusion, groin to reperfusion time, symptomatic intracranial hemorrhage (sICH), modified Rankin Scale (mRS) score at discharge. RESULTS: Within the study period, 167 (71.4%) PROTECT Plus and 67 (28.6%) non-PROTECT patients which met our inclusion criteria. There was no statistically significant difference in the number of patients with successful reperfusion (mTICI >2b) between the techniques (85.0% vs 82.1%; p = 0.58). The PROTECT Plus group had lower rates of mRS ≤2 at discharge (40.1% vs 57.6%; p = 0.016). The rate of sICH was comparable (p = 0.35) between the PROTECT Plus group (7.2%) and the non-PROTECT group (3.0%). CONCLUSION: The PROTECT Plus technique using a BGC, a distal reperfusion catheter and stent retriever is feasible for recanalization of large vessel occlusions. Successful recanalization, first-pass recanalization and complication rates are similar between PROTECT Plus and non-PROTECT stent retriever techniques. This study adds to an existing body of literature detailing techniques that use both a stent retriever and a distal reperfusion catheter to maximize recanalization for patients with large vessel occlusions.

Identifying gaps in the management of atrial fibrillation with anticoagulation for stroke prevention (GIANTS): a quality improvement initiative.

OBJECTIVES: Direct oral anticoagulants (DOACs) are indicated for preventing ischemic stroke in 95% of patients with atrial fibrillation (AF). However, DOACs are largely underutilized or inappropriately dosed. This study aimed to explore the rates of appropriate DOAC use between repatriated and non-repatriated patients with AF who presented with an acute ischemic stroke not deemed candidates for revascularization therapies. MATERIALS AND METHODS: Data were collected via electronic medical records and patients were contacted via telephone to obtain medication information and other missing clinical information. Multivariate logistic regression analyses were conducted to determine associations between appropriate use of a DOAC and repatriation status adjusting for age, sex, and comorbidities. RESULTS: A total of 49 patients were included in the study with a mean follow-up of 31.5 (± 11.9) months. Eleven patients (22.4%) died, and 4 (8.2%) patients were lost to follow-up. Overall, 9 (26.5%) patients (3 non-repatriated and 6 repatriated) were found to be on suboptimal or inappropriate anticoagulation. Repatriation was associated with over six fold (OR 6.53; 95% CI 1.20-35.7) likelihood of suboptimal or inappropriate anticoagulation. CONCLUSIONS: Awareness of this finding is critical to overcome therapeutic inertia in the use of DOACs for ischemic stroke patients with AF. With stroke care becoming increasingly nuanced, peripheral centers may lack the ability to guide anticoagulation in a timely and effective manner. Creation of tertiary short-term follow-up stroke clinics with cardiology follow-up may be an effective strategy to ensure standard of care. Research into systems contributors affecting the appropriate use of DOACs should be elucidated.

Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review.

Intravenous thrombolysis is a standard of care treatment for patients with acute ischemic stroke. Tissue plasminogen activator (tPA) has been the main thrombolytic agent used since the publication of the seminal National Institutes of Neurological Disorders and Stroke trial in 1995. There is now mounting evidence to support the routine use of Tenecteplase (TNK) to treat acute ischemic stroke. TNK is a genetically modified tPA with higher fibrin specificity, longer half-life, and reduced systemic coagulopathy. In this illustrated review, we compare the indications, doses, mechanisms of action, efficacy and safety of TNK and tPA. We provide an overview of published clinical trials studying TNK in acute ischemic stroke, including dose-escalation studies and head-to-head comparisons with tPA. Finally, we summarize current acute stroke guideline recommendations and suggest treatment algorithms to manage the two main complications of intravenous thrombolysis: symptomatic intracerebral hemorrhage and angioedema.

Association of Periodic Limb Movements With Medication Classes: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: To investigate the association between various medication classes and the periodic limb movement index (PLMI) in a clinical cohort of adults who completed in-laboratory polysomnography. METHODS: A single, diagnostic, overnight, in-laboratory polysomnogram was completed for 3,488 patients consecutively referred from 2010 to 2015 to determine PLMI. Medication use and medical comorbidities were collected through patient questionnaires. Associations between medication classes and PLMI were ascertained using multivariable ordinal logistic regression models. RESULTS: The median age of the cohort was 56.0 years (48.2% male). After adjusting for age, sex, body mass index, relevant comorbidities, and sleep measures, the use of selective serotonin reuptake inhibitors (SSRIs) (odds ratio [OR] 1.52) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (OR 1.99) was associated with increased PLMI. Conversely, gabapentinoids (OR 0.71), stimulants (OR 0.52), benzodiazepines (OR 0.79), and dopamine agonists (OR 0.38) were associated with decreased PLMI. A non-statistically significant trend for decreased PLMI with neuroleptic use was observed. No significant associations were found between PLMI and the use of antihypertensives, statins, tricyclic antidepressants, bupropion, anticoagulants, antiplatelets, modafinil, and antihistamines. DISCUSSION: The use of SSRIs and SNRIs was associated with elevated PLMI while the use of gabapentinoids, stimulants, benzodiazepines, and dopamine agonists was associated with decreased PLMI. These results can assist physicians in managing periodic limb movements in sleep (PLMS) and invite further research into the relationship between PLMS and medications with the modulating effects of dose, formulation type, and time of administration. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that SSRIs and SNRIs are associated with elevated PLMI while gabapentinoids, stimulants, benzodiazepines, and dopamine agonists are associated with decreased PLMI.

Dural venous sinus thrombosis after lumbar puncture in a patient with idiopathic intracranial hypertension.

INTRODUCTION: Idiopathic intracranial hypertension (IIH) is one of the most common causes of papilloedema seen by ophthalmologists and neurologists. Patients with IIH routinely undergo lumbar puncture (LP) for diagnosis. Dural venous sinus thrombosis (DVST) is a rare complication of cerebrospinal fluid pressure (CSF)-lowering procedures such as lumbar puncture and epidural and may be an intracranial complication of IIH. CASE DESCRIPTION: A 29-year-old obese woman was diagnosed with severe idiopathic intracranial hypertension (IIH) after she presented with new-onset headache, pulsatile tinnitus and blurred vision. Magnetic resonance imaging (MRI) and venography (MRV) were normal apart from signs of intracranial hypertension. Lumbar puncture (LP) revealed an opening pressure of 40 cm of water. Due to the severity of the papilloedema and vision loss, she was referred for a ventriculoperitoneal shunt and found to have venous sinus thrombosis involving the superior sagittal sinus on the pre-operative computed tomography (CT) head 5 days after the LP. CT venography (CTV) one day later and MRV 3 days later showed significant worsening as the thrombosis extended into the deep venous system. She was started on therapeutic heparin and her symptoms and vision improved and she did not develop any neurological complications. CONCLUSIONS: DVST should be considered in IIH patients who have worsening papilloedema or symptoms of intracranial hypertension. Repeat venous imaging can prevent devastating consequences such as venous infarcts of haemorrhage in these patients.

Predictors of CPAP adherence following stroke and transient ischemic attack.

OBJECTIVE: Continuous positive airway pressure (CPAP) has been shown to improve functional, motor and cognitive outcomes in post-stroke obstructive sleep apnea (OSA). However, rates of CPAP adherence are often low and factors impacting CPAP adherence remain under-explored. Our objective was to determine predictors of CPAP adherence in patients who had a stroke or transient ischemic attack (TIA). METHODS: We screened 313 stroke/TIA patients for OSA using in-hospital polysomnography or the ApneaLink home sleep apnea test. Potential predictors were recorded at baseline and adherence to CPAP was recorded during a six-month follow-up visit. Selected variables from our univariate analyses were included in multivariate regression models to determine predictors of CPAP adherence. For our logistic regression analyses, CPAP adherence (CPAP use of ≥4 h per night) was the dependent outcome variable. In our linear regression analyses, total CPAP use per week (recorded in hours) was the dependent outcome variable. RESULTS: Eighty-eight patients (mean age 67.81 ± 13.09 years, 69.32% male, mean body mass index 27.93 ± 5.23 kg/m2) were diagnosed with OSA, prescribed CPAP, and assessed for adherence at a six-month follow-up visit. In these 88 patients, 46 (52.27%) were adherent with CPAP therapy. From our regression models, two significant predictors of CPAP adherence were identified: greater functional status (p = 0.04) and not endorsing daytime tiredness (p = 0.047) post-stroke/TIA. CONCLUSION: Patients with greater functional capacity and those with less daytime fatigue demonstrated stronger adherence to CPAP therapy. Our findings may facilitate future treatment strategies for enhancing CPAP adherence in the vulnerable stroke/TIA population.

Predictors of in-laboratory polysomnography attendance in a cohort of patients with stroke or TIA.

STUDY OBJECTIVES: After cerebrovascular events, obstructive sleep apnea (OSA) is associated with poor functional outcomes, an increased risk of recurrent stroke, and mortality. Although the significant under-diagnosis of OSA is likely multifactorial in nature, factors associated with attendance at in-laboratory polysomnography (iPSG) are poorly understood. We evaluated demographic, lifestyle, and clinical variables that predicted attendance at iPSG in a cohort of patients with stroke and transient ischemic attack (TIA) enrolled in a clinical research study. METHODS: Demographic, lifestyle, and clinical variables were summarized for the patients who did and did not attend iPSG. Multivariable binary logistic regression analyses were performed to examine four models that thematically aggregated predictors expected to relate to attendance. Further, t-tests for continuous variables, and chi-squared tests for categorical variables, were performed to uncover differences between the two groups. RESULTS: In the 122 participants included in our analyses, mean age was 66.6 ± 15.7 (64.8% males) with only 59.0% of participants attending iPSG. Only Model 1, which investigated the impact of demographic, lifestyle, and cognitive status, was significant (χ2 = 35.31, p < 0.001). Among our variables, (1) younger age, (2) better cognition, (3) higher level of education, and (4) never-smoking status significantly predicted attendance at iPSG. CONCLUSION: By understanding the relationship between variables that significantly predict attendance, we hope our results will translate into practices that promote iPSG attendance, which may help improve outcomes in the stroke/TIA population. CLINICAL TRIALS: SLEep APnea Screening Using Mobile Ambulatory Recorders After TIA/Stroke (SLEAP SMART) (NCT02454023); https://clinicaltrials.gov/ct2/show/NCT02454023.