Stroke Alert
September 1, 2014 3 minutes read
Stroke Alert
By Matthew E. Fink, MD
Professor and Chairman, Department of Neurology, Weill Cornell Medical College, and Neurologist-in-Chief, New York Presbyterian Hospital
SPAN-100 Index: Simple Method to Estimate Clinical Outcome after Ischemic Stroke
SOURCE: Ovbiagele B, et al. A simple risk index and thrombolytic treatment response in acute ischemic stroke. JAMA Neurol 2014;71:848-854.
The Stroke Prognostication Using Age and the NIH Stroke Scale index (SPAN-100) was created by combining the patient age in years plus the NIH Stroke Scale score. A score of 100 or higher was defined as "positive" and identified a high-risk patient with an acute ischemic stroke. The SPAN-100 score measures the known predictors of poor prognosis — advanced age and stroke severity — combining them into a simple score that is used to predict clinical outcome. The SPAN-100 score was shown to be predictive of risk of intracerebral hemorrhage after administration of t-PA, as well as poor clinical outcome. In the current study, in addition to validating the score as an outcome predictor, the authors sought to determine if it could be used as a way of predicting the outcome of treatment with intravenous t-PA.
An international repository of clinical trials data was used and analyzed to assess the validity of this score to predict outcome. The analysis included 7093 patients from four large clinical trials from the years 2002 to 2006. The primary outcome was the risk of death or severe disability at 90 days after stroke onset. The authors found 10.5% of the patients were SPAN-100 positive and 38.5% of the patients received intravenous thrombolysis. Compared with SPAN-100 negative patients, SPAN-100 positive patients were more likely to experience a poor outcome of death or severe disability compared to SPAN-100 negative patients. The adjusted odds ratio for a catastrophic outcome was 9.03 (95% confidence interval, 6.68-12.21). However, there was also an interaction between SPAN-100 index status and thrombolysis treatment, revealing a reduction in the likelihood of severe disability or death in patients who were SPAN-100 positive and received thrombolytic treatment for acute ischemic stroke (odds ratio, 0.46). Interactions were not observed in SPAN-100 negative patients related to thrombolytic therapy. SPAN-100 positivity in this study was associated with poor outcome, but also was associated with a better response to intravenous thrombolysis therapy than previously believed, and suggests that even elderly patients with a high NIH Stroke Score can still benefit from intravenous thrombolysis.
SSRI Use May Increase the Risk of Cerebral Bleeding
SOURCE: Aarts N, et al. Inhibition of serotonin reuptake by antidepressants and cerebral microbleeds in the general population. Stroke 2014;45:1951-1957.
Serotonin-selective reuptake inhibitors (SSRIs) are widely used in the treatment of post-stroke depression as well as anxiety disorders. They are also being studied in clinical trials of post-stroke rehabilitation to see if their use improves recovery. However, observational studies have indicated that the use of SSRIs increases all-cause mortality in elderly people, as well as increases in myocardial infarction, stroke, falls, seizures, and gastrointestinal bleeding. In addition, an observational study and meta-analysis of 16 published trials of more than 500,000 patients indicated an increased risk of intracerebral hemorrhage, with an odds ratio of 1.46. These findings were not a surprise, in light of the known effects that SSRIs have on platelet function by virtue of their specific activities on serotonin reuptake, and decreased platelet function and decreased platelet aggregation results in an increase in hemorrhage risk of all types.
The authors of this study analyzed patients in the population-based Rotterdam study to look at the risk of micro-bleeds in a population that was taking SSRIs. Brain MRIs were available in 5000 patients and accurate pharmacy records were reviewed to identify patients who were taking SSRIs that had high serotonin reuptake inhibition. MRIs were specifically studied for the presence of micro-bleeds as a marker for potential risk for intracerebral hemorrhage.
The use of antidepressants that had strong serotonin reuptake inhibition was not associated with an increased risk of cerebral micro-bleeds, and the authors concluded that the use of these medications does not increase the risk of clinically significant hemorrhagic complications, including intracerebral hemorrhages. In light of the widespread use of these drugs for treatment of post-stroke depression, this is important information to be integrated into the total plan of therapy for the rehabilitation of patients with stroke. However, an observational study of this type does not definitively rule out a bleeding risk for this class of medications.
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