Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Interim Chair and Neurologist-in-Chief, Director, Division of Stroke & Critical Care Neurology, Weill Cornell Medical College and New York Presbyterian Hospital
Aspirin Use May Increase the Risk of Intracerebral Hemorrhage with Amyloid Angiopathy
Source: Biffi A, et. al. Aspirin and recurrent intracerebral hemorrhage in cerebral amyloid angiopathy. Neurology 2010;75:693-698.
In the United States, 15% of all strokes are caused by intracerebral hemorrhage (ICH); and nonfamilial amyloid angiopathy (CAA), caused by beta-amyloid deposition in cerebral arteries and arterioles, is a major cause of lobar ICH, particularly in the elderly. A total of 104 survivors of lobar ICH from a single institution were enrolled in this study and followed for recurrent hemorrhage, with careful counts of microbleeds on MRI and measures of white matter hypodensities (WMH) on CT, with close monitoring of aspirin and warfarin usage.
During median follow-up time of 34 months, there were 29 recurrent lobar ICH. In univariate analysis, significant predictors of lobar ICH recurrence were previous hemorrhage before the index event (HR = 9.8; P < 0.0001), presence of WMH (HR = 3.7; P < 0.01), presence of posterior WMH (HR = 5.7; P < 0.001), presence of 2-4 microbleeds on MRI (HR = 3.27; P < 0.028), and presence of > 5 microbleeds on MRI (HR = 5.25; P < 0.001). Use of aspirin was not a significant risk factor using a univariate analysis, but with a multivariable Cox regression model, adjusting for baseline clinical predictors, aspirin use independently increased the risk of ICH recurrence (HR = 3.95; P < 0.021). Use of an antiplatelet agent after lobar hemorrhage may increase the risk of recurrent ICH.
Coagulopathy from Thrombolysis Should Be Treated if Intracerebral Hemorrhage Occurs
Source: Goldstein JN, et. al. Management of thrombolysis-associated symptomatic intracerebral hemorrhage. Arch Neurol 2010:67: 965-969.
Symptomatic intracerebral hemorrhage (ICH) is the most feared complication of intravenous and intra- arterial thrombolysis and results in high mortality and morbidity. The investigators performed a retrospective review of prospectively collected data in the Get With the Guidelines database to identify all patients who had ICH after thrombolytic therapy from 2003-2007, in order to determine risk factors and outcome.
Of 2,362 patients with acute ischemic stroke, symptomatic ICH occurred in 19 of the 311 patients (6.1%) who received intravenous thrombolysis, and 2 of the 72 (2.8%) who received intra-arterial thrombolysis. Patients with symptomatic ICH had a higher mortality than those without symptoms. Eleven of 20 patients received therapy for coagulopathy (fresh frozen plasma, cryoprecipitate, vitamin K, platelets, aminocaproic acid). Independent predictors of in-hospital mortality included symptomatic ICH (OR = 32.6), increasing NIHSS (OR = 1.2), older age (OR = 1.3), and intra-arterial thrombolysis (OR = 2.9). Treatment for the coagulopathy did not appear to alter the outcome, but the number treated is too small to draw any conclusions. Continued bleeding occurred in 4 of 10 patients who had follow-up scans available. From this limited retrospective survey, the best treatment for symptomatic ICH after thrombolysis cannot been determined.
B Vitamin Supplements After Stroke or TIA Do Not Appear to Reduce the Incidence of Vascular Events
Source: The VITATOPS Trial Study Group. B vitamins in patients with recent transient ischaemic attack or stroke in the VITAmins TO Prevent Stroke (VITATOPS) trial: A randomised, double-blind, parallel, placebo-controlled trial. Lancet Neurology 2010;9:855-865.
Epidemiological studies suggest that raised plasma concentrations of homocysteine might be a risk factor for stroke. The VITATOPS study was designed to determine if lowering plasma homocysteine with once-daily B vitamins (2 mg folic acid, 25 mg B6, 0.5 mg B12) would reduce the combined incidence of non-fatal stroke, non-fatal myocardial infarction, and death attributable to vascular causes in patients with recent stroke or TIA. This study was designed as a randomized, double-blind, parallel, placebo-controlled trial, from 123 medical centers in 20 countries.
From 1998-2008, 8,164 patients were randomly assigned to received B vitamins or placebo and they were followed for a median duration of 3.4 years. Fifteen percent of patients who received B vitamins and 17% assigned to placebo reached the primary endpoints. There were no significant differences between the groups in either the primary endpoints or adverse effects. Administration of B vitamins to this population was safe but did not reduce the incidence of vascular events.
Hemicraniectomy After Large Hemispheric Infarcts Improves Survival at the Cost of Disability
Source: Kelly AG, Holloway RG. Health state preferences and decision-making after malignant middle cerebral artery infarctions Neurology 2010;75:682-687.
Hemicraniectomy is a radical and heroic treatment that reduces mortality by 50% in appropriately selected patients with middle cerebral artery territory infarcts. In the survivors, there are a few patients who recover to live as fully independent adults (mRankin < 3), but there are many others who survive with severe disability (mRankin > 4). The authors reviewed all published series of this treatment in order to construct a decision analysis that was based on quality-adjusted life-years. Survival data and probability of various functional outcome states (modified Rankin 2-3 and 4-5) at 1 year were abstracted from clinical trial data, and utility scores for modified Rankin states were obtained from the literature.
The hemicraniectomy treatment pathway was associated with more quality-adjusted life-years over the first year than medical management alone (0.414 vs. 0.145). Hemicraniectomy remained the preferred option except when the utility associated with the possible outcome was poorly valued by patients, or when the expected surgical mortality was excessively high. It is important to have frank discussions about this treatment with patients and their families to avoid later disappointments with the outcome.
In the United States, 15% of all strokes are caused by intracerebral hemorrhage (ICH); and nonfamilial amyloid angiopathy (CAA), caused by beta-amyloid deposition in cerebral arteries and arterioles, is a major cause of lobar ICH, particularly in the elderly.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content