The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults.

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Incidence and clinical implications of carotid branch occlusion following treatment of internal carotid artery aneurysms with the pipeline embolization device.

BACKGROUND: The use of flow diverters such as the pipeline embolization device (PED) for treatment of intracranial aneurysms carries the risk of side branch occlusion. OBJECTIVE: To determine the incidence and clinical outcomes associated with supraclinoid internal carotid artery (ICA) branch occlusion after deployment of PEDs for ICA aneurysms. METHODS: We reviewed patients who underwent endovascular treatment with PEDs for ICA aneurysms between June 2011 and March 2013. Forty-nine patients (43 women, mean age 56.3±1.8 years, 68 aneurysms) in whom PEDs traversed the origin of supraclinoid ICA branches (ophthalmic [OA], posterior communicating [PcommA], and anterior choroidal artery [AChA]) were selected for this study. Follow-up angiograms (mean follow-up, 12.8±0.8 months) were studied to determine the location of PEDs and the patency of ICA branches. RESULTS: PEDs were placed across the ostia of 49 OAs, 14 PcommAs, and 11 AChAs. Multiple PEDs were deployed in 16 patients. Rate of branch occlusion was 4% (2/49) for the OA, 7.1% (1/14) for the PcommA, and 0% for the AChA. Patients with branch occlusion did not endure new neurological deficits. ICA branch occlusion was not associated with the number of PEDs covering the ostia (P=.76) or the origin of ICA branches from the aneurysm (P=.24). CONCLUSION: The incidence of major supraclinoid ICA branch occlusion after treatment with PEDs was low. These events were not associated with new neurological deficits nor were they related to the number of PEDs deployed or the origin of ICA branches from the aneurysm.

Emergency endovascular management of penetrating gunshot injuries to the arteries in the face and neck: a case series and review of the literature.

INTRODUCTION: Penetrating gunshot injuries (GSI) to supra-aortic arteries that cause life-threatening blood loss or major neurologic deficits are increasingly managed using modern endovascular treatment (EVT). We report our experience with EVT of acute GSIs and review the existing literature. METHODS: Emergency EVT was performed in nine of 10 patients (7 men, age 17-50 years) with acute GSIs to supra-aortic arteries requiring acute management. One patient presented with acute and delayed injuries and underwent EVT 4 weeks after initial admission. Patient selection was based on clinical presentation and radiographic findings from a cohort of 55 patients with GSIs to the face, neck or head between February 2009 and March 2012. RESULTS: EVT was successfully performed in all patients. Two transections of the vertebral arteries were embolized with coils and/or liquid embolic agent (acrylic glue). Eight penetrated external carotid artery branches were occluded with liquid embolic agents (acrylic glue or Onyx) or particles. One severe dissection of the internal carotid artery with a subsequent thromboembolic event was treated with stenting. All except one patient survived with minor or no residual deficits. CONCLUSIONS: Emergency management of GSI injuries to the head and neck may involve all aspects of current EVT. Understanding endovascular techniques and being able to make rapid and appropriate treatment decisions in the setting of acute GSI to the face and neck can be a life-saving measure and greatly benefits the patient's outcome.

Periprocedural antithrombotic strategies in acute ischemic stroke interventional therapy.

In patients undergoing endovascular therapy for acute ischemic stroke, antithrombotic therapies are utilized to prevent distal embolization, arterial reocclusion, or catheter-related embolism. However, this must be weighed against the risk of hemorrhagic complications secondary to existing and ongoing ischemia or silent vessel perforation. In this article, we present an overview of the available literature evaluating antithrombotic therapy in patients undergoing endovascular therapy for acute ischemic stroke and discuss the emerging role of these agents.

Hemodynamics of small aneurysm pairs at the internal carotid artery.

Cerebral aneurysms carry significant risks because rupture-related subarachnoid hemorrhage leads to serious and often fatal consequences. The rupture risk increases considerably for multiple aneurysms. Multiple aneurysms can grow from the same location of an artery, and the interaction between these aneurysms raises the rupture risk even higher. Four aneurysm pair cases at the internal carotid artery are investigated for their hemodynamic behaviors using patient-specific modeling. For each case, aneurysms are separated from the parent artery and three models are reconstructed, one with two aneurysms and the other two models with only one of the two aneurysms. Results show that the relative anatomic location of one aneurysm to the other may determine the hemodynamic environment of an aneurysm. The presence of a proximal aneurysm reduces the intra-aneurysmal flow into the distal aneurysm; the proximal aneurysm and larger aneurysm have a greater area under low wall shear stress. The average intra-aneurysmal inflow ratio ranges from 16% to 41%, and reduction of the inflow ratio by an aneurysm pair varies from 6% to 15%. The maximum wall shear stress increases for serial aneurysms, but decreases for parallel aneurysms. Interaction between parallel aneurysms is not significant; however, the proximal aneurysm in serial aneurysms may be subject to a greater rupture risk.

Case of "slow" stroke from carotid artery occlusion treated by delayed but cautious endovascular intervention.

In a challenging case of carotid occlusion with slowly evolving stroke, we used brain imaging to facilitate endovascular revascularization resulting in the relief of the patient's symptoms. Patients with carotid occlusion and continued neurological worsening or fluctuations present enormous treatment challenges. These patients may present "slow" strokes with subacute infarcts that present significant challenges and risks during attempts at revascularization of the occluded artery. We present such a case in which we used multimodal imaging techniques, including MR-perfusion, to facilitate endovascular revascularization. Our approach of delayed but cautious intra-arterial thrombolytic therapy, guided by brain imaging, and followed by stent placement across the residual stenosis, enabled revascularization of the occluded artery without overt in-hospital complications.

Hemodynamic relationship between intracranial aneurysm and carotid stenosis: review of clinical cases and numerical analyses.

OBJECTIVE: Coexistence of both an intracranial aneurysm and a stenosis at the same internal carotid artery is infrequent, but it may complicate therapeutic management of either disease. It is unclear if a stenosis plays any role in development of intracranial aneurysms. We study patients with intracranial aneurysms at our hospital and investigate if there is a relationship between a carotid stenosis and an intracranial aneurysm. METHODS: Two hundred and nine patients who were treated for their intracranial aneurysms in a 2-year period were reviewed. Fifty-four patients were found to have at least one intracranial aneurysm and one intracranial or extracranial carotid stenosis. Ten of them had bilateral stenoses; 17 aneurysms were on the ipsilateral side of the stenosis, and eight on the contralateral side. Nineteen aneurysms were elsewhere. Two cases were selected for detailed computational fluid dynamics (CFD) analyses: one with an intracranial and the other with an extracranial stenosis. RESULTS: Aneurysms on the contralateral side of a carotid stenosis are significantly larger than those aneurysms on the ipsilateral side or with bilateral stenoses (13.6 versus 6.6 mm; P < 0.01). CFD studies show that wall shear stress at the aneurysm is more likely affected by an adjacent intracranial stenosis than by an extracranial stenosis. CONCLUSIONS: Intracranial carotid aneurysms contralateral to a carotid stenosis are significantly larger than aneurysms with a carotid stenosis elsewhere. Rupture can occur on aneurysms with an extracranial carotid stenosis on the contralateral side or with an intracranial carotid stenosis on the ipsilateral side.

Thrombus burden is associated with clinical outcome after intra-arterial therapy for acute ischemic stroke.

BACKGROUND AND PURPOSE: Studies have established a relation between recanalization and improved clinical outcome in acute ischemic stroke patients; however, intra-arterial clot size has not been routinely assessed. The aim of the study was to determine the impact of intra-arterial thrombus burden on intra-arterial treatment (IAT) and clinical outcome. METHODS: A retrospective review of our IAT stroke database included procedure time, recanalization, symptomatic intracranial hemorrhage, poor outcome (modified Rankin Scale score >/=4 at discharge), and mortality. The modified Thrombolysis in Myocardial Infarction thrombus grade was dichotomized into grades 0 to 3 (no clot or moderate thrombus, <2 vessel diameters) versus grade 4 (large thrombus, >2 vessel diameters). RESULTS: Data were collected on 135 patients with thrombus grading. The baseline median National Institutes of Health Stroke Scale score was higher in patients of grade 4 compared with grades 0 to 3 (19 vs 17, P=0.012). Grade 4 thrombi required longer (median, range) times for IAT (113, 37 to 415 minutes vs 74, 22 to 215 minutes, respectively; P<0.001) and higher rates of mechanical clot disruption (wire, angioplasty, snare, stent, or Merci retriever) compared with grades 0 to 3 (76% vs 53%, P=0.005). There were no differences in rates of symptomatic intracranial hemorrhage (6.6% vs 4.1%, P=0.701) or recanalization (50% vs 61%, P=0.216) in grade 4 versus grades 0 to 3. Multivariate analysis adjusted for age, baseline National Institutes of Health Stroke Scale score, and artery of involvement showed that grade 4 thrombi were independently associated with poor outcome (odds ratio=2.4; 95% CI, 1.06 to 5.57; P=0.036) and mortality (odds ratio=4.0; 95% CI, 1.2 to 13.2; P=0.023). CONCLUSIONS: High thrombus grade as measured by the modified Thrombolysis in Myocardial Infarction criteria may be a risk factor that contributes to poor clinical outcome.

The effect of activated factor VII for intracerebral hemorrhage beyond 3 hours versus within 3 hours.

BACKGROUND AND PURPOSE: Recombinant-activated factor VII (rFVIIa) is an investigational treatment for intracerebral hemorrhage (ICH). We have evaluated the drug's treatment effect based on time to treatment. METHODS: ICH patients treated up to 4 hours from symptom onset were divided based on time to treatment:

Is intra-arterial thrombolysis safe after full-dose intravenous recombinant tissue plasminogen activator for acute ischemic stroke?

BACKGROUND AND PURPOSE: The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA. METHODS: A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition. RESULTS: Sixty-nine patients (mean+/-SD age, 60+/-13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124+/-32 minutes (median, 120 minutes) and IAT, at 288+/-57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%). CONCLUSIONS: IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.

Argatroban tPA stroke study: study design and results in the first treated cohort.

BACKGROUND: The benefit of intravenous recombinant tissue plasminogen activator (rtPA) in acute stroke is linked to clot lysis and artery recanalization. Argatroban is a direct thrombin inhibitor that safely augments the benefit of rtPA in animal stroke models. There are no human data on this combination. DESIGN: We report the first phase of the Argatroban tPA Stroke Study, an ongoing prospective, open-label, dose-escalation, safety and activity study of argatroban and rtPA in patients with ischemic stroke. The primary outcome was incidence of intracerebral hemorrhage; secondary outcome, complete recanalization at 2 hours. After standard-dose intravenous rtPA administration, a 100-mug/kg bolus of argatroban followed by infusion of 1 mug/kg per minute for 48 hours was adjusted to a target partial thromboplastin time of 1.75 times that of the control group. RESULTS: Fifteen patients (including 10 men) were enrolled, with a mean +/- SD age of 61 +/- 13 years. All patients had middle cerebral artery occlusions. Baseline median National Institute of Health Stroke Scale score was 14 (range, 4-25). The mean +/- SD time from symptom onset to argatroban bolus administration was 172 +/- 53 minutes. Symptomatic intracerebral hemorrhage occurred in 2 patients, including 1 with parenchymal hemorrhage type 2. Asymptomatic bleeding occurred in 1 patient and there was 1 death. Recanalization was complete in 6 patients and partial in another 4, and reocclusion occurred in 3 within 2 hours of rtPA bolus administration. CONCLUSION: The safety of low-dose argatroban combined with intravenous rtPA may be within acceptable limits, and its efficacy for producing fast and complete recanalization is promising, but a larger cohort of patients is required to confirm these preliminary observations.

Does clinical-CT 'mismatch' predict early response to treatment with recombinant tissue plasminogen activator?

BACKGROUND: We hypothesized that patients with clinically severe strokes but less severe early ischemic changes on brain CT (i.e., clinical-CT mismatch) may respond better to intravenous recombinant tissue plasminogen activator (i.v. rt-PA) within 3 h of symptom onset. METHODS: In this secondary analysis of the CLOTBUST data, patients with middle cerebral artery occlusions on transcranial Doppler (TCD) were treated with i.v. rt-PA. Alberta Stroke Program Early CT Scores were obtained with raters blinded to the NIH Stroke Scale and TCD results. Two mismatch criteria and three criteria of response to therapy were explored. RESULTS: Of 126 patients, 67% had a mismatch type 1 and 74% had a mismatch type 2. The presence of clinical-CT mismatch by either definition did not correlate with any of the three criteria of response to rt-PA. Recanalization was a strong determinant of response, whether or not mismatch was present. CONCLUSIONS: Mismatch between severity of neurological deficit and CT findings is common but does not predict response to rt-PA therapy given within 3 h.

Endovascular recanalization of internal carotid artery occlusion in acute ischemic stroke.

BACKGROUND: Endovascular therapy (ET) of internal carotid artery (ICA) stenosis is equivalent to carotid endarterectomy for stroke prevention; however, patients with ICA occlusion and acute symptoms are traditionally not candidates for ET. We report our experience in endovascular recanalization of acute stroke patients with ICA occlusion. PATIENTS AND TECHNIQUES: We reviewed our registry for acute stroke patients treated with ET who had (1) ICA occlusion by digital subtraction angiography (thrombolysis in myocardial ischemia=0) with location of type II (above ophthalmic artery involving M1 or A1 but not both) or type III (proximal to the ophthalmic artery but distal to the bifurcation); (2) acute stroke symptoms from the index lesion presenting 3 hours after onset of symptoms; (3) minimal ischemic changes on brain CT scan (less than one third of the MCA territory); (4) attempted ET. Neuroradiologists reviewed angiograms for thrombolysis in cerebral infarction. A blinded vascular neurologist reviewed post-procedural brain imaging for Alberta Stroke Program Early CT (ASPECT) scoring. Outcome scales were assessed. RESULTS: We identified 14 patients, 10 of whom were men (mean age, 58 +/- 14 years; median age, 54 years; age range, 40-74 years). There were 8 left ICA occlusions, 3 type II; and 6 right ICA occlusions, one type II. Median baseline National Institutes of Health Stroke Scale score was 17 (range, 11-25; mean, 18 +/- 4.9). Mean time to ET was 389 +/- 103 minutes (median, 306 minutes; range, 197-1290 minutes). Immediate recanalization occurred in 64%. Decrease in expected stroke volume by brain imaging occurred in 50% with mean ASPECT score of 4 +/- 2.9 (median, 3; range, 0-8; 21% > or = 8). Two hemorrhages occurred, one symptomatic; 3 patients died. Good outcome was achieved in 64% of cases. CONCLUSION: Endovascular therapy of carotid occlusion in hyperacute stroke patients is feasible and may help to reduce stroke volume and increase good outcome in some patients.

Statins and stroke prevention.

Data from studies on the benefits of statins in coronary artery disease patients in preventing recurrent primary and secondary cardiac endpoints, as well as ischemic strokes, imply the potential value of statins in recurrent ischemic stroke prevention without coronary artery disease symptoms or, by extension, primary ischemic stroke prevention. However, data on the latter are lacking, although the ongoing Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study is designed to answer that question. Until these data become available, clinicians are justified in using statins to avert recurrent ischemic strokes due to atherosclerosis, especially if elevated total cholesterol, increased low-density lipoprotein cholesterol, and/or reduced high-density lipoprotein cholesterol, as specified in the National Cholesterol Education Program Third Adult Treatment Panel, are present. This article reviews the pathophysiology of atherosclerosis, particularly the major components of atheromas of cholesterol, smooth muscle cells, inflammation, "foam cells," and connective tissue elements. Emphasis is placed on the first three and the results of statin trials in coronary artery disease, as well as the beneficial pleiotrophic effects of statins in ischemic strokes.

Aggressive mechanical clot disruption: a safe adjunct to thrombolytic therapy in acute stroke?

BACKGROUND AND PURPOSE: This study evaluated the safety and efficacy of aggressive mechanical clot disruption (AMCD) in acute stroke patients with persisting middle cerebral artery (MCA) or internal carotid artery (ICA) occlusion after thrombolytic therapy. METHODS: Retrospective case series were used from a prospectively collected stroke database on consecutive acute ischemic stroke patients treated with intra-arterial (IA) thrombolytics and mechanical clot disruption during a 5-year interval. Thrombolytic dosage, endovascular techniques, immediate and final recanalization rates, symptomatic hemorrhage, mortality, and outcome were determined. RESULTS: Thirty-two patients received AMCD. Median baseline National Institutes of Health Stroke Scale (NIHSS) score was 18, and median time to initiation of IA treatment was 261 minutes from symptom onset. ICA occlusion was noted in 16 patients and MCA occlusion in 16 patients: 22 received combined IV/IA thrombolytics, 3 received IV thrombolytics, 6 received IA thrombolytics, and 1 patient received no thrombolytics before AMCD. No immediate periprocedural complications were noted. Immediate recanalization was achieved in 38% (50% MCA, 25% ICA) and final recanalization in 75% (88% MCA, 63% ICA) of patients. Favorable outcome occurred in 19 (59%) patients, symptomatic cerebral hemorrhage in 3 (9.4%) patients, and mortality in 4 (12.5%) patients. CONCLUSIONS: AMCD can be performed safely with comparable intracerebral hemorrhage and mortality rates to other IA therapies even after use of intravenous thrombolytics in selected patients. Early deployment of this technique leads to immediate recanalization in one third of patients. AMCD may potentially shorten the time to flow restoration and improve overall recanalization rates achieved with IA therapy.

Implications of silent strokes.

"Silent strokes" or "subclinical strokes" refer to incidental findings of strokes on neuroimaging studies, such as computed tomography or magnetic resonance imaging/diffusion-weighted imaging, that are asymptomatic. These include lacunar and other ischemic strokes and minor hemorrhages, particularly in "silent areas" of the brain, but also include leukoaraiosis due to small vessel pathology of a variety of origins. Clinicians need to appreciate their significance because with certain conditions, such as atrial fibrillation and significant carotid stenosis, follow-up of these patients shows an increased incidence of strokes, impaired cognitive function, and dementia. These serious consequences of subclinical strokes require the clinician to be vigilant and institute preventive strategies to avert these untoward outcomes.