Ali Kerro

Direct oral anticoagulant– vs vitamin K antagonist–related nontraumatic intracerebral hemorrhage

Objective: To compare the neuroimaging profile and clinical outcomes among patients with intracerebral hemorrhage (ICH) related to use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF). Methods: We evaluated consecutive patients with NVAF with nontraumatic, anticoagulant-related ICH admitted at 13 tertiary stroke care centers over a 12-month period. We also performed a systematic review and meta-analysis of eligible observational studies reporting baseline characteristics and outcomes among patients with VKA- or DOAC-related ICH. Results: We prospectively evaluated 161 patients with anticoagulation-related ICH (mean age 75.6 ± 9.8 years, 57.8% men, median admission NIH Stroke Scale [NIHSSadm] score 13 points, interquartile range 6–21). DOAC-related (n = 47) and VKA-related (n = 114) ICH did not differ in demographics, vascular risk factors, HAS-BLED and CHA2DS2-VASc scores, and antiplatelet pretreatment except for a higher prevalence of chronic kidney disease in VKA-related ICH. Patients with DOAC-related ICH had lower median NIHSSadm scores (8 [3–14] vs 15 [7–25] points, p = 0.003), median baseline hematoma volume (12.8 [4–40] vs 24.3 [11–58.8] cm3, p = 0.007), and median ICH score (1 [0–2] vs 2 [1–3] points, p = 0.049). Severe ICH (>2 points) was less prevalent in DOAC-related ICH (17.0% vs 36.8%, p = 0.013). In multivariable analyses, DOAC-related ICH was independently associated with lower baseline hematoma volume (p = 0.006), lower NIHSSadm scores (p = 0.022), and lower likelihood of severe ICH (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.13–0.87, p = 0.025). In meta-analysis of eligible studies, DOAC-related ICH was associated with lower baseline hematoma volumes on admission CT (standardized mean difference = −0.57, 95% CI −1.02 to −0.12, p = 0.010) and lower in-hospital mortality rates (OR = 0.44, 95% CI 0.21–0.91, p = 0.030). Conclusions: DOAC-related ICH is associated with smaller baseline hematoma volume and lesser neurologic deficit at hospital admission compared to VKA-related ICH.

FABS: An Intuitive Tool for Screening of Stroke Mimics in the Emergency Department

Background and Purpose— A large number of patients with symptoms of acute cerebral ischemia are stroke mimics (SMs). In this study, we sought to develop a scoring system (FABS) for screening and stratifying SM from acute cerebral ischemia and to identify patients who may require magnetic resonance imaging to confirm or refute a diagnosis of stroke in the emergency setting. Methods— We designed a scoring system: FABS (6 variables with 1 point for each variable present): absence of Facial droop, negative history of Atrial fibrillation, Age <50 years, systolic Blood pressure <150 mm Hg at presentation, history of Seizures, and isolated Sensory symptoms without weakness at presentation. We evaluated consecutive patients with symptoms of acute cerebral ischemia and a negative head computed tomography for any acute finding within 4.5 hours after symptom onset in 2 tertiary care stroke centers for validation of FABS. Results— A total of 784 patients (41% SMs) were evaluated. Receiver operating characteristic curve (C statistic, 0.95; 95% confidence interval [CI], 0.93–0.98) indicated that FABS≥3 could identify patients with SM with 90% sensitivity (95% CI, 86%–93%) and 91% specificity (95% CI, 88%–93%). The negative predictive value and positive predictive value were 93% (95% CI, 90%–95%) and 87% (95% CI, 83%–91%), respectively. Conclusions— FABS seems to be reliable in stratifying SM from acute cerebral ischemia cases among patients in whom the head computed tomography was negative for any acute findings. It can help clinicians consider advanced imaging for further diagnosis.

Neurogenic stunned myocardium in subarachnoid hemorrhage

&NA; “Stunned myocardium,” characterized by reversible left ventricular dysfunction, was first described via animal models using transient coronary artery occlusion. However, this phenomenon has also been noted with neurologic pathologies and collectively been labeled “neurogenic stunned myocardium” (NSM). Neurogenic stunned myocardium resulting from subarachnoid hemorrhage (SAH) is a challenging pathology due to its diagnostic uncertainty. Traditional diagnostic criteria for NSM after SAH focus on electrocardiographic and echocardiographic abnormalities and troponemia. However, tremendous heterogeneity still exists. Traditional pathophysiological mechanisms for NSM encompassed hypothalamic and myocardial perivascular lesions. More recently, research on pathophysiology has centered on myocardial microvascular dysfunction and genetic polymorphisms. Catecholamine surging as a mechanism has also gained attention with particular focus placed on the role of adrenergic blockade in both the prehospital and acute settings. Management remains largely supportive with case reports acknowledging the utility of inotropes such as dobutamine and milrinone and intra‐aortic balloon pump when NSM is accompanied by cardiogenic shock. Neurogenic stunned myocardium that follows SAH can result in many complications such as arrhythmias, pulmonary edema, and prolonged intubation, which can negatively impact long‐term recovery from SAH and increase morbidity and mortality. This necessitates the need to accurately diagnose and treat NSM.

Elevated Pulse Pressure Levels Are Associated With Increased In-Hospital Mortality in Acute Spontaneous Intracerebral Hemorrhage

OBJECTIVES Clinical outcome after intracerebral hemorrhage (ICH) remains poor. Definitive phase-3 trials in ICH have failed to demonstrate improved outcomes with intensive systolic blood pressure (SBP) lowering. We sought to determine whether other BP parameters-diastolic BP (DBP), pulse pressure (PP), and mean arterial pressure (MAP)-showed an association with clinical outcome in ICH. METHODS We retrospectively analyzed a prospective cohort of 672 patients with spontaneous ICH and documented demographic characteristics, stroke severity, and neuroimaging parameters. Consecutive hourly BP recordings allowed for computation of SBP, DBP, PP, and MAP. Threshold BP values that transitioned patients from survival to death were determined from ROC curves. Using in-hospital mortality as outcome, BP parameters were evaluated with multivariable logistic regression analysis. RESULTS Patients who died during hospitalization had higher mean PP compared to survivors (68.5 ± 16.4 mm Hg vs. 65.4 ± 12.4 mm Hg; P = 0.032). The following admission variables were associated with significantly higher in-hospital mortality (P < 0.001): poorer admission clinical condition, intraventricular hemorrhage, and increased admission normalized hematoma volume. ROC analysis showed that mean PP dichotomized at 72.17 mm Hg, provided a transition point that maximized sensitivity and specific for mortality. The association of this increased dichotomized PP with higher in-hospital mortality was maintained in multivariable logistic regression analysis (odds ratio, 3.0; 95% confidence interval, 1.7-5.3; P < 0.001) adjusting for potential confounders. CONCLUSION Widened PP may be an independent predictor for higher mortality in ICH. This association requires further study.

Evaluation of Acute Kidney Injury and Mortality After Intensive Blood Pressure Control in Patients With Intracerebral Hemorrhage

Background We sought to assess the risk of acute kidney injury (AKI) and mortality associated with intensive systolic blood pressure reduction in acute intracerebral hemorrhage. Methods and Results Patients with acute intracerebral hemorrhage had spontaneous cause and symptom onset within 24 hours. We excluded patients with structural causes, coagulopathy, thrombocytopenia, and preexisting end‐stage renal disease. We defined AKI using the Acute Kidney Injury Network criteria. Chronic kidney disease status was included in risk stratification and was defined by Kidney Disease Outcomes Quality Initiative staging. Maximum systolic blood pressure reduction was defined over a 12‐hour period and dichotomized using receiver operating characteristic curve analysis. Descriptive statistics were done using independent sample t tests, χ2 tests, and Mann‐Whitney U tests, whereas multivariable logistic regression analysis was used to evaluate for predictors for AKI and mortality. A total of 448 patients with intracerebral hemorrhage met inclusion criteria. Maximum systolic blood pressure reduction was dichotomized to 90 mm Hg and found to increase the risk of AKI in patients with normal renal function (odds ratio, 2.1; 95% confidence interval, 1.19–3.62; P=0.010) and chronic kidney disease (odds ratio, 3.91; 95% confidence interval, 1.26–12.15; P=0.019). The risk of AKI was not significantly different in normal renal function versus chronic kidney disease groups when adjusted for demographics, presentation characteristics, and medications associated with AKI. AKI positively predicted mortality for patients with normal renal function (odds ratio, 2.41; 95% confidence interval, 1.11–5.22; P=0.026) but not for patients with chronic kidney disease (odds ratio, 3.13; 95% confidence interval, 0.65–15.01; P=0.154). Conclusions These results indicate that intensive systolic blood pressure reduction with a threshold >90 mm Hg in patients with acute intracerebral hemorrhage may be an independent predictor for AKI.

Sulfonylurea drug pretreatment and functional outcome in diabetic patients with acute intracerebral hemorrhage

PURPOSE Intracerebral hemorrhage (ICH) is associated with poor clinical outcome and high mortality. Sulfonylurea (SFU) use may be a viable therapy for inhibiting sulfonylurea receptor-1 and NCCa-ATP channels and reducing perihematomal edema and blood-brain barrier disruption. We sought to evaluate the effects of prehospital SFU use with outcomes in diabetic patients with acute ICH. METHODS We retrospectively analyzed a cohort of diabetic patients presenting with acute ICH at a tertiary care center. Study inclusion criteria included spontaneous ICH etiology and age>18years. Baseline clinical severity was documented using ICH-score. Hematoma volumes (HV) on admission were calculated using ABC/2 formula. Unfavorable functional outcome was documented as discharge modified Rankin Scale scores 2-6. RESULTS 230 diabetic patients with acute ICH fulfilled inclusion criteria (mean age 64±13years, men 53%). SFU pretreatment was documented in 16% of the study population. Patients with SFU pretreatment had significantly (p<0.05) lower median ICH-scores (0, IQR: 0-2) and median admission HV (4cm3, IQR: 1-12) compared to controls [ICH-score: 1 (IQR: 0-3); HV: 9cm3 (IQR: 3-20)]. SFU pretreatment was independently (p=0.033) and negatively associated with the cubed root of admission HV (linear regression coefficient: -0.208; 95%CI: -0.398 to -0.017) in multiple linear regression analyses adjusting for potential confounders. Pretreatment with SFU was also independently (p=0.033) associated with lower likelihood of unfavorable functional outcome (OR=0.19; 95%CI: 0.04-0.88) in multivariable logistic regression models adjusting for potential confounders. CONCLUSION SFU pretreatment may be an independent predictor for improved functional outcome in diabetic patients with acute ICH. This association requires independent confirmation in a large prospective cohort study.

Dual antiplatelet therapy pretreatment in IV thrombolysis for acute ischemic stroke

Objective We sought to determine the safety and efficacy of IV thrombolysis (IVT) in acute ischemic stroke (AIS) patients with a history of dual antiplatelet therapy pretreatment (DAPP) in a prospective multicenter study. Methods We compared the following outcomes between DAPP+ and DAPP− IVT-treated patients before and after propensity score matching (PSM): symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial hemorrhage, favorable functional outcome (modified Rankin Scale score 0–1), and 3-month mortality. Results Among 790 IVT patients, 58 (7%) were on DAPP before stroke (mean age 68 ± 13 years; 57% men; median NIH Stroke Scale score 8). DAPP+ patients were older with more risk factors compared to DAPP− patients. The rates of sICH were similar between groups (3.4% vs 3.2%). In multivariable analyses adjusting for potential confounders, DAPP was associated with higher odds of asymptomatic intracranial hemorrhage (odds ratio = 3.53, 95% confidence interval: 1.47–8.47; p = 0.005) but also with a higher likelihood of 3-month favorable functional outcome (odds ratio = 2.41, 95% confidence interval: 1.06–5.46; p = 0.035). After propensity score matching, 41 DAPP+ patients were matched to 82 DAPP− patients. The 2 groups did not differ in any of the baseline characteristics or safety and efficacy outcomes. Conclusions DAPP is not associated with higher rates of sICH and 3-month mortality following IVT. DAPP should not be used as a reason to withhold IVT in otherwise eligible AIS candidates. Classification of evidence This study provides Class III evidence that for IVT-treated patients with AIS, DAPP is not associated with a significantly higher risk of sICH. The study lacked the precision to exclude a potentially meaningful increase in sICH bleeding risk.

Differential leukocyte counts on admission predict outcomes in patients with acute ischaemic stroke treated with intravenous thrombolysis

To determine the association of differential leukocyte counts on admission with efficacy and safety outcomes in patients with acute ischaemic stroke (AIS) treated with intravenous thrombolysis (IVT).