Khurshid Khan

How Well Are Hypertension, Hyperlipidemia, Diabetes, and Smoking Managed After a Stroke or Transient Ischemic Attack?

Background and Purpose— Stroke prevention clinics (SPCs) are not usually involved with the active management of hypertension, hyperlipidemia, diabetes, and smoking. The effect of consultations generated at SPCs on the adequacy of the management of these risk factors for stroke has not been well described, and few studies have long-term follow-up. Methods— We performed a prospective study of 119 consecutive patients referred to an SPC for secondary prevention. One year after their baseline visit, patients were re-evaluated for the adequacy of the management of the above risk factors, and the proportion of improvement was assessed. Results— One-hundred twelve patients returned for their 1-year follow-up visit. Sixty-six were male, and the average age was 65 years. Hypertension was present in 83 patients, hyperlipidemia in 92, diabetes in 26, and smoking in 38, and 80 had multiple risk factors. At baseline, 66% of patients with hypertension, 17% of patients with hyperlipidemia, and 23% of diabetics had adequate management of their respective risk factors. During 1 year of follow-up, hypertension management improved 20% (P <0.001) and lipid management improved 32% (P <0.001). There was no significant improvement in diabetes management or smoking cessation. Conclusions— Although our understanding of the benefit of addressing hypertension, hyperlipidemia, diabetes, and smoking for secondary prevention of stroke is evolving, we found marked room for improvement in the management of these four risk factors. SPCs may need to be more actively involved in the management of these modifiable risk factors, if we are to significantly impact the risk of recurrent stroke.

Does Current Oral Antiplatelet Agent or Subtherapeutic Anticoagulation Use Have an Effect on Tissue-Plasminogen-Activator-Mediated Recanalization Rate in Patients with Acute Ischemic Stroke?

Objective: Our goal is to assess if current antiplatelet (AP) use has an effect on recanalization rate and outcome in acute stroke patients. Methods: We conducted a retrospective analysis of acute stroke patients who received intravenous (IV) recombinant tissue plasminogen activator (rt-PA) and had transcranial Doppler examination within 3 h of symptom onset. The TCD findings were interpreted using the Thrombolysis in Brain Ischemia flow grading system as persistent arterial occlusion, reocclusion or complete recanalization. Complete recanalization was defined as established Thrombolysis in Brain Ischemia 4 or 5 within 2 h of IV rt-PA. The patients were divided based on their current use of AP agents. Comparisons were made between the different groups based on recanalziation rate, reocclusion and good long-term outcome (mRS ≤2) using χ2 test. Multiple regression analysis was used to identify AP use as a predictor for recanalization and outcome including symptomatic intracranial hemorrhage after controlling for age, baseline NIHSS score, time to treatment, previous vascular event, hypertension and diabetes mellitus. Results: Two hundred and eighty-four patients were included; 154 (54%) males, 130 (46%) females, with a mean age of 69.5 ± 13 years. The median baseline NIHSS score was 16 ± 5. The median time to TCD examination was 131 ± 38 min from symptom onset. The median time to IV rt-PA was 140 ± 34 min. One hundred eighty patients were not on AP prior to their stroke, 76 were on aspirin, 15 were on clopidogrel, 2 were on aspirin-dipyridamole combination, 2 were on both aspirin and clopidogrel, and 9 patients on subtherapeutic coumadin. In patients who were naïve to AP, 68/178 (38.2%) had complete recanalization, whereas in the AP group, 25/91 (28%) had complete recanalization. Patients on aspirin alone had a lower recanalization rate (16/72) as compared to those not on AP (22 vs. 39%) (p = 0.017), while those on clopidogrel had higher rates of complete recanalization (9/19, 60%). There was no difference in the rate of symptomatic intracranial hemorrhages in patients on AP agents as compared to those not on AP (9/180, 5% vs. 9/95, 9.5%) (p = 0.13). A good long-term outcome (mRS ≤2) was achieved in 85/160 (53%) of the patients naïve to AP and in 33/84 (39%) of the patients on AP (p = 0.035). In multiple regression, AP use was not a predictor of either recanalization rate (p = 0.057) or good outcome (p = 0.27). Conclusions: No correlation was found between AP use and recanalization rate and good outcome in patients with acute stroke who received IV rt-PA treatment. Prior AP use should not defer patients from receiving IV rt-PA treatment in an acute stroke setting.

Introduction of portable computed tomography scanners, in the treatment of acute stroke patients via telemedicine in remote communities

Background Thrombolysis is an established treatment in selected patients who present early to hospital after symptoms of acute ischaemic stroke. Treatment can only be offered after the patient has been assessed by highly trained physicians and imaging studies have ruled out a brain haemorrhage. This limits the wider availability of thrombolysis to patients in remote communities, especially in countries with limited resources. There has been considerable success with the use of TeleStroke to overcome such barriers. TeleStroke is feasible in remote hospitals provided there is an available computed tomography scanner, a fundamental prerequisite in the assessment of acute stroke and thrombolysis. This is a luxury not widely available, especially in remote sites. Recently, Neurologica introduced a portable computed tomography scanner that can be operated after minimal training. Methods We report our preliminary experience with the portable computed tomography scanner in a remote community where Telemedicine was successfully used to evaluate and treat patients presenting with symptoms suggestive of an acute ischaemic stroke. The University of Alberta Hospital in Edmonton, Canada was the ‘hub’ site and Wainwright Community Hospital was the ‘spoke’ site. Results Over a 3-month period, 18 patients were evaluated in the emergency department of the remote hospital where the referring physician felt that symptoms indicated potential for thrombolysis. All patients were evaluated remotely by a stroke neurologist in a TeleStroke service situated 207 km from the rural site. After clinical examination, cranial computed tomography scans were obtained with the portable scanner and evaluated by the stroke neurologist. In three patients, thrombolysis was not offered because the computed tomography showed evidence of brain haemorrhage: two intracerebral haemorrhage and one subarachnoid haemorrhage. Three patients meeting the standard criteria received thrombolysis within 4·5 h from onset of symptoms. There was a significant improvement in two patients. One patient did not make a good recovery. Repeat computed tomography scans showed a small haemorrhagic transformation in one patient. In the remaining 12 subjects, symptoms improved rapidly, were outside the window for thrombolysis, or were not consistent with an acute ischaemic stroke. Interpretations Our preliminary study shows that the portable scanner can be used successfully in the evaluation of patients in remote regions that are not within timely reach of stroke experts or do not have available conventional imaging with computed tomography scans. Telemedicine, in combination with the use of portable scanners, offers hope to a large remote population base that would otherwise not have access to appropriate acute stroke treatment.

Single sweep three-dimensional carotid ultrasound: Reproducibility in plaque and artery volume measurements

BACKGROUND There is a need for non-invasive and accurate techniques for assessment of severity of atherosclerotic disease in the carotid arteries. Recently an automated single sweep three-dimensional ultrasound (3D US) technique became available. The aims of this study were to evaluate the feasibility and reproducibility of the automated single sweep method in a cohort of patients undergoing clinically indicated carotid ultrasound. METHODS Consecutive patients with a history of stroke or transient ischemic attack (TIA) and having a plaque in the internal carotid artery (ICA) were recruited for this study. Imaging was performed using a Philips iU 22 ultrasound system equipped with the single sweep volumetric transducer vL 13-5. Analysis was performed offline with software provided by the manufacturer. Two independent observers performed all measurements. RESULTS Of 137 arteries studied (from 79 patients), plaque and artery volumes could be measured in 106 (77%). Reproducibility of plaque volume measurements was assessed in 82 arteries. Bland-Altman analysis demonstrated good inter-observer reproducibility with limits of agreement -0.06 to +0.07 ml. The mean percentage difference between two observers was 5.6% ± 6.0%. Reproducibility of artery volume measurement was assessed in 31 cases. Bland-Altman analysis demonstrated limits of agreement from -0.15 to +0.15 ml. The mean percentage difference was 6.4 ± 5.9%. CONCLUSION The new automated single sweep 3D ultrasound is feasible in the majority of patients. Good reproducibility in plaque and artery volume measurements makes this technique suitable for serial assessment of carotid plaques.

DWI lesion volume reduction following acute stroke treatment with transient partial aortic obstruction.

Diffusion‐weighted imaging (DWI) identifies acute cerebral ischemia and DWI lesions are thought to indicate irreversibly damaged areas. However, new evidence suggests that DWI lesions may be reversible, especially with reperfusion. We present a patient who showed substantial reversal of her acute DWI lesion following partial aortic occlusion with Neuroflo™, a novel dual balloon catheter (Neuroflo™, CoAxia, MN).

Rapid Assessment and Treatment of Transient Ischemic Attacks and Minor Stroke in Canadian Emergency Departments: Time for a Paradigm Shift.

A majority of acute cerebrovascular syndromes are transient ischemic attacks (TIA) or minor ischemic strokes. They are often thought of and managed as though benign, but are in fact a warning of impending disabling stroke. The risk of stroke progression or recurrence is highest in the first hours to days from initial symptom onset, with a 6.7% risk at 48 hours and a 10% risk by 7 days after a TIA.1,2 The highest risk period is early, with a median time to a recurrence or progression event of 1 day; many events occur overnight after the initial ictus.3 Many strokes are preventable after a TIA. Rapid diagnosis and treatment reduces the risk of stroke by as much as 80%4,5 and significantly reduces mortality, long-term disability, and costs.6,7 The estimated annual cost avoidance in Canada from the rapid assessment and treatment of TIA is

Detection of patent foramen ovale by 3D echocardiography.

313.8 million (of which

The correlation between admission blood glucose and intravenous rt‐PA‐induced arterial recanalization in acute ischemic stroke: a multi‐centre TCD study

269.2 million are indirect costs).8 To be most effective, the diagnosis and treatment of all TIAs and minor strokes must recognize the natural biology of the condition and should ideally occur on the same day as the event. Currently, this is not consistently achieved in Canada. There are several overlapping challenges with TIA/minor stroke management, including (1) establishing an accurate diagnosis of brain ischemia quickly; (2) establishing accurate triage approaches to risk-stratify patients; and (3) establishing systems of care that expedite both the diagnostic evaluation and initiation of treatment. Rapid access to both brain and vascular imaging is a unifying component of the solution to all these challenges. The clinical diagnosis of TIA/minor stroke is not always straightforward because a …

Real-Time Hemodynamic Assessment of Downstream Effects of Intracranial Stenoses in Patients with Orthostatic Hypoperfusion Syndrome

TECHNICAL ADVANCES IN PATENT FORAMEN OVALE (PFO) DEVICE CLOSURE RESULTED IN GREATER CLINICAL IMPORTANCE TO OPTIMALLY DIAGNOSE INTRACARDIAC SHUNTS. Two-dimensional transesophageal echocardiography (2DTEE) with agitated saline contrast is currently the gold standard for diagnosing PFO. However, direct

Small vessel disease/white matter disease of the brain and its association with osteoporosis.

Background The relationship between hyperglycemia and arterial recanalization following intravenous recombinant tissue-plasminogen activator treatment in acute ischemic stroke is not well understood. Aim We aimed to evaluate the effects of hyperglycemia in thrombolysed ischemic stroke patients on recanalization rate and clinical outcome. Methods We studied 348 (231 subjects from the CLOTBUST databank and 117 subjects from the CLOTBUST trial phase II) with documented intracranial artery occlusion treated with intravenous recombinant tissue-plasminogen activator. Serum glucose was determined at baseline before intravenous recombinant tissue-plasminogen activator administration. Hyperglycemia was defined as a glucose level ≥140 mg/dl (7·7 mmol/l). Transcranial Doppler findings were interpreted using the thrombolysis in brain ischemia flow grading system as persistent arterial occlusion, re-occlusion or complete recanalization. Poor clinical outcome was defined by modified Rankin score > 2 at three-months. Results At baseline, 138 patients (37·4%) were hyperglycemic and 210 patients (56·9%) normoglycemic. Baseline characteristics based on glucose ≥ 140 (7·7 mmol/l) or less 140: age (70·0 ± 12·4 vs. 67·3 ± 14·1, P = 0·065), baseline National Institutes of Health Stroke Scale (17·0 ± 5·5 vs. 15·8 ± 5·5, P = 0·054), time to recombinant tissue-plasminogen activator (141·4 ± 69·1 vs. 145·3 ± 48·4 mins, P = 0·56), and history of diabetes mellitus [60/138 (43·5%) vs. 22/210 (10·5%), P < 0·001]). Patients with hyperglycemia have a higher rate of persisting occlusion [72/138 (52·2%) vs. 66/210 (31·4%)] and less rate of complete recanalization [34/138 (24·6%) vs. 82/210 (39%), P < 0·001]. Median time to recanalization in patients with severe hyperglycemia (glucose ≥ 200) (11 mmol/l) and glucose <200 was 163 ± 79 and 131 ± 90 mins, respectively (P = 0·045). Sixteen patients (11·6%) in the hyperglycemic group and 12 (5·7%) in the normoglycemic group had symptomatic intracerebral hemorrhage (P = 0·049). Seventy-eight patients (69%) in the hyperglycemia group and 72 patients (41·6%) in the normoglycemic group had poor clinical outcome (three-month modified Rankin score > 2) (P ≤ 0·001). After adjusting for stroke risk factors, patients with hyperglycemia were more likely to have poor clinical outcome (three-month modified Rankin score > 2) (adjusted odds ratio = 2·22, 95% confidence interval: 1·2–4·11, P = 0·011) and low complete recanalization rate (adjusted odds ratio: 0·5, confidence interval: 0·3–0·92, P = 0·025) with trend of increase risk of symptomatic intracerebral hemorrhage (adjusted odds ratio: 2·07, confidence interval:0·8–5·1, P = 0·114). There was no association between baseline glucose as a continuous variable and poor clinical outcome, but there was with the complete recanalizations rate. Conclusion Hyperglycemia is associated with low rate of complete recanalization and poor clinical outcome in intravenous recombinant tissue-plasminogen activator-treated patients. Further studies are needed to evaluate whether lowering hyperglycemia is beneficial in the management of acute stroke patients.