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LKS Current Awareness Bulletin
Stroke – June 2019
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Stroke and pulmonary embolism
Ischemic stroke in children: Clinical presentation, evaluation, and diagnosis
Stroke in the newborn: Management and prognosis
For references where there is a link to the full text please use your NHS Athens username & password to access https://openathens.nice.org.uk/ Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults Author(s): Seminog, Olena O; Scarborough, Peter; Wright, F Lucy; Rayner, Mike; Goldacre, Michael J Source: BMJ (Clinical research ed.); May 2019; vol. 365 ; p. l1778 Abstract: OBJECTIVES To study trends in stroke mortality rates, event rates, and case fatality, and to explain the extent to which the reduction in stroke mortality rates was influenced by changes in stroke event rates or case fatality. DESIGN Population based study. SETTING Person linked routine hospital and mortality data, England.PARTICIPANTS795 869 adults aged 20 and older who were admitted to hospital with acute stroke or died from stroke. MAIN OUTCOME MEASURES Stroke mortality rates, stroke event rates (stroke admission or stroke death without admission), and case fatality within 30 days after stroke. RESULTS Between 2001 and 2010 stroke mortality rates decreased by 55%, stroke event rates by 20% and case fatality by 40%. The study population included 358 599 (45%) men and 437 270 (55%) women. Average annual change in mortality rate was -6.0% (95% confidence interval -6.2% to -5.8%) in men and -6.1% (-6.3% to -6.0%) in women, in stroke event rate was -1.3% (-1.4% to -1.2%) in men and -2.1% (-2.2 to -2.0) in women, and in case fatality was -4.7% (-4.9% to -4.5%) in men and -4.4% (-4.5% to -4.2%) in women. Mortality and case fatality but not event rate declined in all age groups: the stroke event rate decreased in older people but increased by 2% each year in adults aged 35 to 54 years. Of the total decline in mortality rates, 71% was attributed to the decline in case fatality (78% in men and 66% in women) and the remainder to the reduction in stroke event rates. The contribution of the two factors varied between age groups. Whereas the reduction in mortality rates in people younger than 55 years was due to the reduction in case fatality, in the oldest age group (≥85 years) reductions in case fatality and event rates contributed nearly equally. CONCLUSIONS Declines in case fatality, probably driven by improvements in stroke care, contributed more than declines in event rates to the overall reduction in stroke mortality. Mortality reduction in men and women younger than 55 was solely a result of a decrease in case fatality, whereas stroke event rates increased in the age group 35 to 54 years. The increase in stroke event rates in young adults is a concern. This suggests that stroke prevention needs to be strengthened to reduce the occurrence of stroke in people younger than 55 years. Cardiac output monitoring with thermodilution pulse-contour analysis vs. non-invasive pulse-contour analysis Author(s): Boisson, M; Poignard, M E; Pontier, B; Mimoz, O; Debaene, B; Frasca, D
Source: Anaesthesia; Jun 2019; vol. 74 (no. 6); p. 735-740 Abstract: Intravenous fluid boluses guided by changes in stroke volume improve some outcomes after major surgery, but invasive measurements may limit use. From October 2016 to May 2018, we compared the agreement and trending ability of a photoplethysmographic device (Clearsight) with a PiCCO, calibrated by thermodilution, for haemodynamic variables in 20 adults undergoing major elective surgery. We analysed 4519 measurement pairs, including before and after 68 boluses of 250 ml crystalloid. The bias and precision of stroke volume measurement by Clearsight were -0.89 ± 4.78 ml compared with the invasive pulse-contour cardiac output device. The coefficient of agreement for stroke volume variation after fluid boluses between the two devices was 0.79 ('strong'). Fluid boluses that increased stroke volume by ≥ 10% increased mean absolute volume (SD) and mean percentage (SD) stroke volume measurements similarly for the invasive pulse-contour cardiac output and Clearsight devices: 9 (4) ml vs. 8 (4) ml and 16% (8%) vs. 15% (10%), respectively, p > 0.05. The non-invasive Clearsight pulse-contour analysis was similar to an invasive pulse-contour device in measuring absolute and changing stroke volumes during major surgery. Genistein: mechanisms of action for a pleiotropic neuroprotective agent in stroke Author(s): Schreihofer, Derek A; Oppong-Gyebi, Anthony Source: Nutritional neuroscience; Jun 2019; vol. 22 (no. 6); p. 375-391 Abstract: Genistein is a plant estrogen promoted as an alternative to post-menopausal hormone therapy because of a good safety profile and its promotion as a natural product. Several preclinical studies of cerebral ischemia and other models of brain injury support a beneficial role for genistein in protecting the brain from injury whether administered chronically or acutely. Like estrogen, genistein is a pleiotropic molecule that engages several different mechanisms to enhance brain health, including reduction of oxidative stress, promotion of growth factor signalling, and immune suppression. These actions occur in endothelial, glial, and neuronal cells to provide a coordinated beneficial action to ischemic challenge. Though many of these protective actions are associated with estrogen-like actions of genistein, additional activities on other receptors and intracellular targets suggest that genistein is more than a mere estrogen-mimic. Importantly, genistein lacks some of the detrimental effects associated with post-menopausal estrogen treatment and may provide an alternative to hormone therapy in those patients at risk for ischemic events. We can obtain full-text for the following articles from another library - please do ask us or click the link under the reference to request Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source Author(s): Diener, Hans-Christoph; Sacco, Ralph L; Easton, J Donald; Granger, Christopher B; Bernstein, Richard A; Uchiyama, Shinichiro; Kreuzer, Jörg; Cronin, Lisa; Cotton, Daniel; Grauer, Claudia; Brueckmann, Martina; Chernyatina, Marina; Donnan, Geoffrey; Ferro, José M; Grond, Martin; Kallmünzer, Bernd; Krupinski, Jerzy; Lee, Byung-Chul; Lemmens, Robin; Masjuan, Jaime; Odinak, Miroslav; Saver, Jeffrey L; Schellinger, Peter D; Toni, Danilo; Toyoda, Kazunori; RE-SPECT ESUS Steering Committee and Investigators Source: The New England journal of medicine; May 2019; vol. 380 (no. 20); p. 1906-1917 Abstract: BACKGROUND Cryptogenic strokes constitute 20 to 30% of ischemic strokes, and most cryptogenic strokes are considered to be embolic and of undetermined source. An earlier randomized trial showed that rivaroxaban is no more effective than aspirin in preventing recurrent stroke after a presumed embolic stroke from an undetermined source. Whether dabigatran would be effective in preventing recurrent strokes after this type of stroke was unclear. METHODS We conducted a multicentre, randomized, double-blind trial of dabigatran at a dose of 150 mg or 110 mg twice daily as compared with aspirin at a dose of 100 mg once daily in patients who had had an embolic stroke of undetermined source. The primary outcome was recurrent stroke. The primary safety outcome was major bleeding. RESULTS A total of 5390 patients were enrolled at 564 sites and were randomly assigned to receive dabigatran (2695 patients) or aspirin (2695 patients). During a median follow-up of 19 months, recurrent strokes occurred in 177 patients (6.6%) in the dabigatran group (4.1% per year) and in 207 patients (7.7%) in the aspirin group (4.8% per year) (hazard ratio, 0.85; 95% confidence interval [CI], 0.69 to 1.03; P = 0.10). Ischemic strokes occurred in 172 patients (4.0% per year) and 203 patients (4.7% per year), respectively (hazard ratio, 0.84; 95% CI, 0.68 to 1.03). Major bleeding occurred in 77 patients (1.7% per year) in the dabigatran group and in 64 patients (1.4% per year) in the aspirin group (hazard ratio, 1.19; 95% CI, 0.85 to 1.66). Clinically relevant nonmajor bleeding occurred in 70 patients (1.6% per year) and 41 patients (0.9% per year), respectively. CONCLUSIONS In patients with a recent history of embolic stroke of undetermined source, dabigatran was not superior to
aspirin in preventing recurrent stroke. The incidence of major bleeding was not greater in the dabigatran group than in the aspirin group, but there were more clinically relevant nonmajor bleeding events in the dabigatran group. (Funded by Boehringer Ingelheim; RE-SPECT ESUS ClinicalTrials.gov number, NCT02239120.) Request this article from the library Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke Author(s): Ma, Henry; Campbell, Bruce C V; Parsons, Mark W; Churilov, Leonid; Levi, Christopher R; Hsu, Chung; Kleinig, Timothy J; Wijeratne, Tissa; Curtze, Sami; Dewey, Helen M; Miteff, Ferdinand; Tsai, Chon-Haw; Lee, Jiunn-Tay; Phan, Thanh G; Mahant, Neil; Sun, Mu-Chien; Krause, Martin; Sturm, Jonathan; Grimley, Rohan; Chen, Chih-Hung; Hu, Chaur-Jong; Wong, Andrew A; Field, Deborah; Sun, Yu; Barber, P Alan; Sabet, Arman; Jannes, Jim; Jeng, Jiann-Shing; Clissold, Benjamin; Markus, Romesh; Lin, Ching-Huang; Lien, Li-Ming; Bladin, Christopher F; Christensen, Søren; Yassi, Nawaf; Sharma, Gagan; Bivard, Andrew; Desmond, Patricia M; Yan, Bernard; Mitchell, Peter J; Thijs, Vincent; Carey, Leeanne; Meretoja, Atte; Davis, Stephen M; Donnan, Geoffrey A; EXTEND Investigators Source: The New England journal of medicine; May 2019; vol. 380 (no. 19); p. 1795-1803 Abstract: BACKGROUND The time to initiate intravenous thrombolysis for acute ischemic stroke is generally limited to within 4.5 hours after the onset of symptoms. Some trials have suggested that the treatment window may be extended in patients who are shown to have ischemic but not yet infarcted brain tissue on imaging. METHODS We conducted a multicenter, randomized, placebo-controlled trial involving patients with ischemic stroke who had hypoperfused but salvageable regions of brain detected on automated perfusion imaging. The patients were randomly assigned to receive intravenous alteplase or placebo between 4.5 and 9.0 hours after the onset of stroke or on awakening with stroke (if within 9 hours from the midpoint of sleep). The primary outcome was a score of 0 or 1 on the modified Rankin scale, on which scores range from 0 (no symptoms) to 6 (death), at 90 days. The risk ratio for the primary outcome was adjusted for age and clinical severity at baseline. RESULTS After 225 of the planned 310 patients had been enrolled; the trial was terminated because of a loss of equipoise after the publication of positive results from a previous trial. A total of 113 patients were randomly assigned to the alteplase group and 112 to the placebo group. The primary outcome occurred in 40 patients (35.4%) in the alteplase group and in 33 patients (29.5%) in the placebo group (adjusted risk ratio, 1.44; 95% confidence interval [CI], 1.01 to 2.06; P = 0.04). Symptomatic intracerebral hemorrhage occurred in 7 patients (6.2%) in the alteplase group and in 1 patient (0.9%) in the placebo group (adjusted risk ratio, 7.22; 95% CI, 0.97 to 53.5; P = 0.05). A secondary ordinal analysis of the distribution of scores on the modified Rankin scale did not show a significant between-group difference in functional improvement at 90 days. CONCLUSIONS Among the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 and 9.0 hours after stroke onset or at the time the patient awoke with stroke symptoms resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group. (Funded by the Australian National Health and Medical Research Council and others; EXTEND ClinicalTrials.gov numbers, NCT00887328 and NCT01580839.) Request this article from the library Are gait changes linked to CSF flow changes in the sagittal sinus? Author(s): Gallagher, R; Bateman, G; Marquez, J; Osmotherly, P Source: Neuroradiology; Jun 2019; vol. 61 (no. 6); p. 659-666 Abstract: PURPOSE To identify if specific findings on magnetic resonance imaging (MRI) cerebrospinal fluid (CSF) flow studies can be utilised to identify which patients with idiopathic normal pressure hydrocephalus (iNPH) will have improved gait following a CSF tap test (TT). METHODS Prospective study of patients undergoing a CSF TT for iNPH. Functional gait was assessed using the timed up and go (TUG) test before and after the CSF TT. MRI CSF flow studies accompanied the CSF TT. The minimum clinically important difference for the TUG (3.63 s) was used as a cut off value to categorise patients as responders to the CSF TT. RESULTS Fifty-three patients underwent CSF TT and MRI CSF flow studies. Significant differences were identified between groups for (non-responder vs responder) superior sagittal sinus flow (47.10% vs 40.41%), sagittal sinus stroke volume (274 vs 176.5 μl), sagittal sinus to arterial stroke volume ratio (0.203 vs 0.164), sagittal sinus area (42.2 mm2 vs 36.2 mm2) and circumference (27.7 mm vs 24.95 mm). No differences were present for aqueduct stroke volume, arterial stroke volume or aqueduct net flow. CONCLUSION A link between gait improvement resulting from CSF drainage and sagittal sinus measurements indicates that the sagittal sinus may play a role in the manifestation of symptoms in iNPH. This may have implications for the diagnosis of iNPH and potentially inform clinical decision making regarding surgical intervention. Request this article from the library
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Other News Stroke survivor gets tech support to speak again Alisha Malhotra was 26 years old when she had a stroke that left her with the language disorder aphasia. The condition, which impairs the production of speech and the comprehension of language, left Alisha having to learn how to speak again. An aphasia clinic, The National Brain Appeal Aphasia Service, has opened at University College London Hospital, where they are using ground-breaking technology to help patients like Alisha regain their speech. Source: BBC News Published: 15
th June 2019
Stroke survivors 'need mental health support' The majority of Northern Ireland's 37,000 stroke survivors have experienced a mental health problem, according to the Stroke Association. The charity has said those problems can include anxiety, depression or even suicidal thoughts. Carla Thompson, a mother of three from Bangor in County Down, had a stroke when she was 28. She believes there should be more support for stroke survivors after they leave hospital. Source: BBC News Published: 18
th June 2019
Higher risk of stroke can follow midlife type 2 diabetes New research on thousands of twins in Sweden has uncovered a significant link between type 2 diabetes in midlife and the risk of stroke and blocked brain arteries later in life. However, the link did not apply to brain bleeds, which can also cause strokes. Source: Medical News Today Published: 12
th June 2019
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