Inclusion of Risk Biomarkers Improves Stroke Prediction

MedicalResearch.com Interview with:
Dr. Ashkan Shoamanesh MD FRCPC
Assistant Professor
Division of Neurology, Department of Medicine
McMaster University and
Dr. Jose Rafael Romero, MD
Associate Professor of Neurology
Boston University School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The Framingham Heart Study is a population-based study of individuals residing in the community. Identifying people who are at risk for stroke can help us determine who would benefit most from existing or new therapies to prevent stroke. As inflammatory pathways are believed to contribute to vascular disease and stroke, we tested whether circulating biomarkers of inflammation and endothelial dysfunction could improve the predictive ability of the Framingham Stroke Risk Profile score, a model that contains classical vascular risk factors such as high blood pressure and diabetes.

Our main observation was that inclusion of 4 biomarkers (C-reactive protein, tumor necrosis factor receptor-2, total homocysteine, and vascular endothelial growth factor) in the Framingham Stroke Risk Profile improved its ability to predict a stroke (net reclassification improvement of 0.34 [0.12–0.57]).

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Pre-Hospital Start of IV Thrombolysis Might Result in Improved Functional Outcome in Stroke Patients.

MedicalResearch.com Interview with:
Dr Alexander Kunz MD
Department of Neurology
Charité-University Medicine Berlin
Berlin, Germany

MedicalResearch.com: What is the background for this study?

Response: Systemic thrombolysis with tissue plasminogen activator (tPA) in acute ischemic stroke has been an approved therapy for over 20 years now. To date, tPA can be administered to eligible patients within a 4.5 hours time window after the onset of symptoms. Results from large thrombolysis trials and meta-analyses have shown, that the beneficial effects of tPA are inversely correlated with the delay from symptoms onset to start of tPA treatment. This relationship is frequently summarized in the slogan “Time is brain!”

Currently, several research groups are evaluating the concept of pre-hospital thrombolysis using a mobile stroke treatment unit (MSTU) in order to achieve significant reductions in onset-to-treatment delays. MSTU are specialized ambulances equipped with a CT scanner and a mini-laboratory.

In Berlin, Germany, we have been operating an MSTU (stroke emergency mobile vehicle, STEMO) since 2011. Previous studies had shown that start of tPA treatment was 25min earlier when patients were cared by STEMO than within conventional care, i.e. admission to hospital by regular ambulance and in-hospital tPA treatment. However, these studies did not prove, that earlier treatment in STEMO is associated with better outcome. Therefore, the aim of the current study was to compare 3-month functional outcome after tPA in patients with acute ischemic stroke who received STEMO care vs conventional care.

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Stroke Risk Elevated in Some Patients with NAION

MedicalResearch.com Interview with:

Rong-Kung Tsai MD, PhD Professor and Director Institute of Eye Research Buddhist Tzu Chi Medical Center; Director, Institute of Medical Sciences Tzu Chi University, Hualien, Taiwan

Dr. Rong Kung-Tsai

Rong-Kung Tsai MD, PhD
Professor and Director
Institute of Eye Research
Buddhist Tzu Chi Medical Center;
Director, Institute of Medical Sciences
Tzu Chi University, Hualien, Taiwan

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Non-arteritic anterior ischemic optic neuropathy (NAION) is pathogenetically different from stroke, stroke is caused by thromboembolism. However, they share many (but not all) systemic vascular risk factors. Previous small scale studies got controversial results. Using the National Health Insurance Research Database (NHIRD) in Taiwan to conduct the cohort study, 414 patients were included in the NAION group and 789 in the control group (base one million beneficiaries). The incidence of NAION is 3.72/100,000 person-years in Taiwan, and patients with NAION have more chances to develop ischemic stroke (p=0.003), but not hemorrhage stroke.

The subgroup analyses further showed the risk of ischemic stroke among the subjects with NAION and with comorbidities was 3.35 times higher than those without NAION. However, in patients with NAION but no comorbidities, there is no increase risk of stroke development.

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New Onset Atrial Fibrillation Strongest Predictor of Stroke After TAVR

MedicalResearch.com Interview with:

Josep Rodés-Cabau, MD Director, Catheterization and Interventional Laboratories Quebec Heart and Lung Institute Professor, Faculty of Medicine, Laval University Quebec City, Quebec, Canada

Dr. Josep Rodés-Cabau

Josep Rodés-Cabau, MD
Director, Catheterization and Interventional Laboratories
Quebec Heart and Lung Institute
Professor, Faculty of Medicine, Laval University
Quebec City, Quebec, Canada

MedicalResearch.com: What is the background for this study?

Response: Transcatheter aortic valve replacement (TAVR) is increasingly used in patients with severe aortic stenosis deemed at prohibitive or high surgical risk. Recently, a randomized trial demonstrated the non-inferiority of TAVR compared to surgical aortic valve replacement in intermediate risk patients for the outcome of death and disabling stroke at 2 years. Therefore, TAVR indications are likely to expand to younger and lower risk patients in the near future.

While the short-term (30-day) cerebrovascular event (CVE) rate post-TAVR has decreased over time, it remains the most dreadful complication of TAVR, and still occurs in 2% to 3% of patients. A few dedicated studies identified numerous predictors of CVE which mainly differ from one study to another. However, identifying the risk factors of CVE is of paramount relevance in clinical practice to implement preventive strategies, either instrumental (embolic protection devices) or pharmacological in high-risk patients. Thus, we performed a systematic review and meta-analysis using random-effect models to provide pooled estimates of sixteen (8 patient-related and 8 procedural-related) clinically-relevant predictors of CVE within 30 days post TAVR.

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Adding Black Race To Scoring System Improves Stroke Prediction in AFib

MedicalResearch.com Interview with:

Dr. Mary Vaughan Sarrazin PhD Associate Professor Department of Internal Medicine University of Iowa Roy and Lucille Carver College of Medicine, and Iowa City VA Medical Center, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE) Iowa City

Dr. Mary Vaughan Sarrazin

Dr. Mary Vaughan Sarrazin PhD
Associate Professor
Department of Internal Medicine
University of Iowa Roy and Lucille Carver College of Medicine, and
Iowa City VA Medical Center, Center for Comprehensive Access & Delivery
Research and Evaluation (CADRE)
Iowa City

MedicalResearch.com: What is the background for this study?

Response: Atrial fibrillation is associated with a higher risk of stroke. The CHA2DS2VASc score (congestive heart failure, hypertension, age 75 or older, diabetes, previous stroke, vascular disease, age 65-74, female sex) reflects stroke risk and is used to guide decisions regarding anticoagulation. Our prior work suggests that African Americans have a higher risk of stroke compared to other patients with atrial fibrillation, even after risk factor adjustments. In the current study, we used Medicare data to test whether addition of black race to CHA2DS2VASc score improves stroke prediction in patients with atrial fibrillation.

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Specialized Stroke Care Centers Improve Outcomes

MedicalResearch.com Interview with:

Kimon Bekelis, MD Chief Resident Department of Neurosurgery Dartmouth-Hitchcock School of Medicine

Dr. Kimon Bekelis

Kimon Bekelis, MD Chief Resident
Department of Neurosurgery
Dartmouth-Hitchcock School of Medicine

MedicalResearch.com: What is the background for this study?

Response: Physicians often must decide whether to treat acute stroke patients locally, or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of specialized  Primary Stroke Center care.

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Profound Disparities By Race in Delivery of Care to Stroke Patients

MedicalResearch.com Interview with:

Romanus Roland Faigle, M.D., Ph.D. Assistant Professor of Neurology The Johns Hopkins Hospital

Dr. Roland Faigle

Romanus Roland Faigle, M.D., Ph.D.
Assistant Professor of Neurology
The Johns Hopkins Hospital

MedicalResearch.com: What is the background for this study?

Response: Stroke care entails a variety of procedures and interventions, which generally fall into one of the two following categories: 1) curative/preventative procedures (such as IV thrombolysis and carotid revascularization), which intent to prevent injury and restore function; and 2) life-sustaining procedures (such as gastrostomy, mechanical ventilation, tracheostomy, and hemicraniectomy), which intent to address complications from a stroke and to prevent death. The use of curative/preventative procedures is supported by excellent evidence and is guided by well-defined criteria, while those are largely lacking for life-sustaining procedures. Therefore, curative/preventative are desirable for eligible patients, while life-sustaining procedures indicate the need to address undesired complications and in itself have questionable utility. We wanted to determine whether race differences in the use of the individual stroke-related procedures exist, and whether presence and directionality of differences by race follow a pattern unique to each of the 2 procedure groups.

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Even Light Smoking Elevates Risk of Brain Bleeding From Intracranial Aneurysm

MedicalResearch.com Interview with:
Joni Valdemar Lindbohm, MD
Department of Public Health
University of Helsinki, Finland

MedicalResearch.com: What is the background for this study?

Response: Approximately 1-6% percent of people carry an unruptured intracranial aneurysm but most of these never rupture during lifetime and cause subarachnoid hemorrhage (SAH). In SAH, the rupture of an aneurysm causes bleeding into the lining between the brain’s surface and underlying tissue. Despite advances in operative techniques, SAH can lead to death in up to 45% of the cases. Because life style risk factors are critical in development of subarachnoid hemorrhage, it is important to characterize the risk factor profile of those with an elevated risk.

Widely accepted risk factors for SAH are increasing age, smoking, hypertension and female sex. However, the reasons for an elevated risk in women have remained uncovered and the effect of smoking habits are not well understood.

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Chronic Periodontal Disease Quadruples Risk of Lacunar Stroke

MedicalResearch.com Interview with:

Dr. Yago Leira, DDS Pre-Doc researcher at Health Research Institute of Santiago de Compostela (Spain) and Department of Periodontology, Faculty of Medicine and Dentistry University of Santiago de Compostela (Spain)

Dr. Yago Leira

Dr. Yago Leira, DDS
Pre-Doc researcher at Health Research Institute of Santiago de Compostela (Spain) and Department of Periodontology, Faculty of Medicine and Dentistry
University of Santiago de Compostela (Spain)

MedicalResearch.com: What is the background for this study?

Response: Periodontal disease is a chronic oral inflammatory disease caused by bacterial infection, which affects 20% to 50% of the adult population. Lacunar stroke, a type of cerebral small vessel disease, is responsible for almost 25% of the ischaemic strokes. It may be hypothesized that chronic periodontitis leads to a low-grade state of systemic inflammation altering endothelial function and blood vessels health, which could be related to the onset of atherosclerosis. Moreover, lacunar stroke could be linked with an inflammation process that can be associated with endothelial dysfunction.

In the last decade, several observational studies have suggested an association between periodontal disease and ischaemic stroke. However, none of them have studied the relationship between chronic periodontitis and lacunar stroke independently of known vascular risk factors that both diseases may share (e.g., ageing, hypertension, diabetes mellitus or hypercholesterolemia).

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Obese Black Patients With Abnormal Sleep Have Greater Stroke Risk Than Whites

MedicalResearch.com Interview with:

Azizi Seixas, Ph.D. Post-Doc Fellow Department of Population Health Center for Healthful Behavior Change NYU School of Medicine

Dr. Azizi Seixas

Azizi Seixas, Ph.D.
Post-Doc Fellow
Department of Population Health
Center for Healthful Behavior Change
NYU School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Compared with whites, blacks are disproportionately affected by strokes. The overwhelming prevalence of obesity among blacks compared to whites has been suggested as a possible explanation for the disproportionate rates of strokes among blacks compared to whites. Recent findings linking insufficient sleep and stroke as well as the disproportionate burden of insufficient sleep among blacks compared to whites might provide a unique mechanism explaining why blacks have higher rates of stroke. However, it is unclear whether insufficient sleep and obesity contributes to the higher rates of stroke among blacks compared to whites.

To test our hypothesis, we utilized data from the National Health Interview Survey from 2004-2013 with a sample size of 288,888 individuals from the United States. Using Bayesian Belief Network (BBN) analysis, a form of machine learning analysis, we assessed the mediating effects of BMI on the relationship between short sleep duration (≤6 hrs. total sleep duration), long sleep duration (≥9 hrs. total sleep duration), and stroke, and whether race/ethnicity differences in obesity moderated these relationships.

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Blacks and Asians Have Lower Mortality Than Whites After Ischemic Stroke

MedicalResearch.com Interview with:

Nilay Kumar M.B.B.S. Attending physician at Cambridge Health Alliance, Cambridge, MA Instructor in Medicine at Harvard Medical School, Boston, MA

Dr. Nilay Kumar

Nilay Kumar M.B.B.S.
Attending physician at Cambridge Health Alliance, Cambridge, MA
Instructor in Medicine at Harvard Medical School
Boston, MA

 MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Racial differences in stroke mortality have major health policy implications. A large body of evidence has shown significant racial differences in the incidence of stroke and associated mortality rate (death due to stroke per unit population per year) in the United States. Few studies to date have addressed racial differences in in-hospital outcomes after acute ischemic stroke using population level datasets. Previous studies have shown inconsistent results with respect to racial differences in in-hospital case fatality rate after acute ischemic stroke. Additionally, racial minorities have been known to be less likely to receive evidence based reperfusion therapies for several cardiovascular diseases including acute myocardial infarction and ischemic stroke. Previous studies on racial differences in stroke outcomes have rarely included Asian and Pacific Islanders. Against this background, we aimed to ascertain racial differences in outcomes of acute ischemic stroke hospitalization in the US using a nationally representative sample.

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Aspirin + Clopidogrel Effectiveness in TIA Depends on CYP2C19 Loss-of-Function Allele

MedicalResearch.com Interview with:

Dr. Yongjun Wang  Principal Investigator No. 6 Tiantanxili Dongcheng District, Beijing, China

Dr. Yongjun Wang

Dr. Yongjun Wang 
Principal Investigator
No. 6 Tiantanxili
Dongcheng District, Beijing, China

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Clopidogrel requires conversion to an active metabolite by hepatic cytochrome p450 (CYP) iso-enzymes to exert an antiplatelet effect, and polymorphisms of the CYP2C19 gene have been identified as strong predictors of clopidogrel nonresponsiveness. However, data are limited regarding the association between CYP2C19 genetic variants and clinical outcomes of clopidogrel-treated patients with minor stroke or transient ischemic attack.

The main findings of this study is that the combined treatment of clopidogrel and aspirin compared with aspirin alone reduced the risk of a new stroke only in the subgroup of patients with minor ischemic stroke or TIA who were not carriers of the CYP2C19 loss of function alleles.

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MRI Brain Scans Can Predict Disruption of Blood-Brain Barrier in Stroke Patients

MedicalResearch.com Interview with:

Dr. Richard Leigh MD Neuro Vascular Brain Imaging Unit National Institute of Neurological Disorders and Stroke National Institutes of Health, Bethesda, MD

Dr. Richard Leigh

Dr. Richard Leigh MD
Neuro Vascular Brain Imaging Unit
National Institute of Neurological Disorders and Stroke
National Institutes of Health, Bethesda, MD

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Patients who suffer an ischemic stroke have limited treatment options. One of the reasons for this is that our treatments can sometimes make the stroke worse by transforming the ischemic stroke into a hemorrhagic stroke. In our study we identified a new piece of information that we can extract from the patient’s MRI scan that informs us on the risk of having a hemorrhage.

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Non-Contrast CT Yields Prognostic Findings in Hemorrhagic Stroke

MedicalResearch.com Interview with:

Dr-Gregoire-Boulouis.jpg

Dr. Gregoire Boulouis

Dr. Gregoire Boulouis MD MS
Research Fellow at Massachusetts General Hospital / Harvard Med. School
Boston, Massachusetts

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Boulouis: Hemorrhagic Stroke or Intracerebral hemorrhage (ICH) still has a poor prognosis. A substantial proportion of patients will experience ongoing intracranial bleeding and their hematomas will grow in size in the first hours following presentation, a phenomenon called ‘hemorrhage epxansion’. Patients with hemorrhage expansion have been shown to have significantly worse clinical outcome. If all baseline ICH characteristics (location, initial hemorrhage volume, ..) are non modifiable at the time of diagnosis, hemorrhage expansion, however, represents one of the few potential targets to improve outcome in ICH patients. An accurate selection of patients at high risk of expansion is needed to optimize patients’ selection in expansion targetted trials and, eventually, to help stratifying the level of care at the acute phase.

In this study, we investigated whether the presence of non-contrast Computed Tomography hypodensities within the baseline hematoma, a very easily and reliably assessed imaging marker, was associated with more hemorrhage expansion.

A total of 1029 acute phase ICH patients were included ; approximately a third of them demonstrated CT hypodensities at baseline. In this population, CT hypodensities were independently associated with hemorrhage expansion with an odds ratio of 3.42 (95% CI 2.21-5.31) for expansion in fully adjusted multivariable model.

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After Hemorrhagic Stroke, Patients at High Risk of Early and Delayed Dementia

MedicalResearch.com Interview with:

Alessandro Biffi, MD Behavioral Neurology and Neuropsychiatry Departments of Neurology and Psychiatry Massachusetts General Hospital / Harvard Medical School

Dr. Alessandro Biffi

Alessandro Biffi, MD
Behavioral Neurology and Neuropsychiatry
Departments of Neurology and Psychiatry
Massachusetts General Hospital / Harvard Medical School

MedicalResearch.com: What is the background for this study?

Dr. Biffi: Intracerebral Hemorrhage (ICH) is the most severe form of stroke. It is a form of hemorrhagic (i.e. bleeding) stroke that accounts for ~ 15% of all acute cerebrovascular conditions, affecting ~ 70,000 Americans every year. However, because of its severity it is responsible for almost half of all stroke-related disability worldwide. Survivors of ICH are at very high risk for cognitive impairment (up to and including dementia) following the acute cerebral bleeding event. However, we possess very limited understanding of the time dynamics and risk factors for post-ICH dementia. In particular, prior to our study it was unclear whether the acute cerebral injury due to ICH would be the only mechanism potentially responsible for subsequent development of dementia.

This question is motivated by prior observations suggesting that Intracerebral Hemorrhage represents the acute manifestation of cerebral small vessel disease, a progressive degenerative disorder of small caliber arteries of the central nervous system.

There exist two major subtypes of small vessel disease:

1) cerebral amyloid angiopathy, caused by the deposition of a toxic protein product, beta-amyloid, in the blood vessels (in a process similar to the formation of beta-amyloid plaques that cause Alzheimer’s disease);

2) arteriolosclerosis, caused by long-standing elevated blood pressure. ICH survivors have been previously shown to harbor very severe small vessel disease, which has been linked to dementia in patients without cerebral bleeding.

Our hypothesis was that early-onset dementia (occurring in the first 6 months after ICH) is a manifestation of the acute neurological damage associated with cerebral bleeding, whereas delayed onset dementia (developing beyond 6 months from the acute ICH event) is associated with known markers of small vessel disease, including imaging findings on CT/MRI and genetic markers (such as the APOE gene).

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Multiple Brain Microbleeds Linked To Cognitive Decline and Risk of Dementia

MedicalResearch.com Interview with:

Meike Vernooij, MD PhD Associate professor Radiology and Epidemiology Neuroradiologist and head & neck radiologist Rotterdam, The Netherlands

Dr. Meike Vernooij

Meike Vernooij, MD PhD
Associate professor
Radiology and Epidemiology
Neuroradiologist and head & neck radiologist
Rotterdam, The Netherlands

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Vernooij: Background of this study was the fact that small brain bleeds, so-called cerebral microbleeds, are recognized increasingly as markers on brain scans of disease of the brain’s small vessels. In earlier years, microbleeds were demonstrated to be very frequent in patients with stroke, and also in persons with Alzheimer’s disease. Yet, our previous work indicated that microbleeds are not only common in patients, but are also frequently seen (in up to 1 in 5 individuals over age 45) in presumably healthy persons. Our main research question was therefore whether the presence of microbleeds on brain scans of asymptomatic, stroke-free and dementia-free individuals, was related to risk of cognitive decline and risk of dementia. We studied this in a population of > 4,800 persons whom we followed for nearly 6 years.

Our main findings are that presence of microbleeds, especially when multiple (esp > 4), relates to cognitive decline and risk of dementia, in particular Alzheimer’s disease.

MedicalResearch.com: What should readers take away from your report?

Dr. Vernooij:  Our results indicate that microbleeds mark the presence of diffuse vascular and neurodegenerative brain damage.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Vernooij:  Future research should focus on exact mechanisms how microbleeds lead to dementia and cognitive decline, to identify possible preventive pathways.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Akoudad S, Wolters FJ, Viswanathan A, et al. Association of Cerebral Microbleeds With Cognitive Decline and Dementia. JAMA Neurol. Published online June 06, 2016. doi:10.1001/jamaneurol.2016.1017.

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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No Clinical Benefit With Intensive Blood-Pressure Lowering in Acute Cerebral Hemorrhage

MedicalResearch.com Interview with:
Adnan I. Qureshi, M.D
Zeenat Qureshi Stroke Research Center
University of Minnesota
Minneapolis, MN

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Qureshi: An acute hypertensive response in patients with intracerebral hemorrhage is common and may be associated with hematoma expansion and increased mortality. The Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial was designed to determine the efficacy of rapidly lowering systolic blood pressure in patients in an earlier time window after symptom onset than evaluated in previous trials. The trial was based on evidence that hematoma expansion and subsequent death or disability might be reduced with very early and more aggressive reduction in systolic blood pressure in those at higher risk due to presence of high systolic blood pressure at presentation. The trial randomized eligible subjects with intracerebral hemorrhage to test the superiority of intensive (goal 110-140 mmHg) over standard (goal 140-180 mmHg) systolic blood pressure reduction using intravenous nicardipine within 4.5 hours of symptom onset. Of a total of 1000 subjects that were recruited with a mean (standard deviation) baseline systolic blood pressure of 200.6 (27.0) mmHg, 500 were assigned to intensive-treatment and 500 to standard-treatment. Enrollment was stopped following a pre-specified interim analysis because of futility.

The primary endpoint of death or disability at 3 months post-randomization was observed in 38.7% (186/481) of subjects receiving intensive treatment and 37.7% (181/480) subjects receiving standard treatment (relative risk: 1.03; 95% confidence interval: 0.85 to 1.27), adjusted for age, initial Glasgow Coma scale, and presence or absence of intraventricular hemorrhage. The rate of renal adverse events within 7 days of randomization was significantly higher among subjects randomized to intensive treatment. Compared to a target systolic blood pressure of 140-180 mmHg, treating subjects with intracerebral hemorrhage to a target systolic blood pressure of 110-140 mmHg did not lower the rate of death or disability.

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Black-White Disparity in Stroke Deaths Due To More Strokes in Blacks

MedicalResearch.com Interview with:

George Howard, Dr.P.H. Professor of biostatistics Birmingham School of Public Health University of Alabama

Dr. George Howard

George Howard, Dr.P.H.
Professor of biostatistics
Birmingham School of Public Health
University of Alabama

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Howard: What has been known for many decades is that death rates from stroke are much higher in the black than white population, particularly between the ages of 45 – 65 (or maybe even a little older). These racial differences in stroke are among the greatest disparities for any disease, clearly it is a priority to reduce this disparity.

However, there are two reasons more blacks could die from a disease:

1) more blacks get the disease, or

2) once you get the disease, it is more likely to kill blacks.

The implications of knowing which of these is the major contributor is profound. If the driving force is more blacks are having more stroke, then we need to focus out attention on activities before stroke occur. For example, prevention of the greater prevalence of hypertension and diabetes in blacks, and also reducing the differences in the control of blood pressure and glucose. However, if the driving force is a higher chance of death in blacks once stroke occur, then we need to focus on the disparities in how black stroke patients are cared for compared to white stroke patients. That is, the former requires community-based efforts, while the latter requires hospital-based efforts.

What we found was that nearly all the difference was that blacks are having more strokes … not that they are more likely to die once stroke occurs.

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Shift Work May Increase Risk of Stroke

MedicalResearch.com Interview with:

David Earnest, Ph.D. Professor in the Department of Neuroscience and Experimental Therapeutics Texas A&M Health Science Center College of Medicine

Dr. David Earnest

David Earnest, Ph.D.
Professor in the Department of Neuroscience and Experimental Therapeutics
Texas A&M Health Science Center College of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Earnest: When body clocks are disrupted, as they are when people engage in shift work or go to bed and get up at radically different times every few days, more severe ischemic strokes can result.

MedicalResearch.com: What should readers take away from your report?

Dr. Earnest:  Whenever possible, go to bed and get up at the same time each day and keep regular mealtimes. If you do need to keep an irregular schedule, it is especially important to be mindful of stroke risk and try especially hard to eliminate other risk factors, such as hypertension and obesity.

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Arterial Stiffness Suggests Poor Outcome After Ischemic Stroke

MedicalResearch.com Interview with:
Johann Auer MD
Department of Cardiology and Intensive Care
St Josef Hospital
Braunau, Austria

MedicalResearch.com: What should readers take away from your report?

Response: Acute hypertensive response in stroke patients is associated with an increased risk of death or dependency and clinical deterioration. Arterial stiffness is associated with the risk of developing stroke, fatal stroke, cerebral small vessel disease, cognitive decline, and early clinical outcome after ischemic stroke. Moreover, patients having elevated aortic stiffness are more likely to develop acute hypertensive response in the early phase of stroke.

The intriguing question remains, whether the impaired prognosis associated with an increase in arterial stiffness is mediated – at least to some degree – by an acute hypertensive response. Furthermore, fundamental questions about the optimal threshold that define abnormal blood pressure dynamics and the impact of treatment on acute hypertensive response, arterial stiffness, and on the risk of future cardiovascular events remain unanswered.

Until such questions are adequately addressed in future clinical trials, acute hypertensive response as well as arterial stiffness will remain risk markers rather than a treatment target.

Nevertheless, this study confirms the value of assessment of central hemodynamics and arterial stiffness for selecting high risk patients with poor outcomes after ischemic stroke.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Arterial stiffness, central blood pressures, wave reflections and acute hypertensive response in stroke

Auer, J. et al.
Atherosclerosis , Volume 0 , Issue 0 ,
DOI: http://dx.doi.org/10.1016/j.atherosclerosis.2016.05.034

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Elevated Blood Pressure Is Risk Factor For Vascular Dementia

MedicalResearch.com Interview with:

Kazem Rahimi, DM, MSc Oxford Martin School University of Oxford United Kingdom

Dr. Kazem Rahimi

Kazem Rahimi, DM, MSc
Oxford Martin School
University of Oxford
United Kingdom

MedicalResearch.com: What is the background for this study?

Dr. Rahimi: Vascular dementia is the second most common cause of dementia and is increasing in prevalence worldwide. Vascular dementia often occurs after stroke and can cause apathy, depression, and a decline in cognitive function, and can eventually result in death. High blood pressure (BP) has been identified as a potential risk factor for the development of vascular dementia. However, previous studies, which have been small in size, have reported conflicting results on the relationship between blood pressure and vascular dementia.

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Ideal Blood Pressure After Stroke Differs For Blacks, Whites

MedicalResearch.com Interview with:

Azizi Seixas, Ph.D. Fellow NYU Langone School of Medicine  Department of Population Health Center for Healthful Behavior Change

Dr. Azizi Seixas

Azizi Seixas, Ph.D.
Fellow
NYU Langone School of Medicine
Department of Population Health
Center for Healthful Behavior Change
 

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Seixas: Twenty-five percent of strokes in the US are attributed to high blood pressure. Studies indicate that lowering blood pressure after a stroke significantly reduces risk of recurrent stroke by almost 50%. However, recent evidence suggests that lowering blood pressure did not lower risk of recurrent stroke or mortality. In fact, epidemiological evidence indicates that low to normal blood pressure (120-140mmHg) had the highest cumulative all-cause mortality compared to high (140-149mmHg) and very high (>=150 mmHg) blood pressure. However, these studies did not look at this relationship among blacks/African Americans, non-White Hispanics and non-Hispanic Whites.

Please see link for more background information as reported recently by the AHA.

http://news.heart.org/high-blood-pressure-causing-deaths-despite-drop-heart-disease-stroke-deaths/

MedicalResearch.com: What are the main findings?

Dr. Seixas: We found that black stroke survivors who have a post-stoke blood pressure in the low-normal range <140 mmHg were 46% more likely to die compared to those who had a blood pressure in the range of 140-149mmHg, over a five year period. Non-Hispanic Whites stroke survivors with a very high post-stroke blood pressure (>= 150mmHg) had a 79% greater odds of dying over a five year period.

MedicalResearch.com: What should readers take away from your report?

Dr. Seixas: Black stroke survivors with low-normal blood pressure and white stroke survivors with very high blood pressure are at increased all-cause mortality risk. Our findings with blacks suggest there may be another factor[s] responsible for mortality.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Seixas: Future research should investigate which factors might be interacting with low-average blood pressure to increase mortality risk.

MedicalResearch.com: Is there anything else you would like to add?

Dr. Seixas: Our findings do not suggest that blood pressure is the cause of mortality but instead indicates that it plays a very important role in mortality in stroke survivors.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation: Abstract presented at the 2016 American Society of Hypertension

Racial/ethnic differences in post-stroke blood pressure trajectory and mortality risk

Seixas, Azizi et al.
Journal of the American Society of Hypertension , Volume 10 , Issue 4 , e51

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Hospitalizations for Stroke Down Nationwide, But Not for Young or African Americans

MedicalResearch.com Interview with:
Lucas Ramirez, M.D
Resident Physician | LAC-USC Medical Center
USC Keck School of Medicine | Class of 2013 

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Ramirez: Prior studies have shown differences in stroke rates in certain geographical regions among age and racial groups. Few studies have analyzed these differences on a national level.  Our study found that nationally, stroke hospitalization have decreased, though among blacks and young age groups, they have increased.

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Lower Dose of tPA Found Safer For Patients With Acute Ischemic Stroke

MedicalResearch.com Interview with:

Professor Craig Anderson Professor of Stroke Medicine and Clinical Neuroscience Sydney Medical School at the University of Sydney Institute of Neurosciences of Royal Prince Alfred Hospital

Prof. Craig Anderson

Professor Craig Anderson
Professor of Stroke Medicine and Clinical Neuroscience
Sydney Medical School at the University of Sydney
Institute of Neurosciences of Royal Prince Alfred Hospital

MedicalResearch.com: What is the background for this study?

Prof. Anderson: Intravenous use of the clot-busting drug, alteplase (or rtPA), at a dose of 0.9 mg/kg body weight is the only proven medical treatment of acute ischemic stroke.  However, a  major drawback to the treatment is an increased risk of major bleeding in the brain, or intracerebral hemorrhage (ICH), that occurs in about 5% of cases, and can be fatal.  This balance of effectiveness (recovery from disability) and risks (ICH, and bleeding elsewhere and uncommon drug allergic reactions) has led to much of the controversy over the net benefit of the drug.  The optimal dose of the drug has never been established, but the Japanese drug safety regulatory authority, has approved a lower dose (0.6mg/kg) on the basis of a small, non-randomized, open study which showed comparable outcomes and lower risk of ICH than historical controls.  This ‘east-west’ divide over the approved dose of alteplase has led to much variation in the dose of alteplase used in clinical practice in Asia – according to a doctor’s perceived risk of ICH in individual patients and the affordability of this relatively expensive treatment in low resource settings.  Data from the Get-with-the Guidelines Quality Registry in the United States suggests Asian patients are at higher risk of ICH after standard-dose alteplase than non-Asians.

Our research aimed to resolve this uncertainty over the optimal dose of alteplase, as an international, active-comparator, open-label, blinded outcome assessed, clinical trial of low-dose (0.6 mg/kg) versus standard-dose (0.9mg/kg) in 3310 patients recruited from over 100 hospitals in 13 countries between 2012 and 2015.

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Anticoagulants Remove Excess Stroke Risk Posed By Atrial Fibrillation

MedicalResearch.com Interview with:

Dr. Ben Freedman OAM Deputy Director Research Strategy, Heart Research Institute/Charles Perkins Centre Professor of Cardiology, Sydney Medical School Head Vascular Biology Anzac Research Institute Honorary VMO, Concord Repatriation General Hospital University of Sydney

Dr. Ben Freedman

Dr. Ben Freedman OAM 
Deputy Director Research Strategy, Heart Research Institute/Charles Perkins Centre
Professor of Cardiology, Sydney Medical School
Head Vascular Biology Anzac Research Institute
Honorary VMO, Concord Repatriation General Hospital
University of Sydney

MedicalResearch.com: What is the background for this study?

Dr. Freedman: Guidelines recommend that patients with atrial fibrillation (AF) at high enough risk for stroke should be treated with anticoagulant. Anticoagulant drugs are remarkably effective in reducing stroke risk by about two thirds, and death by between a quarter and a third. Unfortunately, strokes can still occur when patients are prescribed anticoagulant for Atrial Fibrillation, and it is often presumed this residual risk of stroke represents treatment failure, though there are few data about this important issue.

MedicalResearch.com: What are the main findings?

Dr. Freedman: We were able to compare the risk of stroke in a cohort of patients with AF commenced on anticoagulant, with a very large closely-matched cohort seen in general practice at the same time but without AF. This is a unique comparison. We found that the residual risk of stroke in such anticoagulant-treated patients was virtually identical to that in the matched control cohort. The implication is that the residual risk of stroke may not be treatment failure, but the risk of non-cardioembolic stroke in people of a similar age and stroke risk profile but without Atrial Fibrillation. The residual risk of death in those on anticoagulant was higher than the matched controls, and intermediate between the control rate and the mortality rate for untreated AF.

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Mediterranean Diet Linked to Lower Risk of Heart Disease and Stroke

MedicalResearch.com Interview with:

Professor Ralph Stewart MBChB (Otago), FRACP, FCSANZ, MD Auckland City Hospital University of Auckland, New Zealand

Prof. Ralph Stewart

Professor Ralph Stewart MBChB (Otago), FRACP, FCSANZ, MD
Auckland City Hospital
University of Auckland, New Zealand

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Stewart: A number of studies have suggested a favorable effect of a Mediterranean dietary pattern on the risk of heart disease, but few large studies have evaluated this dietary pattern in a global population of patients with known coronary heart disease.  We assessed a Mediterranean diet score based on frequency of consumption of common foods using a very simple questionnaire.  Globally this included a very broad range of diets – showing the benefits of this dietary pattern  can be achieved with many different foods.

We founds that greater adherence to this diet was associated with a lower risk of recurrent heart attacks, strokes and deaths from any cause.  In contrast a western diet score, which measured more consumption of foods thought to be unhealthy, including processed carbohydrates, sweetened foods and drinks and deep fried foods were not associated with the risk of cardiovascular events.
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Stroke Patients Transferred to Another Hospital Are Younger and Sicker

MedicalResearch.com Interview with:

Mathew J. Reeves, PhD  Department of Epidemiology and Biostatistics Michigan State University East Lansing, MI

Dr. Mat Reeves

Mathew J. Reeves, PhD
Department of Epidemiology and Biostatistics
Michigan State University
East Lansing, MI 

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Reeves:
  The transfer of stroke patients with ischemic stroke to primary and comprehensive stroke centers so they can receive specialized care including tPA (thrombolysis) and endovascular (catheter based) care is becoming increasingly important with the release or trial data showing substantial benefit for endovascular treatment in eligible patients.

  A major goal of integrated stroke systems of care is to ensure that stroke patients requiring specialized care beyond the capability of the initial hospital are identified and transferred to a specialist center as quickly as possible.

  Surprisingly, there is relatively little written about the frequency and outcomes of stroke patients who are transferred between hospitals, especially in the context of large quality improvement registries such as the Coverdell Stroke Registry or Get-With-The- Guidelines- Stroke

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Cerebral Microbleeds Raise Risk of Thrombolysis Therapy in Acute Ischemic Stroke

MedicalResearch.com Interview with:
Dr. Georgios Tsivgoulis MD
Department of Neurology, The University of Tennessee Health Science Center, Memphis
Second Department of Neurology, Attikon Hospital, School of Medicine, University of Athens, Athens, Greece

Medical Research: What is the background for this study?

Dr. Tsivgoulis: Cerebral microbleeds (CMBs) have been established as an independent predictor of cerebral bleeding, but there are contradictory data regarding the potential association of CMB burden with the risk of symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT).

Medical Research:  What are the main findings?

Dr. Tsivgoulis: We analyzed data from 9 prospective cohort studies, comprising 2479 total AIS patients, to investigate the association of high cerebral microbleed burden (>10 CMBs on pre-IVT MRI-scan) with the risk of sICH following IVT for AIS from. The risk of sICH after IVT was found to be higher in patients with evidence of CMB presence, compared to patients without CMBs, while a higher risk for sICHafter IVT was also detected in patients with high CMB burden (>10 CMBs), when compared to patients with 0-10 or 1-10 CMBs on pre-treatment MRI. In the individual patient data meta-analysis, high CMB burden was associated with increased likelihood of sICH before and after adjusting for potential confounders.

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Social Isolation and Loneliness Raise Risk of Heart Disease and Stroke

MedicalResearch.com Interview with:

Nicole Valtorta NIHR Doctoral Research Fellow Department of Health Sciences University of York, UK

Nicole Valtorta

Nicole Valtorta
NIHR Doctoral Research Fellow
Department of Health Sciences
University of York, UK

Medical Research: What is the background for this study? What are the main findings?

Response: Lonely and socially isolated adults are at increased risk of mortality. The influence of social relationships on morbidity is widely accepted, but the size of the risk to cardiovascular health is unclear. We systematically reviewed the evidence from prospective cohort studies to investigate the association between loneliness or social isolation and incident coronary heart disease (CHD) and stroke. We identified 23 papers reporting data from 16 longitudinal datasets, for a total of 4,628 CHD and 3,002 stroke events. Reports of eleven studies (CHD) and eight studies (stroke) provided data suitable for meta-analyses, the results of which indicated that deficiencies in social relationships are associated with an increased risk of developing CHD and stroke. People who were lonely or isolated had, on average, a 29% greater risk of incident CHD; similarly, the risk of developing stroke was 32% greater among isolated individuals.

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Morning Home Blood Pressure Readings Linked To CAD and Stroke Risk

MedicalResearch.com Interview with:

Kazuomi Kario, MD, PhD, FACP, FACC, FAHA, FESC Professor, Chairman Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine (JMU) JMU Center of Excellence, Cardiovascular Research and Development (JCARD) Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network Staff Visiting Professor of Medicine, UCL Institute of Cardiovascular Science University College London, London UK

Dr. Kazuomi Kario

Kazuomi Kario, MD, PhD, FACP, FACC, FAHA, FESC
Professor, Chairman
Division of Cardiovascular Medicine, Department of Medicine
Jichi Medical University School of Medicine (JMU)
JMU Center of Excellence, Cardiovascular Research and Development (JCARD)
Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network
Staff Visiting Professor of Medicine,
UCL Institute of Cardiovascular Science
University College London, London UK

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Kario: The relationship between out-of-office blood pressure (BP), such as ambulatory BP and home BP, and cardiovascular events has been investigated in several studies. However, there is insufficient evidence as yet regarding which BP measurement predicts coronary artery disease (CAD) events most strongly.

The HONEST Study is the largest prospective observational study in the world, which enrolled >20,000 hypertensive patients. The study observed cardiovascular events, monitoring both clinic BP and home BP on treatment of antihypertensive agent.

The present analysis shows that home BP measured in morning (morning home BP) is a strong predictor of both CAD and stroke events in future, and may be superior to clinic BP in this regard. Furthermore, there does not appear to be a J-curve in the relationship between morning home BP and CAD or stroke events.

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Intestinal Bacterial Play a Role in Inflammation After Stroke

MedicalResearch.com Interview with:

Josef Anrather, VMD Finbar and Marianne Kenny Research Scholar Associate Professor, Feil Family Brain and Mind Research Institute Weill Cornell Medical College New York, NY10065

Dr. Josef Anrather

Josef Anrather, VMD
Finbar and Marianne Kenny Research Scholar
Associate Professor, Feil Family Brain and Mind Research Institute
Weill Cornell Medical College
New York, NY10065

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Anrather: Worldwide, stroke is causing 5.6 million deaths annually. This ranks stroke as the second most common cause of death. Moreover, stroke is a leading cause of long-term disability. Stroke, even though primarily a vascular disease, has a strong inflammatory component both in rodent models and in clinics. While it is widely accepted that commensal bacteria shape the gastrointestinal immune system and have a strong impact on gastrointestinal immune diseases including Inflammatory Bowel Disease, Chron’s Disease and colitis, only recently it became evident that intestinal bacteria, at least in animal models, could alter disease course of a variety of autoimmune diseases including rheumatoid arthritis, diabetes, and multiple sclerosis. This was the point when our laboratory became interested in exploring the impact of intestinal bacteria on stroke. Although stroke is not an autoimmune disease and a role of the adaptive immune system during the acute phase of stroke is unlikely, we hypothesized that lymphoid cells more closely associated with the innate immune system, such as γδ T cells, might be also a target for intestinal bacteria.

Our study establishes a link between intestinal commensal bacteria and stroke outcome. Additionally, we show that immune cells in the gut matter and that the composition of intestinal immune cells has an impact on the immune response to stroke. One of the components identified by our study are γδ T cells which are regulated by the intestinal flora.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Anrather: The major message of our study is that stroke cannot be seen entirely as a isolated disease of the brain. There are components outside the brain that can influence the course and outcome of stroke. In our study we have identified the intestinal flora as a regulator of immune cells that participate in stroke. These immune cells are regulated in the gut through interaction with the commensal microbiota and can traffic to the meninges where they orchestrate the inflammatory response after stroke.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Anrather: Although the intestinal flora in humans seems relatively homogeneous among individuals at the phyla level, there is high inter-individual variation at lower taxonomic levels and only one third of bacterial genes are shared among individuals. This raises the question whether association with specific bacterial families or species could determine disease risk.

Future work will have to focus on establishing large population-level databases of enterotypes of the human gut microbiome, so we can use these epidemiological data to ask the question whether a certain microbial makeup is correlated with the frequency of cardiovascular events and – in the end – with stroke outcome. Once such microbial traits are identified there is the possibility of dietary or probiotic intervention to establish a flora with beneficial effect on the cardiovascular system.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Corinne Benakis, David Brea, Silvia Caballero, Giuseppe Faraco, Jamie Moore, Michelle Murphy, Giulia Sita, Gianfranco Racchumi, Lilan Ling, Eric G Pamer, Costantino Iadecola, Josef Anrather.
Commensal microbiota affects ischemic stroke outcome by regulating intestinal γδ T cellsNature Medicine, 2016; DOI: 10.1038/nm.4068

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

More Medical Research Interviews on MedicalResearch.com

 

 

 

Monoclonal Antibody Idarucizumab Reverses Anticoagulant Effect of Dabigatran In Patients With Brain Bleed

MedicalResearch.com Interview with:

Richard A. Bernstein MD, PhD Director, Northwestern Stroke Program Professor of Neurology Feinberg School of Medicine of Northwestern University

Dr. Richard Bernstein

Richard A. Bernstein MD, PhD
Director, Northwestern Stroke Program
Professor of Neurology
Feinberg School of Medicine of Northwestern University

Medical Research: What is the background for this study?

Dr. Bernstein: Patients on blood thinners, including dabigatran, have an increased risk of bleeding including in the brain.  We believe that reversing the blood thinning effects of dabigatran in the setting of bleeding might improve outcome by helping the bleeding to stop.

Medical Research: What are the main findings?

Dr. Bernstein: We found that in 18 patients taking dabigatran  with intracranial bleeding, Idarucizumab completely and nearly instantaneously reversed the blood thinning effect of dabigatran.

Medical Research: What should clinicians and patients take away from your report?

Dr. Bernstein: Patients taking dabigatran with intracranial bleeding can have the anticoagulant effect of dabigatran rapidly and completely reversed with Idarucizumab.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Bernstein: My presentation is derived from a cohort of the first 90 patients enrolled in reverse-AD. We will publish a similar analysis from the complete reverse ad cohort of 500 patients when we are finished enrolling.

Citation:

International Stroke Conference Oral Abstracts – Session Title: Intracerebral Hemorrhage Oral Abstracts II:Abstract 213: Effect of Idarucizumab on Intracranial Bleeding in Dabigatran-treated Patients: Initial Results From RE-VERSE AD

Richard A Bernstein, Charles V Pollack, Jr., Jeffrey I Weitz, Paul A Reilly, John Eikelboom, Menno V Huisman, Pieter W Kamphuisen, Jörg Kreuzer, Jerrold H Levyand Thorsten Steiner

Richard A. Bernstein MD, PhD (2016). Monoclonal Antibody Idarucizumab Reverses Anticoagulant Effect of Dabigatran In Patients With Brain Bleed MedicalResearch.com

Assessment Tool Helps Predict Risk of Early Recurrent Stroke

MedicalResearch.com Interview with:

Hakan Ay MD, FAHA Associate Professor of Neurology and Radiology Stroke Service, Department of Neurology

Dr. Hakan Ay

Hakan Ay MD, FAHA
Associate Professor of Neurology and Radiology
Stroke Service, Department of Neurology
Director of Stroke Research,
A.A. Martinos Center, Department of Radiology
Massachusetts General Hospital
Harvard Medical School
Boston MA, USA

Medical Research: What is the background for this study? What are the main findings?

Dr. Ay: Recurrent stroke is an important public health problem. One quarter of all strokes are recurrent strokes. Approximately one out of every 10 patients with stroke develops a second stroke within the next 2 years. The most critical period for recurrence after stroke is the first 90 days; approximately half of recurrent strokes that occur within 2 years occur within the first 90 days. The RRE tool was developed at the Massachusetts General Hospital in 2010 to assess the 90-day risk of recurrent stroke. The RRE was subsequently tested in a separate cohort of patients with transient stroke symptoms (mini strokes) admitted to the Massachusetts General Hospital in 2011. The current study expands upon prior two studies by showing that the RRE tool provides reliable risk estimates when tested in cohorts of patients recruited from different academic centers in various parts of the world. The study reports that the RRE can stratify approximately one-half of patients with stroke either at high-risk or at low-risk with a reasonable accuracy.

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Statins Improve Outcomes in Acute Ischemic Atherothrombotic Stroke

MedicalResearch.com Interview with:

Georgios Tsivgoulis , M.D., Ph.D., MSc, FESO Assistant Professor of Neurology University of Athens, Athens, Greece Visiting Associate Professor of Neurology Director of Stroke Research Department of Neurology University of Tennessee Health Science Center

Dr. Georgios Tsivgoulis

Georgios Tsivgoulis , M.D., Ph.D., MSc, FESO
Assistant Professor of Neurology
University of Athens, Athens, Greece
Visiting Associate Professor of Neurology
Director of Stroke Research
Department of Neurology
University of Tennessee Health Science Center

Medical Research: What is the background for this study? What are the main findings?

Dr. Tsivgoulis: Literature data suggest that taking statins before an acute ischemic stroke may improve early outcomes including early neurological deterioration, mortality and disability in patients with acute ischemic stroke. However,the potential beneficial effect of statin pretreatment has never been investigated in acute ischemic stroke due to large artery atherosclerosis. The research question in this specific subgroup of ischemic stroke patients is of great importance, as large-artery atherosclerotic stroke carries the highest risk of early recurrent stroke in comparison to other acute ischemic stroke subtypes.

Using prospectively collected data from over 516 consecutive patients with acute large-artery atherosclerotic stroke from seven tertiary-care stroke centers during a three-year period we found that statin pretreatment in patients with acute large-artery atherosclerotic stroke is associated with better early outcomes in terms of neurological improvement, disability, survival and stroke recurrence.

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Mail Order Pharmacies Linked To Better Compliance With Stroke Medications

MedicalResearch.com Interview with:
Dr-William-Patrick-Neil

William P. Neil, MD

Vascular Neurologist
SCPMG Regional Stroke Champion
Neurology   

Medical Research: What is the background for this study?

Dr. Neil: Stroke survivors are less likely to have a recurrent stroke, or other complications if they take their medications as prescribed by their doctor. Mail order pharmacies are increasingly being used to deliver medications for a variety of diseases, and their use is associated with better medication adherence.  We wanted to see whether stroke patients who use mail-order pharmacies were more likely to have good medication adherence than those who used  local pharmacies.

Medical Research: What are the main findings?

Dr. Neil: We looked through a large electronic medical database in California, and found a total of 48,746 people discharged from the hospital with a stroke, and who also filled either a cholesterol medication or an anticoagulant (blood thinner). Of these, 136,722 refills were from a local pharmacy and 68,363 were by mail. Overall, patients were adherent to the medications 46.5% of the time if they picked up the medication from the pharmacy and 74% of the time if they had prescriptions mailed to them.

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Atrial Fibrillation In Stroke Patients Deemed Underestimated

MedicalResearch.com Interview with:

Dr. Rolf Wachter Head Senior physician University of Goettingen Göttingen, Germany

Dr. Rolf Wachter

Dr. Rolf Wachter
Head Senior physician
University of Goettingen
Göttingen, Germany

Medical Research: What is the background for this study? What are the main findings?

Dr. Wachter: Atrial Fibrillation is a known risk factor for stroke, and in stroke patients, it is a strong predictor of adverse outcome, if it is not adequately treated (e.g. by anticoagulation). However, in its paroxysmal form, Atrial Fibrillation (AF) may escape routine diagnostics. We aimed to show that we can increase the number of patients with detected AF if we do more monitoring for atrial fibrillation. As a unique feature of our study, we did not focus on a certain stroke subtype (i.e. cryptogenic stroke), but we aimed to consider all patients >= 60 years in whom the detection of  Atrial Fibrillation has a clinical relevance.

The main finding of our study was that enhanced and prolonged Holter ECG monitoring (3×10 days of monitoring, analysed in a dedicated core lab) tripled the number of detected AF cases (from 4.5 to 13.5 %). 11 patients had to undergo enhanced and prolonged monitoring to find one additional case of Atrial Fibrillation.

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What Normalizes Bleeding Time Best After Coumadin Related Brain Bleed?

MedicalResearch.com Interview with:

Thorsten Steiner, MD, PhD Klinikum Frankfurt Hoechst and Heidelberg University Hospital Germany

Dr. Thorsten Steiner

Thorsten Steiner, MD, PhD
Klinikum Frankfurt Hoechst and Heidelberg University Hospital
Germany

Medical Research: What is the background for this study? What are the main findings?

Dr. Steiner: Background of the study is intracranial hemorrhage (ICH) related to vitamin-K antagonists. The mortality rate is about 60%. Main reason for the high mortality rate is hematoma expansion which occurs in about 50% during the acute phase right after the start of symptoms. We performed an investigator initiated randomized controlled trial (RCT) and found that a 4-factor prothrombin complex (PCC) is superior to fresh frozen plasma (FFP) in normalizing the international normalized ratio (INR) and prevents hematoma expansion. This let to more deaths within 48 hours in the FFP-group but had no clinical impact at 3 months – but our study was powered to detect INR normalization and not a clinical endpoint.
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Women and Minorities Have Worse Outcomes After Stroke

MedicalResearch.com Interview with:

Cheryl Bushnell, MD, MHS Professor of Neurology Director, Wake Forest Baptist Stroke Center Wake Forest Baptist Health Medical Center Boulevard Winston Salem, NC 27157

Dr. Cheryl Bushnell

Cheryl Bushnell, MD, MHS
Professor of Neurology
Director, Wake Forest Baptist Stroke Center
Wake Forest Baptist Health
Medical Center Boulevard
Winston Salem, NC  27157 

Medical Research: What is the background for this study? What are the main findings?

Dr. Bushnell: The catalyst for the study was to see if comorbidities and the management of them might influence functional status.  But, we pre-specified gender and race because we knew these could be important predictors of outcome.  As it turns out, the results of our analysis did, in fact, show that gender and race were the most significant predictors of poor functional outcome.

Medical Research: What should clinicians and patients take away from your report?

Dr. Bushnell: The take-home message is that women and minorities have poorer functional outcome after stroke, but the reasons for this outcome need to be further explored.  Our model showed that we only explained 31% of the variance in SIS-16 with gender, race/ethnicity, and stroke severity, so unmeasured factors are extremely important.  We could speculate from this dataset and other published data that women may be more likely to have functional deficits prior to stroke, be unmarried/widowed, live alone, or institutionalized after stroke.  Non-white stroke survivors may have poorer access to care, have multiple strokes, and more comorbidities.

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Long Term Risk of Seizures After Stroke Remains High

MedicalResearch.com Interview with:

Alexander Merkler, MD Fellow in neuro critical care Weill Cornell Medical College and New York-Presbyterian Hospital, New York

Dr. Alexander Merkler

Alexander Merkler, MD
Fellow in neuro critical care
Weill Cornell Medical College and
New York-Presbyterian Hospital, New York

Medical Research: What is the background for this study? What are the main findings?

Dr. Merkler:  Patients with stroke often ask about what type of problems they may expect in the future. As neurologists, we often warm our patients about the risk for recurrent stroke, infections, clots, eating difficulty, and depression. Although seizures are a well-known complication of stroke, there was little data regarding the long-term rate of seizures in patients who have a stroke. Therefore, we sought to evaluate the long-term risk of seizures following stroke in order to better advise physicians and patients on the likelihood of developing seizures after suffering a stroke. We identified over 600,000 patients with stroke and found that the rate of seizures after stroke is high – 15.3% of all patients with stroke will develop seizures. Patients who have hemorrhagic stroke face an even higher rate of seizures – 24% of patients with hemorrhagic type stroke will develop seizures. The rate of seizures after ischemic stroke was significantly higher than previous literature – 13.5% of patients with an ischemic stroke had a seizure in our study.
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Unruptured Brain Arteriovenous Malformations: Treat or Leave Alone?

MedicalResearch.com Interview with:

Christian Stapf, MD Full Professor, Department of Neurosciences Université de Montréal Principal Scientist, CRCHUM Montréal Canada

Dr. Christian Stapf

Christian Stapf, MD
Full Professor, Department of Neurosciences
Université de Montréal
Principal Scientist, CRCHUM
Montréal Canada 

Medical Research: What is the background for this study?

Dr. Stapf: Brain arteriovenous malformations are abnomal tangles of falsely linked arteries and veins in the brain. They may be asymptomatic, or lead to headaches, epileptic seizures or – worst case – to stroke, usually by intracranial hemorrhage. Brain AVMs are relatively rare, but approximately 5000 patients are discovered every year in the U.S.and Canada, 3000 of whom will have an unruptured malformation at the diagnosis.

The ARUBA trial tested if it was better to remove an unruptured  Brain arteriovenous malformations in order to prevent death and stroke, or if patients were better off living with an AVM without undergoing intervention.

Medical Research: What are the main findings?

Dr. Stapf:  The trial results showed that an initially unruptured Brain arteriovenous malformations if left untreated may lead to hemorrhage in 2.1% every year. However this risk increases by the factor 4.5, if you start treating the AVM for attempted eradication. The risk of developing a significant neurological deficit also increase by the factor 2.5 after treatment, and there was no benefit for epileptic seizures or headaches.

Medical Research: What should clinicians and patients take away from your report?

Dr. Stapf: Living with an unruptured brain  Brain arteriovenous malformations is far safer than to attempt interventional therapy. This is true when looking at all interventional treatment types (surgery, embolization or radiotherapy). Leaving an unruptured AVM untreated reduces the risk of death and stroke by 78%.

Medical Research: What should clinicians and patients take away from your report?

Dr. Stapf: Preventive intercventions in patients diagnosed with an unruptured brain AVM are potentially dangerous, and cannot safely be recommended based on current knowledge. We have to find safer ways to treat these lesions without adding more harm.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Stapf: The trial was funded by NIH/NINDS and patients were enrolled at specialized Treatment Centers across the U.S., Canada, Brazil, South Corea, and eight European countries.

Citation: Presented at 2016 ISC Conference February 2016

Carotid Endarterectomy versus Stenting for Treatment of Carotid Artery Stenosis: Long-term Results of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST)

 

Carotid Stenosis for Stroke Prevention: Both Surgery and Stenting Give Long Lasting Results

MedicalResearch.com Interview with:

Thomas G. Brott, M.D. Professor of neurology and director for research and The Eugene and Marcia Applebaum Professor of Neurosciences and James C. and Sarah K. Kennedy Dean for Research. Mayo Clinic in Jacksonville, Fla

Dr. Thomas Brott

Thomas G. Brott, M.D.
Professor of neurology and director for research and
The Eugene and Marcia Applebaum Professor of Neurosciences and James C. and Sarah K. Kennedy Dean for Research.
Mayo Clinic in Jacksonville, Fla

Medical Research: What is the background for this study? What are the main findings?

Dr. Brott: Revascularization for carotid artery stenosis is the accepted treatment for symptomatic patients with >50% stenosis and for asymptomatic patients with >70% stenosis.  The original CREST report in 2010 showed both surgery and stenting were the safe methods to treat severe carotid stenosis.  But the follow-up averaged 2.5 years and Medicare-age patients live for an average of 18-20 years.  These patients and their families needed to know if surgery and stenting are durable in preventing stroke.

CREST was designed to answer the questions of clinical and anatomic durability for the long-run.

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Post Menopausal Stroke Risk Raised In Women With Later Life Pregnancy

MedicalResearch.com Interview with:

Dr. Adnan Quershi MD Professor of Neurology, Neurosurgery and Radiology University of Minnesota

Dr. Adnan Qureshi

Dr. Adnan Qureshi MD
Professor of Neurology, Neurosurgery and Radiology
University of Minnesota 

Medical Research: What is the background for this study?

Dr. Quershi: Women who have the last pregnancy at advanced age (usually defined as pregnancy at age of 40 years or greater) have higher risk of developing hypertension, hypertension related disorders, and diabetes mellitus during pregnancy. There is some evidence that disproportionately higher rates of cardiovascular risk factors continue years after the pregnancy. Perhaps there are unknown medical conditions triggered during pregnancy at advanced age. These changes continue to progress without being clinically evident until years later manifesting as a cardiovascular event.

Medical Research: What are the main findings?

Dr. Quershi: We analyzed the data for 72,221 women aged 50-79 years who were enrolled in the observational arm of the Women’s Health Initiative Study. We determined the effect of pregnancy in advanced age (last pregnancy at age≥40 year) on risk of ischemic stroke, hemorrhagic stroke, myocardial infarction, and cardiovascular death over a mean period  of 12 years. A total of 3306 (4.6%) of the 72,221 participants reported pregnancy in advanced age. Compared with pregnancy in normal age, the rate of ischemic stroke (2.4% versus 3.8%, p<0.0001), hemorrhagic stroke (0.5% versus 1.0%, p<0.0001), myocardial infarction (2.5% versus 3.0%, p<0.0001), and cardiovascular death (2.3% versus 3.9%, p<0.0001) was significantly higher among women with pregnancy in advanced age. In multivariate analysis, women with pregnancy in advanced age were 60% more likely to experience a hemorrhagic stroke even after adjusting for differences in age, race/ethnicity, congestive heart failure, systolic blood pressure, atrial fibrillation, alcohol use and cigarette smoking were adjusted.

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Fast Stroke Treatment Key To Better Outcomes

MedicalResearch.com Interview with:

Michael D Hill, MD MSc FRCPC Calgary Stroke Program Professor, Dept Clinical Neurosciences Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary Calgary, Canada

Dr. Michael D. Hill

Michael D Hill, MD MSc FRCPC
Calgary Stroke Program
Professor, Dept Clinical Neurosciences
Hotchkiss Brain Institute
Cumming School of Medicine, University of Calgary
Calgary, Canada 

Medical Research: What is the background for this study? What are the main findings?

Dr. Hill: The HERMES collaboration is a pooled analysis of 5 randomized controlled trials of endovascular stroke therapy.  The purpose is of this analysis is to assess the relationship between time from stroke onset and effect size.

The main finding is that there is a declining effect size as time elapses from stroke onset.  Shorter onset to reperfusion times are associated with better outcomes.  However, the slope of the decline is shallow compared to past estimates.  We believe this is because imaging selection identifies a group a patients in whom there is slow growth of the core infarct.

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Mouth Bacteria Linked to Stroke And Stroke-Related Dementia

MedicalResearch.com Interview with:

Dr. Robert Friedland MD Mason C. and Mary D. Rudd Endowed Chair In Neurology Professor, Dept. of Neurology University of Louisville Health Care Outpatient Center Louisville, KY 40292

Dr. Robert Friedland

Dr. Robert Friedland MD
Mason C. and Mary D. Rudd Endowed Chair In Neurology
Professor, Dept. of Neurology
University of Louisville Health Care Outpatient Center
Louisville, KY 40292

Medical Research: What is the background for this study? What are the main findings?

Dr. Robert Friedland: Oral infectious diseases are associated with stroke. Previous research by this group has shown that oral bacteria, cnm-positive Streptococcus mutans, was associated with cerebral microbleeds and intracerebral hemorrhage. We developed this study to investigate the roles of this bacteria in patients entering the hospital for all types of stroke. Among the patients who experienced intracerebral hemorrhage (ICH), 26 percent were found to have a specific bacterium in their saliva, cnm-positive S. mutans. Among patients with other types of stroke, only 6 percent tested positive for the bacterium. We also evaluated MRIs of study subjects for the presence of cerebral microbleeds (CMB), small brain hemorrhages which may cause dementia and also often underlie ICH. We found that the number of CMBs was significantly higher in subjects with cnm-positive S. mutans than in those without.
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Is the Evidence for the Anticoagulant Rivaroxaban Valid?

MedicalResearch.com Interview with:

Dr. Deborah Cohen

Dr. Deborah Cohen

Dr. Deborah Cohen
Associate Editor BMJ
BMA House, Tavistock Square
London

Medical Research: What is the background for this study? What are the main findings?

Dr. Cohen: Anyone familiar with warfarin understands the critical role of INR values in determining the proper dose for warfarin patients. The INR value in an individual patient is the most important piece of information a doctor considers when determining the warfarin dose. If the doctor gives too little warfarin then the patient may be at undue risk of stroke; if too much, the patient may be at undue risk of a major bleed.

The BMJ investigation revealed that the INR device used to manage the ~7,000 warfarin patients in the ROCKET trial (which served as the basis for approval of the non-valvular atrial fibrillation indication) was defective.

As such – doctors were relying upon a defective device in determining the dose of the warfarin patients – which has a direct influence on the stroke and bleeding risk in that patient. Since this was a comparative trial – any deficiency in the performance of the comparator arm (warfarin) would skew the results in favour of the study drug (rivaroxaban).

Since INR directly influences strokes and bleeds – the primary efficacy and safety endpoints – it very much questions, if not undermines, the overall results of this trial.

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Aggressive Medical Management For Patients At Highest Risk of Recurrent Stroke

Michael F. Waters, MD, PhD Department of Neurology Department of Neuroscience McKnight Brain Institute University of Florida College of Medicine Gainesville, Florida

Dr. Waters

MedicalResearch.com Interview with:
Michael F. Waters, MD, PhD
Department of Neurology
Department of Neuroscience
McKnight Brain Institute
University of Florida College of Medicine
Gainesville, Florida

Medical Research: What is the background for this study? What are the main findings?

Dr. Waters: This study was based on a subgroup of medically managed patients with severe, symptomatic, intracranial, atherosclerotic disease. Historically we know that these patients have a very high rate of additional strokes, and multiple studies have attempted to determine the best management for these patients. In SAMMPRIS, we were able to prove that aggressive medical management was superior to stenting in these patients. However, certain patients in the medically managed group still had a very high rate of repeat strokes, as much as 30% of those with certain risk factors. This study was an attempt to identify those risk factors to determine which patients were at the greatest risk for another stroke.

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Some Hemorrhagic Strokes Can Have Transient Symptoms

Sandeep Kumar, MD Assistant Professor of Neurology Harvard Medical School Director, Inpatient Stroke Service Department of Neurology, Stroke Division Beth Israel Deaconess Medical Center Boston, MA 02215

Dr. Sandeep Kumar

MedicalResearch.com Interview with:
Sandeep Kumar, MD

Assistant Professor of Neurology
Harvard Medical School
Director, Inpatient Stroke Service
Department of Neurology, Stroke Division
Beth Israel Deaconess Medical Center
Boston, MA 02215

Medical Research: What is the background for this study? What are the main findings?

Dr. Kumar: Transient deficits that start suddenly and typically last for a few minutes to a few hours are the hallmark of a transient ischemic attack (TIA) or a minor ischemic stroke. In this single-center observational study, we have reported similar clinical presentation in some patients with intracerebral hemorrhage (ICH) that are difficult to distinguish from cerebral ischemia based only on clinical signs and symptoms.

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Focus Groups Help Develop Patient-Centered Decision Support For Stroke Patients and Caregivers

MedicalResearch.com Interview with:
Carole Decker, RN, PhD, CPHQ, FAHA

Director, Cardiovascular Outcomes Research
Saint Luke’s Mid America Heart Institute
Kansas City, MO 64111

Medical Research: What is the background for this study? What are the main findings?

Dr. Decker: Stroke is the leading cause of disability and the fifth leading cause of death. The utilization of thrombolytic therapy is the national standard of care for acute ischemic stroke (AIS) treatment resulting in improved outcomes at 90 days and yet only 7% of patients with AIS receive a thrombolytic. The American College of Emergency Physicians emphasizes the importance of using a shared medical decision-making model with AIS patients and their caregivers to discuss benefits and risks of treatment. The recommended door-to-needle (emergency door to thrombolytic administration) is 60 minutes to achieve the optimal patient outcomes which can be problematic in that conversation on benefits and risks occurs in a hurried emergency setting.

Multiple risk models to identify individualized benefits and risks of thrombolytic therapy have been developed but few are used prospectively and are not used at the point of care. Our team created ePRISM (Personalized Risk Information Services Manager), a Web-based tool, to generate personalized documents with patient-specific outcomes based on validated risks models. To support knowledge transfer and creation of a shared decision-making tool, our multidisciplinary team conducted qualitative interviews to define the information needs and preferred presentation format for stroke survivors, caregivers, and clinicians considering thrombolytic treatment.

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Hemodynamic Imaging Helps Predict Stroke Risk in Posterior Circulation Stroke

Dr. Amin Hanjani

Dr. Amin Hanjani

MedicalResearch.com Interview with:
Sepideh Amin-Hanjani, MD FAANS FACS FAHA

Professor & Program Director
Co-Director, Neurovascular Surgery
Department of Neurosurgery
University of Illinois at Chicago
Past Chair, AANS/CNS Cerebrovascular Section 

Medical Research: What is the background for this study? What are the main findings?

Dr. Amin-Hanjani: Posterior circulation strokes account for up to 30% of all ischemic strokes, and atherosclerotic occlusive disease of the vertebrobasilar (VB) is responsible for approximately one third of these cases. Symptomatic atherosclerotic VB occlusive disease is associated with a high risk of recurrent stroke despite medical therapy, in the range of 10-15% within 2 years. There have been advances in treatment options, particularly endovascular angioplasty and stenting, aimed at reverting the blockage; however these procedures themselves carry risks, and are likely to benefit only selected patients who are at highest risk without intervention. Our study, VERiTAS, aimed to determine if measurement of blood flow in the posterior circulation vessels could identify the high risk patients. Flow measurements were performed using the technique of quantitative magnetic resonance angiography (QMRA) relying on standard MR sequences and  the commercial software NOVA. These flow measurements were used to designate patients presenting with symptomatic vertebrobasilar disease as flow compromised or not, and patients were then followed for a median of 23 months in a blinded fashion to determine the risk of subsequent strokes. We found that among 72 such patients, only one quarter (18 patients) demonstrated flow compromise on QMRA, but that this group had a significantly higher risk of subsequent stroke at one year, 22% vs only 4% in the other group. The hazard ratio for subsequent stroke was markedly elevated at 11.5 even after adjusting for age and other stroke risk factors.
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Telemedicine Can Support Rapid Stroke Treatment in Ambulances

Ken Uchino, MD FAHA FANA Director, Vascular Neurology Fellowship Research Director, Cerebrovascular Center, Cleveland Clinic Associate Professor of Medicine (Neurology) Cleveland Clinic Lerner College of Medicine of CWRU Cleveland, OH 44195

Dr. Ken Uchino

MedicalResearch.com Interview with:
Ken Uchino, MD FAHA FANA

Director, Vascular Neurology Fellowship
Research Director, Cerebrovascular Center, Cleveland Clinic
Associate Professor of Medicine (Neurology)
Cleveland Clinic
Lerner College of Medicine of CWRU
Cleveland, OH 44195

Medical Research: What is the background for this study? What are the main findings?

Dr. Uchino: Treatment for acute ischemic stroke is time dependent. Multiple studies have reported strategies to improve time to treatment after arrival in the hospital. Mimicking pre-hospital thrombolysis of acute myocardial infarction pioneered 30 years ago, two groups in Germany have implemented pre-hospital ischemic stroke thrombolysis using mobile stroke unit (“stroke ambulance”) that includes CT scan and laboratory capabilities. These units have been demonstrated to provide stroke treatment earlier than bringing patients to the emergency departments.

Our report extends the concept mobile stroke unit further by using telemedicine for remote physician presence. The other mobile stroke units were designed to have at least one physician on board. This allows potential multiple or geographically distant units to be supported by stroke specialists.

The study demonstrates that after patient arrival in the ambulance, the time to evaluation (CT scanning and blood testing) and to thrombolytic treatment is as quick or better as patient arrival in emergency department door. We are reporting the overall time efficiency after emergency medical service notification (911 call) in a separate paper.

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