Stroke Horizon Scanning Bulletin Volume 12 Issue 8

Happy New Year to all our readers. We are thinking of you all and hope you are keeping safe.

Please find the December 2020 issue of the Stroke Horizon Scanning Bulletin below.

Contents include:

• Stroke Prevention in Atrial Fibrillation: Looking Forward
• ReStore Soft Exo-Suit for gait rehabilitation: Medtech innovation briefing [MIB239]
• COVID-19 associated arterial ischaemic stroke and multisystem inflammatory syndrome in children: a case report
• Age in relation to comorbidity and outcome in patients with high-risk TIA or minor ischemic stroke: A Swedish national observational study
• Safety and Outcome of Decompressive Hemicraniectomy After Recombinant Tissue Plasminogen Activator Thrombolysis for Acute Ischemic Stroke: A Systematic Review
• Venous and arterial thromboembolic events with immune checkpoint inhibitors: A systematic review
• Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review.
• Multivariable risk scores for predicting short term outcomes for emergency department patients with unexplained syncope: a systematic review
• Long-Term Efficacy of Extracorporeal Shock Wave Therapy on Lower Limb Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
• Interventions for improving oral health in people after stroke
• Fluoxetine for stroke recovery improvement – the doubleblind, randomised placebo-controlled FOCUS-Poland trial
• Five-Year Risk of Acute Myocardial Infarction After Acute Ischemic Stroke in Korea.
• Urate, Blood Pressure, and Cardiovascular Disease: Evidence From Mendelian Randomization and Meta-Analysis of Clinical Trials
• Heterogeneity of diabetes as a risk factor for major adverse cardiovascular events in anticoagulated patients with atrial fibrillation: an analysis of the ARISTOTLE trial 19
• Iron chelators for acute stroke
• Blood pressure targets in adults with hypertension
• Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride
• Does coronavirus cause stroke? A look at the current research
• Stroke risk, phenotypes, and death in COVID-19: Systematic review and newly reported cases
• Clinical Characteristics of Stroke with COVID-19: A Systematic Review and Meta-Analysis
• Patterns of Infarction on MRI in Patients With Acute Ischemic Stroke and Cardio-Embolism: A Systematic Review and Meta-Analysis
• Antiphospholipid Antibody and Recurrent Ischemic Stroke: A Systematic Review and Meta-Analysis
• Quality of Stroke Patient Information Applied in Randomized Controlled Trials-Literature Review
• A systematic review of social service and community resource interventions following stroke
• The Association of Overt and Subclinical Hyperthyroidism with the Risk of Cardiovascular Events and Cardiovascular Mortality: Meta-Analysis and Systematic Review of Cohort Studies
• Scientists test new “algorithm” to help prevent heart attacks
• Symptoms of depression linked to increased risk of heart disease and stroke
• People with heart and circulatory conditions at higher risk of dying from flu
• Trial resumes to prevent dementia after a stroke
• Scientists discover why the heart slows down at night
• The BHF’s research highlights of 2020
• THROMBOLYSIS IN UNKNOWN STROKE ONSET: BROADENING THE HORIZON WITH ADVANCED BRAIN IMAGING

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Stroke Horizon Scanning Bulletin Volume 12 Issue 7

Stroke Prevention in Older Adults

Source: Stroke

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Date of publication: 30 October 2020

Publication type: Research Article

In a nutshell:

The risks of stroke and dementia increase steeply with age, and both are preventable. At present, the best way to preserve cognitive function is to prevent stroke. Therapeutic nihilism based on age is common and unwarranted. We address recent advances in stroke prevention that could contribute greatly to prevention of stroke and dementia at a time when the aging of the population threatens to markedly increase the incidence of both. Issues discussed: (1) old patients benefit even more from lipid-lowering therapy than do younger patients; (2) patients with stiff arteries are at risk from a target systolic blood pressure <120 mm Hg; (3) the interaction of the intestinal microbiome, age, and renal function has important dietary implications for older adults; (4) anticoagulation with direct-acting oral anticoagulants should be prescribed more to old patients with atrial fibrillation; (5) B vitamins to lower homocysteine prevent stroke; and (6) most old patients in whom intervention is warranted for carotid stenosis would benefit more from endarterectomy than from stenting. An 80-year-old person has much to lose from a stroke and should not have effective therapy withheld on account of age. Lipid-lowering therapy, a more plant-based diet, appropriate anticoagulation or antiplatelet therapy, appropriate blood pressure control, B vitamins to lower homocysteine, and judicious intervention for carotid stenosis could do much to reduce the growing burden of stroke and dementia.

Length of publication: Journal article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Cost of stroke care will soar in coming years without investment in prevention

Source: GM

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Date of publication: 16 October 2020

Publication type: Web Article

Details

As it launches its Winter Resilience Campaign, Age UK publishes new research that shows just how crushingly hard day to day life has been for millions of older people during the pandemic and how important it is that we support our older population through the winter.

Length of publication: Web article

Simulation training programs for acute stroke care: Objectives and standards of methodology

Source: European Stroke Journal

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Date of publication: 1^st November 2020

Publication type: Research Article

In a nutshell:

The European Stroke Organisation (ESO) Simulation Committee was established in 2017 with the intent to promote simulation education and training in the stroke field. The application of simulation methodology in education and training improves healthcare professional performances in real clinical practice and patient outcomes. We evaluated the implementation of simulation training in stroke medicine, how it can significantly affect stroke pathways and quality of care. We herewith describe simulation techniques in the acute stroke setting. Simulation programs place the trainees in a safe environment, allowing both role-playings for decision making training and procedural simulation for technical skills improvement. This paper includes the position of the Committee on the key points, principles, and steps in order to set up and promote simulation programs in European stroke centers. Stroke is an emergency, and hyperacute phase management requires knowledge, expertise, optimal multidisciplinary team working, and timely actions in a very narrow time window. The ESO Simulation Committee promotes the implementation of simulation training in stroke care according to a specific and validated methodology.

Length of publication: Journal article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Robot-assisted training compared with an enhanced upper limb therapy programme and with usual care for upper limb functional limitation after stroke: the RATULS three-group RCT

Source: Health Technology Assessment

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Date of publication: 21^st October 2020

Publication type: Research Article

In a nutshell:

Abstract

Objective: The objectives were to determine the clinical effectiveness and cost-effectiveness of robot-assisted training, compared with an enhanced upper limb therapy programme and with usual care.

Design: This was a pragmatic, observer-blind, multicentre randomised controlled trial with embedded health economic and process evaluations.

Interventions: Robot-assisted training using the Massachusetts Institute of Technology-Manus robotic gym system (InMotion commercial version, Interactive Motion Technologies, Inc., Watertown, MA, USA), an enhanced upper limb therapy programme comprising repetitive functional task practice, and usual care.

Main outcome measures: The primary outcome was upper limb functional recovery ‘success’ (assessed using the Action Research Arm Test) at 3 months. Secondary outcomes at 3 and 6 months were the Action Research Arm Test results, upper limb impairment (measured using the Fugl-Meyer Assessment), activities of daily living (measured using the Barthel Activities of Daily Living Index), quality of life (measured using the Stroke Impact Scale), resource use costs and quality-adjusted life-years.

Results: A total of 770 participants were randomised (robot-assisted training, n = 257; enhanced upper limb therapy, n = 259; usual care, n = 254). Upper limb functional recovery ‘success’ was achieved in the robot-assisted training [103/232 (44%)], enhanced upper limb therapy [118/234 (50%)] and usual care groups [85/203 (42%)]. These differences were not statistically significant; the adjusted odds ratios were as follows: robot-assisted training versus usual care, 1.2 (98.33% confidence interval 0.7 to 2.0); enhanced upper limb therapy versus usual care, 1.5 (98.33% confidence interval 0.9 to 2.5); and robot-assisted training versus enhanced upper limb therapy, 0.8 (98.33% confidence interval 0.5 to 1.3). The robot-assisted training group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale) than the usual care group at 3 and 6 months. The enhanced upper limb therapy group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale), better mobility (as measured by the Stroke Impact Scale mobility domain) and better performance in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the usual care group, at 3 months. The robot-assisted training group performed less well in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the enhanced upper limb therapy group at 3 months. No other differences were clinically important and statistically significant. Participants found the robot-assisted training and the enhanced upper limb therapy group programmes acceptable. Neither intervention, as provided in this trial, was cost-effective at current National Institute for Health and Care Excellence willingness-to-pay thresholds for a quality-adjusted life-year.

Conclusions: Robot-assisted training did not improve upper limb function compared with usual care. Although robot-assisted training improved upper limb impairment, this did not translate into improvements in other outcomes. Enhanced upper limb therapy resulted in potentially important improvements on upper limb impairment, in performance of activities of daily living, and in mobility. Neither intervention was cost-effective.

Length of publication: Journal article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Parenchymatous hematoma in patients with atraumatic subarachnoid hemorrhage: Characteristics, treatment, and clinical outcomes

Source: International journal of Stroke

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Date of publication: 19^th November 2020

Publication type: Research Article

In a nutshell:

Background

Data regarding the influence of concomitant parenchymatous hematoma (PH) on long-term outcomes in patients with atraumatic subarachnoid hemorrhage (SAH) are scarce. Further, it is not established if these patients benefit from surgical intervention.

Aim

The aim of this study was to determine the influence of concomitant PH in SAH patients on functional long-term outcome, and whether these patients may benefit from surgical hematoma evacuation.

Methods

Over a 5-year period, all consecutive patients with SAH treated at the Departments of Neurology, Neuroradiology, and Neurosurgery, at the University Hospital Erlangen (Germany) were recorded. In addition to the clinical and imaging characteristics of SAH, we documented the presence, location, and volume of PH as well as treatment parameters. Outcome assessment at 12 months included functional outcome (modified Rankin scale (mRS), favorable = 0–2), health-related quality of life, and long-term complications. For outcome analysis, a propensity score matching (ratio 1:1, caliper 0.1) was performed to compare SAH patients with and without PH. Sub-analyses were performed regarding PH treatment (surgical evacuation vs. conservative).

Results

A total of 494 patients with atraumatic SAH were available. Eighty-five (17.2%) had PH on initial imaging. SAH patients with PH had a worse clinical condition on admission and had a greater extent of subarachnoid/intraventricular hemorrhage. Median PH volume was 11.0 ml (5.4–31.8) with largest volumes observed in patients with ruptured middle cerebral artery (MCA)-aneurysm (31.7 ml (16.3–43.2)). After propensity-score matching (PSM), patients with PH had worse functional outcomes at 12 months (modified Rankin scale (mRS) 0–2: PH 31.8% vs. ØPH57.7% p < 0.001), and a lower rate of self-reported health compared to patients without PH (EQ-5D VAS: PH 50(30–70) vs. ØPH 80(65–95); p < 0.001). In PH patients, surgical evacuation was associated with a higher rate of favorable outcome at 12 months compared to those treated conservatively (surgery 14/28 (50.0%) vs. conservative 14/57 (24.6%); adjusted odds-ratio (OR; 95%CI): 1.34 (1.08–1.66); p = 0.001), irrespective of aneurysm location. Subgroup-analysis revealed positive associations of surgical hematoma evacuation with outcome in subgroups with larger PH volumes (>10 ml; OR (95%CI): 1.39 (1.09–1.79)), frontal PH location (OR 1.59 (1.14–2.23)), and early surgery (within 600 min after onset; OR 1.42 (1.03–1.94)).

Conclusions

Concomitant PH occurs frequently in patients with SAH and is associated with functional impairment after 1 year. Surgical evacuation of PH may improve outcomes in these patients, irrespective of aneurysm-location.

Length of publication: Journal article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Recommendations for lipid modification in patients with ischemic stroke or transient ischemic attack: A clinical guide by the Hellenic Stroke Organization and the Hellenic Atherosclerosis Society

Source: International journal of Stroke

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Date of publication: 19^th November 2020

Publication type: Guideline

In a nutshell:

This document presents the consensus recommendations of the Hellenic Stroke Organization and the Hellenic Atherosclerosis Society for lipid modification in patients with ischemic stroke or transient ischemic attack. This clinical guide summarizes the current literature on lipid management and can be of assistance to the physicians treating stroke patients in clinical practice.

Length of publication: guideline

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Frequency and predictors of occult cancer in ischemic stroke: A systematic review and meta-analysis

Source: International journal of Stroke

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Date of publication: 16^th November 2020

Publication type: Review

In a nutshell:

Background

The optimal approach for cancer screening after an ischemic stroke remains unclear.

Aims

We sought to summarize the existing evidence regarding the frequency and predictors of cancer after an ischemic stroke.

Summary of review

We searched seven databases from January 1980 to September 2019 for articles reporting malignant tumors and myeloproliferative neoplasms diagnosed after an ischemic stroke (PROSPERO protocol: CRD42019132455). We screened 15,400 records and included 51 articles. The pooled cumulative incidence of cancer within one year after an ischemic stroke was 13.6 per thousand (95% confidence interval [CI], 5.6–24.8), higher in studies focusing on cryptogenic stroke (62.0 per thousand; 95% CI, 13.6–139.3 vs 9.6 per thousand; 95% CI, 4.0–17.3; p = 0.02) and those reporting cancer screening (39.2 per thousand; 95% CI, 16.4–70.6 vs 7.2 per thousand; 95% CI, 2.5–14.1; p = 0.003). Incidence of cancer after stroke was generally higher compared to people without stroke. Most cases were diagnosed within the first few months after stroke. Several predictors of cancer were identified, namely older age, smoking, and involvement of multiple vascular territories as well as elevated C-reactive protein and d-dimers.

Conclusions

The frequency of incident cancer after an ischemic stroke is low, but higher in cryptogenic stroke and after cancer screening. Several predictors may increase the yield of cancer screening after an ischemic stroke. The pooled incidence of post-stroke cancer is likely underestimated, and larger studies with systematic assessment of cancer after stroke are needed to produce more precise and valid estimates.

Length of publication: Journal article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Revisiting promising preclinical intracerebral hemorrhage studies to highlight repurposable drugs for translation

Source: International journal of Stroke

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Date of publication: 13^th November 2020

Publication type: Review

In a nutshell:

Intracerebral hemorrhage is a devastating global health burden with limited treatment options and is responsible for 49% of 6.5 million annual stroke-related deaths comparable to ischemic stroke. Despite the impact of intracerebral hemorrhage, there are currently no effective treatments and so weaknesses in the translational pipeline must be addressed. There have been many preclinical studies in intracerebral hemorrhage models with positive outcomes for potential therapies in vivo, but beyond advancing the understanding of intracerebral hemorrhage pathology, there has been no translation toward successful clinical application. Multidisciplinary preclinical research, use of multiple models, and validation in human tissue are essential for effective translation. Repurposing of therapeutics for intracerebral hemorrhage may be the most promising strategy to help relieve the global health burden of intracerebral hemorrhage. Here, we have reviewed the existing literature to highlight repurposable drugs with successful outcomes in preclinical models of intracerebral hemorrhage that have realistic potential for development into the clinic for intracerebral hemorrhage.

Length of publication: Journal article

Clinical features of and risk factors for intracranial aneurysms associated with moyamoya disease

Source: International journal of Stroke

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Date of publication: 11^th November 2020

Publication type: Journal article

Abstract:

Background

The clinical features of aneurysms associated with moyamoya disease (MMD) and risk factors for the formation and rupture of aneurysms are not well defined.

Aims

In this study, we retrospectively analyzed clinical data of MMD patients and examined the potential risk factors for the formation and rupture of aneurysms in these patients.

Methods

The medical records of all MMD patients in our hospital from April 2012 to May 2019 were reviewed. The logistic regression analysis was used to determine the independent association between various potential risk factors and the presence or rupture of intracranial aneurysms in MMD patients.

Results

Of 2230 MMD patients, 182 (8.2%) cases had intracranial aneurysms. The mean age of onset in patients with aneurysms was 47.2 years, which was significantly higher when compared with those without aneurysms (p < 0.001). In logistic regression analysis, age of onset remained significantly associated with the presence of intracranial aneurysms, while female gender, hypertension, diabetes mellitus, and coronary artery disease were not. Besides, intracranial aneurysms were significantly associated with intracranial hemorrhage in MMD patients (odds ratio [OR] = 5.19; 95% confidence interval [CI], 3.80–7.09). About 60% aneurysms >5 mm in size, and 62.1% aneurysms with irregularly shaped morphology were ruptured. Aneurysms located in basilar tip, collateral or moyamoya vessels were more likely to present with rupture.

Conclusions

Age was an important risk factor for intracranial aneurysms formation in MMD patients. Aneurysms increased the risk of intracerebral hemorrhage in MMD patients, and their ruptures were correlated with aneurysms size, location, and morphology.

Length of publication: Journal article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Stroke in COVID-19: A systematic review and meta-analysis

Source: International journal of Stroke

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Date of publication: 11^th November 2020

Publication type: Review

Background

Coronavirus disease 2019 (COVID-19) has become a global pandemic, affecting millions of people. However, the relationship between COVID-19 and acute cerebrovascular diseases is unclear.

Aims

We aimed to characterize the incidence, risk factors, clinical–radiological manifestations, and outcome of COVID-19-associated stroke.

Methods

Three medical databases were systematically reviewed for published articles on acute cerebrovascular diseases in COVID-19 (December 2019–September 2020). The review protocol was previously registered (PROSPERO ID = CRD42020185476). Data were extracted from articles reporting ≥5 stroke cases in COVID-19. We complied with the PRISMA guidelines and used the Newcastle–Ottawa Scale to assess data quality. Data were pooled using a random-effect model.

Summary of review

Of 2277 initially identified articles, 61 (2.7%) were entered in the meta-analysis. Out of 108,571 patients with COVID-19, acute CVD occurred in 1.4% (95%CI: 1.0–1.9). The most common manifestation was acute ischemic stroke (87.4%); intracerebral hemorrhage was less common (11.6%). Patients with COVID-19 developing acute cerebrovascular diseases, compared to those who did not, were older (pooled median difference = 4.8 years; 95%CI: 1.7–22.4), more likely to have hypertension (OR = 7.35; 95%CI: 1.94–27.87), diabetes mellitus (OR = 5.56; 95%CI: 3.34–9.24), coronary artery disease (OR = 3.12; 95%CI: 1.61–6.02), and severe infection (OR = 5.10; 95%CI: 2.72–9.54). Compared to individuals who experienced a stroke without the infection, patients with COVID-19 and stroke were younger (pooled median difference = −6.0 years; 95%CI: −12.3 to −1.4), had higher NIHSS (pooled median difference = 5; 95%CI: 3–9), higher frequency of large vessel occlusion (OR = 2.73; 95%CI: 1.63–4.57), and higher in-hospital mortality rate (OR = 5.21; 95%CI: 3.43–7.90).

Conclusions

Acute cerebrovascular diseases are not uncommon in patients with COVID-19, especially in those whom are severely infected and have pre-existing vascular risk factors. The pattern of large vessel occlusion and multi-territory infarcts suggests that cerebral thrombosis and/or thromboembolism could be possible causative pathways for the disease.

Length of publication: Journal article