Stroke Alert: A Review of Current Clinical Stroke Literature

By Matthew E. Fink, MD, Interim Chair and Neurologist-in-Chief, Director, Division of Stroke & Critical Care Neurology, Weill Cornell Medical College and New York Presbyterian Hospital

Are There Sex Differences in the Results from Carotid Endarterectomy and Stenting?

Source: Howard VJ, et al. Influence of sex on outcome of stenting versus endarterectomy: A subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Lancet Neurol 2011;10:530-537.

Crest failed to demonstrate any significant differ-ence in the primary endpoint (composite of stroke, myocardial infarction, or death during the 4-year follow-up period) between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients with symptomatic or asymptomatic carotid artery stenosis. A prespecified secondary aim was to examine differences by sex, since previous studies suggested a higher periprocedural complication rate and lower efficacy from these interventions in women compared to men.

Between 2001 and 2008, 2502 patients were randomized to CEA or CAS, and 872 (34.9%) were women. Rates of the primary endpoint for CAS versus CEA in women were 8.9% vs 6.7% (hazard ratio [HR] = 1.35, 0.82 – 2.23). Periprocedural events occurred in 6.8% of women assigned to CAS vs 3.8% of women assigned to CEA (HR = 1.84). The results of CREST supported the findings suggested by previous studies that there is a higher incidence of complications, both periprocedural and long-term, in women who undergo CAS compared to CEA for the treatment of carotid artery stenosis. Complications may be related to the smaller diameter of the internal carotid arteries in women, but other factors may play a role.

Intravenous Thrombolysis Is Less Effective in Elderly Patients

Source: Bhatnagar P, et al. Intravenous thrombolysis in acute ischaemic stroke: A systematic review and meta-analysis to aid decision making in patients over 80 years of age. J Neurol Neurosurg Psychiatry 2011;82:712-717.

The pivotal ninds intravenous thrombolysis trial (N Engl J Med 1995) did not include patients > 80 years of age, but recently, many elderly patients are being treated with thrombolytic drugs with increasing frequency, and an age cutoff for thrombolysis has not been defined. Investigators in the UK performed a meta-analysis of 13 published studies, systematically evaluating outcome measures of mortality, functional recovery by modified Rankin scale, and the rate of symptomatic intracranial hemorrrhage (SICH) at 3 months following IV thrombolysis with alteplase in < 80 and > 80-year-old patients with acute ischemic stroke (AIS).

By combining the results of the studies, the overall odds ratio was 2.77 (95% confidence interval [CI] 2.25 to 3.40) for death, 0.49 (95% CI; 0.40 to 0.61) for achieving a favorable outcome, and 1.31 (95% CI; 0.93 to 1.84) for SICH in > 80-year-old patients compared to < 80 years old. Patients > 80 years old appear to have a lower probability of having a favorable outcome and a higher mortality rate compared with patients < 80 years old, but their rate of SICH is not significantly increased. This analysis supports the continued enrollment of elderly patients in clinical trials of thrombolysis and provides risk-benefit information that can be used in the clinical treatment of such patients.

Hypertonic Saline in Treatment of Intracerebral Hemorrhage

Source: Wagner I, et al. Effects of continuous hypertonic saline infusion on perihemorrhagic edema evolution. Stroke 2011;42:1540-1545.

Neurological deterioration after intracerebral hematoma (ICH) usually is due to the mass effect of the hematoma with its associated perihematoma edema. Surgical evacuation has not been proven to be better than best medical care, and treatment options are limited. The investigators explored the use of early continuous infusion of hypertonic saline as a treatment modality that might reduce brain edema.

Twenty-six consecutive patients with spontaneous lobar and basal ganglia/thalamic ICH > 30 mL were treated with continuous 3% hypertonic saline infusion to achieve Na of 145 to 155 mmol/L and osmolality of 310-320 mOsmol/kg. Measurements of absolute and relative edema volume were assessed on repeated cranial CT and compared to historical controls (n = 64) from a database with hematoma > 30 mL.

The treatment group had an absolute edema volume that was significantly smaller between day 8 and day 14 and a relative edema volume (absolute edema/hematoma volume) that was smaller between day 2 and day 14. Treated patients had fewer intracranial pressure crises (ICP > 20 mmHg for > 20 min) than the historical controls (12 vs 56) and in-hospital mortality was 11.5% for the group treated with hypertonic saline compared to 25% for the historical controls. This non-randomized, consecutive series suggests that continuous infusion of hypertonic saline may have a beneficial effect on the outcome for patients with ICH, but this must be confirmed by a randomized, controlled clinical trial.