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

Early Treatment of Ruptured Aneurysm Improves Outcomes

Source: Phillips TJ, et al. Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome? Stroke 2011;42:1936-1945.

Investigators at the royal melbourne hospital in Australia reviewed their 11-year database of consecutive ruptured intracranial aneurysms treated with endovascular coiling or craniotomy and analyzed outcome using the modified Rankin Scale at 6 months. They separated patients into those who were treated within 24 hours (230 cases) and those treated after 24 hours (229 cases). Delay in treatment was due to nonclinical logistical factors. Between the groups, there was no difference in age, sex, smoking history, family history, or size and location of the aneurysm. Poor clinical grade patients were overrepresented in the early treatment group, and increasing age and poor clinical grade were predictors of poor outcome in both groups.

Eight percent of patients treated in < 24 hours were dependent or dead at 6 months compared to 14.4% of those treated > 24 hours, resulting is a relative risk reduction of 44% and an absolute risk reduction of 6.4% (X2, P = 0.044). In addition, 3.5% of cases coiled within 24 hours were dependent or dead at 6 months compared to 12.5% of cases coiled at 1 to 3 days, an 82% reduction in relative risk and 10.2% reduction in absolute risk (X2, P = 0.040). There was no difference in clinical grade in the groups coiled early or late. This study supports the view that treatment of ruptured aneurysms within 24 hours is associated with an improved outcome, and this benefit is more pronounced with coiling.

Cerebral Microhemorrhages May Be a Marker for β-Amyloid and Alzheimer's Disease

Source: Yates PA, et al. Cerebral microhemorrhages and brain β-amyloid in aging and Alzheimer's disease. Neurology 2011;77: 48-54.

Cerebral microhemorrhages (MH) frequently are found in older persons scanned with gradient-echo and susceptibility-weighted MRI (SWI), and have been linked to β-amyloid deposition using Pittsburgh compound B (PiB) PET scanning in patients with Alzheimer's disease (AD) and cerebral amyloid angiopathy (CAA). The authors investigated whether Aβ deposition in healthy elderly individuals is associated with lobar microhemorrhages (LMH).

In a cross-sectional study of 84 elderly healthy controls (HC), 28 subjects with mild cognitive impairment (MCI), and 26 subjects with probable AD, subjects underwent 3-Tesla SWI and PIB PET. Scans were classified as PIB+ or PIB– and MH were counted and classified as lobar or nonlobar. Lobar microhemorrhages were found in 30.8% of AD patients, 35.7% of MCI, and 19% of HC. The prevalence of LMH among PIB+ subjects was the same regardless of clinical diagnosis (AD 30.8%, MCI 38.9%, HC 41.4%, P > 0.7), and there was a positive correlation between the number of LMH, the intensity of PIB binding, and increasing age. Based on these PIB PET studies, Aβ deposition in older adults is strongly correlated with the presence of lobar microhemorrhages.

Intracranial Stenting for High-Grade Symptomatic Stenosis — Not Ready for Prime Time

Source: Fiorella DJ, et al. US Wingspan Registry. 12-month follow-up results. Stroke 2011;42:1976-1981. Jiang WJ, et al. Outcome of patients with ≥ 70% symptomatic intracranial stenosis after wingspan stenting. Stroke 2011;42:1971-1975.

Intracranial stenting for symptomatic high-grade stenosis was heralded with great enthusiasm but has recently been put on hold by the cessation of enrollment in the NIH-supported Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) #NCT00576692 study because of an unexpectedly high rate of complications in the stent group during the first 30 days (National Institute of Neurological Disorders and Stroke Clinical Alert, April 11, 2011). The SAMMPRIS investigators reported a 14% rate of stroke or death in the first 30 days compared to 5.8 rate in the medical arm. Therefore, the above two papers should be viewed in this context — the randomized study that was designed to answer whether stenting is better than medical therapy already has determined that early complications are more frequent with stenting.

Fiorella et al reported the results of a Wingspan registry of 158 patients from five centers who underwent stenting for symptomatic intracranial lesions of 50%- 99% and they reported an average follow-up duration of 14.2 months. The cumulative rate for primary endpoint events (stroke or death) was 15.7% for all patients and 13.9% for those with high-grade stenosis (70%-99%). Of 13 ipsilateral strokes occurring after 30 days, three resulted in death, and 10 of 13 occurred within 6 months of the procedure.

Jiang et al reported a single-center series from Beijing, China, of 100 consecutive patients with intracranial stenosis ≥ 70% and symptoms within 90 days of enrollment. Endpoints were stroke or death within 30 days, or any stroke after 30 days. During a mean follow-up of 1.8 years, nine patients developed stroke (five within 30 days and four afterward). The authors note that their results were favorable when compared to the WASID trial (N Engl J Med 2005;352:1305-1316).

The observations from these non-randomized trials, incorporated with the early data from SAMMPRIS, lead us to the conclusion that intracranial stenting for symptomatic stenosis is not ready to be used as standard treatment, and intensive medical therapies are still the preferred approach for symptomatic intracranial stenosis.