Stroke Alert: A Review of Current Clinical Stroke Literature

By Matthew E. Fink, MD, Professor and Chairman, Department of Neurology, Weill Cornell Medical College, and Neurologist-in-Chief, New York Presbyterian Hospital

Which Patients Taking Warfarin for Atrial Fibrillation Have an Ongoing Risk for Stroke?

Source: Albertson IE, et al. Risk of stroke or systemic embolism in atrial fibrillation patients treated with warfarin. A systematic review and meta-analysis. Stroke 2013;44:1329-1336.

In a review of six randomized clinical trials, with a total of 58,883 patients treated with warfarin for atrial fibrillation, the authors calculated the risk of ongoing embolic stroke and used regression analysis to determine the characteristics that were associated with increased stroke risk. They found the following significant risk factors for stroke in those who were taking oral anticoagulants, with a 95% confidence interval — age > 75 years (relative risk [RR] = 1.46), female sex (RR = 1.30), previous stroke or TIA (RR = 1.85), moderate and severe renal impairment (moderate RR = 1.54 and severe RR = 2.22), previous aspirin use (RR = 1.19), Asian race (RR = 1.70), and CHADS score ≥ 3 (RR = 1.64).

These risk factors should be assessed and monitored in all patients who are taking warfarin in order to lower their stroke risk as much as possible. It is not known whether the new direct thrombin inhibitors and factor X inhibitors will demonstrate similar findings as those of patients who are taking warfarin.


Who Gets Chronic Pain After a Stroke?

Source: O’Donnell MJ, et al. Chronic pain syndromes after ischemic stroke. PRoFESS Trial. Stroke 2013;44:1238-1243.

The frequency and consequences of chronic pain syndromes after stroke are poorly understood. The authors used prospective data from the Prevention Regimen for Effectively Avoiding Second Stroke (PRoFESS). Patients were followed for up to 2.5 years, and included 15,754 patients with all types of ischemic stroke. On the last follow-up visit, a structured pain questionnaire was administered to identify those who developed a chronic pain syndrome, and 1665 participants (10.6%) were found to have chronic pain. The etiologies were central poststroke pain (2.7%), peripheral neuropathic pain (1.5%), pain from spasticity (1.3%), and pain from shoulder subluxation (0.9%). More than one pain sub-type was reported in 86 participants (0.6%).

In an analysis of risk factors for the development of pain, the following predictors were significant — stroke severity, female sex, alcohol intake, statin use, depressive symptoms, diabetes mellitus, antithrombotic medications, and peripheral vascular disease. Patients who developed a chronic pain syndrome were also more likely to become dependent (OR = 2.16; 95% CI 1.82-2.56). In addition, patients who had chronic pain as a result of peripheral neuropathy, spasticity, or shoulder subluxation were more likely to have cognitive decline. Chronic pain syndromes occur in about 10% of stroke patients and may have significant impact on recovery and functional outcomes.


Clinical Features and Outcome of Basilar Artery Occlusion

Source: Ohe Y, et al. Clinical review of 28 patients with basilar artery occlusion. J Stroke Cerebrovasc Dis 2013;22:358-363.

The authors performed a retrospective review of clinical presentation, treatment, and outcomes in 28 patients with basilar artery occlusion. Ages ranged from 39 to 100 years, with a mean age of 72. There were 18 men and 10 women. Hypertension was present in 21 patients, diabetes in 4, dyslipidemia in 11, and atrial fibrillation in 10 patients. Clinical severity, based on a high NIHSS score and a low Glasgow Coma Score, predicted a poor outcome with 79% of the patients having a poor outcome, and only 21% recovering with a good outcome. MRI showed the location of the infarcts to be in the caudal pons in 6 patients, mid-pons in 9, and upper pons and midbrain in 13 (top of the basilar). There were associated infarcts in the cerebellum, thalamus, and occipital lobes in most patients. One patient was treated with IV thrombolysis, and five patients underwent percutaneous endovascular angioplasty, with three successfully recanalized. However, two of the three who were recanalized still had poor neurological outcomes.

There were no underlying risk factors that predicted a good outcome compared to a bad outcome. The clinical severity on admission predicted outcome, and the various therapies did not appear to influence the outcomes, although the number of patients is too small to draw any firm conclusions.