Infarction in the anterior choroidal artery territory: clinical progression and prognosis factors

Chausson N, et al.  JSCD; 2014; 23:8: 2012-7.

 

Authors describe the phenotypes of  anterior choroidal stroke in heretofore unappreciated ways.  They prospectively enrolled patients with AChA disease

 

*One hundred patients were found out of 1234 total (8.1 %) who had AChA strokes

 

*  Main risk factors found were hypertension and (79 %) and diabetes (31 %). 

 

*  88 % had "lacunar" (motor syndrome in 51, sensorimotor in 23, ataxic hemiparesis in 14, isolated ataxia in 4, other 7)

*  only four patients had hemianopia

*  cardioembolic and atherothrombotic causes wee rare

*  3 % mortality but 26 % poor outcomes, invariably due to residual motor deficit and/or spasticity

* Progressive strokes were seen in 46, and 16 with fluctuations, wiht progressions over a mean of 56 hours and being almost exclusively motor

* Use of iv tpa did nto help prevent progression (tpa was used in 12/46 progressors and 9/54 nonprogressors)

* predictor of poor outcome was those who reached an NIHSS of 6 or greater, clinical progression, and infarct size > 15 mm

* Progression was nearly always due to infarct expansion on DWI

* Authors suggest new treatments are needed for this disease.

 

 

Recurrence in Intracranial atherosclerotic disease (ICAD): a stenosis based analysis

Gouvela a, et al.  JSCD, 2014: 23:8:2080-4.

Authors confirmed prior work showing extremely high recurrence rate of stroke in this type of disease:  12.3 per 100 patient years, with mean time to recurrence being 1.7 months among symptomatic intracranial stenosis (SIS) and 0.88 per 100 patient years among asymptomatic intracranial stenosis (AIS). 

They investigated 1302 patients retrospectively, with 218 strokes in 158 patients, of which 77 were symptomatic and 141 asymptomatic.  Patients with AIS were older, had more AF

blogger note-- interesting article that splits ICAD ina new way, to AIS and SIS that has very different clinical outcomes.

Odds ratio and population attributable risk of 10 factors estimated to acount for 90 % of ischemic stroke risk

Risk factor            OR              PAR    (confidence intervals available elsewhere)

 

hypertension          2.64            34.6

current smoking     2.09            18.9

waist to hip ratio    1.65             26.5

Diet risk score       1.35             18.8

Regular exercise    0.69             28.5

Diabetes mellitus   1.36             5.0

ETOH (> 30/mo)     1.51             3.8

Stress/depression   1.30            4.6

Cardiac causes       2.38            6.7

ratio apo B/A1        1.89             24.9

 

Notes

Spouses of smokers have double risk of stroke.  Much benefit of cessation occurs in first 6 months.  Cessation leads to return to baseline risk within five years.

 

Fives risk factors  related to lifestyle and risk

1. Absent current smoking

2. 30 + minutes per day of exercise

3. healthy diet

4.  moderate ETOh consumption

5.  BMI < 25

If all five risk factors are favorable,   RR is -.2, PAR is -53.

 

Cretan Mediterranean diet is the best one; those randomized to it had 70 % less CV events within 27 months

This diet contains more fat esp olive oil.  Its much lower in meat and dairy products and uses fruit as desert. It has high levels of canola nad olive oil, high fruit/vegetable/lentils/beans and nuts.  Avoid trans fats and egg yolks; meat every other day.

 

Ottawa Model of Smoking Cessation

systematic

Identify smoking status-- have you used any form of tobacco in the past six months? The past seven days?

Document-- smoking history (pack years); previous quit attempts, time to first cigarette

Advise--- "There is nothing more important that cessation. We can help you with that"

Pharmacotherapy-- readily available medicine, prescribed appropriately

Followup-- FP; telephone calls; community resources.

ACC/AHA Guisdelines for postcardiac surgery atrial fibrillation; and CABG in general

* patients with pre-existing AF receiving antiarrhythmics or rate controlling agents should be continued ont hese in postop period.

 

*  Oral beta blocker is recommended to prevent post op AF in patients undergoing cardiac surgery-- unless contraindicated

 

*  An AV nodal blocking agent is recommended for postop rate control in patients who develop postop AF

 

* Preop amiodarone decreases the incidence of AF in patients undergoing cardiac surgery  and represents appropriate prophylactic therapy for patients at high risk of AF

 

*  Its reasonable to restore sinus rhythm pharmacologically or through cardioversion among patients who develop postoperative AF

 

*  It is reasonable to administer anti-arrhytmics to maintain SR in patients with postop refractory or recurrent AF

*  Antithrombotic medication is reasonable to administer in patients who develop postop AF

 

*  Prophylactic sotalol may be considered in high risk patients. 

 

Additional points for cardiac surgery-- evidence based

 

*Matching preop and postop BP may reduce the risk of perioperative stroke or death  III/B

 

* Preop statins reduce the perioperative stroke risk in cardiac surgery  IB/A

 

*  Antiplatelet therapy eg ASA reduces the postop stroke risk without increasing the risk of bleeding complications  Ia/A

 

*  Discontinuing warfarin or antiplatelet agents in anticipation of surgery increases the risk of perioperative stroke, with the highest risk in patients with CAD

Benefit of CEA in different conditions

Degree of stensois         Studies        Recc           Risk reduction

 

Symptomatic stenosis

   70-99%                       NASCET     CEA LEVEL A       16.5 % at two years

   >60 %                         ECST               "                     11.6 % at 3 years

   50-69 %                       NASCET           "                    10.1 % at 5 years

 

 

Asymptomatic stenosis

 

>60 %                            ACAS, ACST     "                     6.3 % at five years

RISK OF HEMORRHAGE

 

-- some literature favors early surgery for patients without early ICH on CT scans

 

-- of those who hemorrhaged, hemorhhage occured 3-6 days after surgery when patients were improving or ambulatory.  They occurred in 6/900 patients studied

 

-- Dosick et al. reported 9.5 % restroke incidence with six week waiting period before CEA

 

--In NASCET 4.9 % of 103 patients  (5 patients) had restroke within 30 days of trial entry if treated medically

 

-- In a variety of studies patients operated within 3 weeks had 3 % stroke risk, those operated beyong 3 weeks had a 5.3 % stroke risk

 

 

 

 

Timing of tpa; outcomes

0-90 minites  odds ratio for favorable outcome at 3 months based on 4 point decline of NIHSS is 2.11

90-180 minutes-- odds ratio is 1.69

 

In NINDS trials, poor outcomes as defined by MRS >3 at 24 hours were predicted by NIHSS>22

OR

NIHSS>17 plus AF

Duration of dual antiplatelet therapy after implantation of drug eluting stents

Park et al. NEJM 2010; 362: 1374-82. 
Conclusion
use of dual antiplatelet therapy more than 12 months among patients who received drug eluting stents was not significantly more effective than aspirin monotherapy. 

Lenient v. strict rate control in patients with atrial fibrillation

Gelder et al.  NEJM 2010; 362: 1363-73

study of 614 patients showed that among patients with permanent AF, lenient rate control is as effective as strict rate control and is easier to achieve.