Stroke: Highlights of Selected Articles
Nils Henninger MD
Hemorrhagic Manifestations of Reversible Cerebral Vasoconstriction Syndrome: Frequency, Features, and Risk Factors
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe headaches, focal deficits, seizures, and multifocal constriction of intracerebral arteries that resolves spontaneously in 3 months. It may be associated with both ischemic and hemorrhagic strokes. More than half of the cases of RCVS occur in the postpartum setting or in association with sympathomimetic or serotoninergic agents. The authors prospectively analyzed 89 consecutive patients with RCVS. Thirty-four percent of patients (n=30) developed at least 1 type of intracranial hemorrhage. Subarachnoid hemorrhage was the most frequent (n=27), followed by intracerebral hemorrhage (n=11), and then subdural hemorrhage (n=2). This study revealed that women and migrainers are at higher risk of intracranial hemorrhage. History of hypertension and blood pressure surges during the acute phase of RCVS were not associated with hemorrhage risk. Patients with hemorrhage had a greater risk of persistent focal deficits and were more likely to not be able to return to work at 6 months. RCVS should be considered in the differential diagnosis of patients with spontaneous intracranial hemorrhage. Women and migrainers are at high risk of intracranial hemorrhage with RCVS.
See p 2505.
Intravenous Alteplase for Stroke in Those Older Than 80 Years Old
Treating stroke patients older than 80 with intravenous tissue plasminogen activator (tPA) remains controversial. In this issue of Stroke, Ford and colleagues present the outcomes and complications seen in tPA-treated patients >80 years (n=1831) versus ≤80 years (n=19 411) in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) database. The unadjusted symptomatic intracerebral hemorrhage (sICH) rate did not differ significantly between patients >80 years versus ≤80 years with the SITS-MOST definition but was significantly increased in the >80 years group using the National Institute of Neurological Disorders and Stroke definition. Fatal sICH (SITS-MOST definition) rate was similar in both age groups. After adjustment for baseline variables, there was no statistically significant difference in sICH rates between the 2 age groups, regardless of the used definition. The odds ratio for mortality in the >80 years group was higher (30% versus 12%) and for functional independence (mRS 0 to 2) lower (35% versus 57%) at 3 months. Compared to baseline, National Institutes of Health Stroke Scale scores improved to a similar extent in both age groups at 2 hours, 24 hours, and 7 days. Lastly, analysis of the age ranges <60, 61–70, 71–80, 81–90, and >90 years indicated no age-related increase in sICH (SITS-MOST definition). Though a progressive increase in mortality was observed, functional dependence (mRS 3 to 5) was similar across assessed age ranges. This study is important because it provides robust and reliable data that tPA-treated patients >80 years (1) do not have a higher risk for clinically significant sICH; (2) have early clinical improvement similar to younger patients; and (3) have poor outcomes related to increased mortality rather than to an increased rate of functional dependence.
See p 2568.
Impact of Microalbuminuria on Incident Stroke: A Meta-Analysis
Identifying risk factors underlying atherosclerotic disease may help optimize patient care. Microalbuminuria, which is traditionally seen as a sign of early kidney disease, has also been increasingly recognized as a marker of endothelial dysfunction. In this issue of Stroke, Meng Lee and colleagues present data from a meta-analysis of 12 prospective cohort studies (total 48 596 participants and 1263 stroke events) to assess the association of microalbuminuria and the risk of stroke. Included studies were derived from general as well as type 2 diabetes mellitus and stroke history populations. The majority of studies were from a white-dominant population. Follow-up duration ranged from 1.1 years to 13.4 years, and the reported prevalence of microalbuminuria ranged from 12% to 40% in the included studies. After adjustment for established cardiovascular risk factors, presence of microalbuminuria was associated with greater subsequent stroke risk. The association was highest with ischemic stroke risk and essentially neutral for hemorrhagic stroke risk. Patients with microalbuminuria had an overall risk of future stroke that was approximately 90% greater than in those without microalbuminuria, and the impact of microalbuminuria was greatest in the population with a history of stroke. Nevertheless, the authors caution that potential publication bias may have resulted in an overestimation of the association between microalbuminuria and future stroke risk. Furthermore, given that this meta-analysis was based on observational studies, a causal relationship between ischemic stroke and microalbuminuria could not be proven. Nevertheless, the presented analysis supports the notion that microalbuminuria is an independent, and potentially modifiable, ischemic stroke risk factor.
See p 2625.