Intravenous Thrombolysis in Patients With Ischemic Stroke With Isolated Homonymous Hemianopia: Analysis of Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) Registry
Homonymous hemianopia can cause severe disability. Hemianopia of vascular origin has the worst prognosis for spontaneous recovery. Ischemic stroke resulting in homonymous hemianopia only results in low National Institutes of Health Stroke Scale of 1 or 2. As a result, intravenous thrombolysis may be withheld from these patients if decision analyses are based on the low National Institutes of Health Stroke Scale score even if the outcome is not good. In the National Institute of Neurological Disorders and Stroke tissue-type plasminogen activator trial, only one patient with isolated homonymous hemianopia received intravenous tissue-type plasminogen activator. This study analyzed the outcome of patients with isolated homonymous hemianopia in the largest stroke thrombolysis database, the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR). After searching the SITS Registry, 72 patients were identified with isolated homonymous hemianopia. Fifty-six percent of these patients had improvement in the visual deficit within 7 days postthrombolysis and 26% achieved full recovery. Patients with improvement had lower systolic blood pressure before thrombolysis and lower frequency of being on antiplatelet agent before admission. Fifty-one of 72 patients achieved good 3-month outcome, half of them an excellent outcome. These results emphasize the small number of patients with isolated hemianopia due to ischemic stroke who receive intravenous thrombolysis. They also show that the treatment of these patients appears safe and is likely to result in meaningful improvement. Although one must keep in mind the limitations of this study, mainly the lack of a control group, the results certainly emphasize the importance of not withholding treatment in this population and others like it presenting with disabling deficits despite low National Institutes of Health Stroke Scale scores.
See p 2695.
Biological Signatures of Asymptomatic Extra- and Intracranial Atherosclerosis: The Barcelona-AsIA (Asymptomatic Intracranial Atherosclerosis) Study
The local expression and severity of atherosclerosis differ among vulnerable individuals. It is thought that there are environmental, molecular, and genetic factors that affect the atherogenic process. The main objective of the present study is to investigate whether there is a differential profile of vascular risk factors and relevant biomarkers between asymptomatic intracranial atherosclerosis and cervical carotid atherosclerosis in a randomly recruited stroke-free white population. The Barcelona-AsIA study (Asymptomatic Intracranial Atherosclerosis study) is an ongoing population-based, cross-sectional, and longitudinal study that includes a random sample of 933 subjects >50 years with a moderate to high vascular risk (based on REGICOR score) and without a history of stroke or coronary disease. All subjects completed a duplex ultrasound study of the cervical and intracranial vessels and significant atherosclerotic stenoses were confirmed by MR angiography. A panel of biomarkers involved in atherothrombogenesis was determined: C-reactive protein, asymmetric-dimethylarginine resistin, and plasminogen activator inhibitor. Insulin resistance was quantified by Homeostasis Model Assessment index. After multinomial regression analyses, male sex, hypertension, smoking, and alcoholic abuse were independent risk factors of isolated extracranial atherosclerotic disease but not intracranial atherosclerotic disease (ICAD). Age and diabetes were independent risk factors of atherosclerosis in both locations, but diabetes conferred a substantially higher risk for ICAD. Metabolic syndrome and insulin resistance were independent risk factors of moderate to severe ICAD but were not risk factors of moderate to severe extracranial atherosclerotic disease. As for biomarkers, asymmetric-dimethylarginine (an endogenous inhibitor of endothelial nitric oxide) was independently associated with isolated ICAD and resistin (a protein shown to be a marker of coronary and carotid atherosclerosis) with combined ICAD–extracranial atherosclerotic disease. These findings suggest asymptomatic ICAD and extracranial atherosclerotic disease seem to be characterized by a differential risk factor and molecular profile in this white population. This has important potential clinical implications for the management of asymptomatic intracranial atherosclerosis.
See p 2712.
Detection of Paroxysmal Atrial Fibrillation by 30-Day Event Monitoring in Cryptogenic Ischemic Stroke: The Stroke and Monitoring for Atrial Fibrillation in Real Time (SMART) Registry
Approximately 40% of all ischemic strokes are cryptogenic. Of these, a significant percentage may be due to undetected paroxysmal atrial fibrillation (PAF). Both PAF and chronic atrial fibrillation (AF) are risk factors for ischemic stroke. Anticoagulation is superior to antiplatelet therapy in the prevention of ischemic stroke in both PAF and chronic AF. The Stroke and Monitoring for Atrial fibrillation in Real Time (SMART) Registry was a prospective multicenter cohort study designed to determine the yield of long-term (30-day) cardiac event recording in cryptogenic stroke. Thirty-day outpatient electrocardiographic loop recording was performed with the CardioPAL SAVI and events were autocaptured from cardiac rhythm state changes or by a button press. Monitors were worn for 24.5±8.7 days. A new diagnosis of PAF was made in 26 of 236 patients (11.0%). In patients with PAF, the first episode was recorded an average of 11.4±8.6 days after initiation of monitoring with a median of 2 events detected per patient. Twenty-four percent of events were detected late in the 30-day window. Most (approximately 94%) PAF events were asymptomatic. These results suggest that many patients with cryptogenic stroke have undiscovered AF. That most events of AF were discovered late in the recording enhances the importance of performing prolonged cardiac monitoring. Because the majority of AF was asymptomatic enhances the importance of autotriggered AF recording. These results coupled with similar published results and the therapeutic implications of finding previously undetected AF suggest that prolonged cardiac monitoring with autotriggered recording should be performed in patients with cryptogenic stroke.
See p 2788.
- © 2012 American Heart Association, Inc.
- Intravenous Thrombolysis in Patients With Ischemic Stroke With Isolated Homonymous Hemianopia: Analysis of Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) Registry
- Biological Signatures of Asymptomatic Extra- and Intracranial Atherosclerosis: The Barcelona-AsIA (Asymptomatic Intracranial Atherosclerosis) Study
- Detection of Paroxysmal Atrial Fibrillation by 30-Day Event Monitoring in Cryptogenic Ischemic Stroke: The Stroke and Monitoring for Atrial Fibrillation in Real Time (SMART) Registry
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