Prevalence of Positive Troponin and Echocardiogram Findings and Association With Mortality in Acute Ischemic Stroke
The association and co-occurrence of acute ischemic stroke (AIS) and myocardial infarction has been well established, and one may be the consequence of the other. AIS is a known cause of hypertroponinemia without myocardial infarction. However, occult ischemic cardiomyopathy may also be present in AIS patients. In this article, Wrigley et al sought to better explore these relationships by determining the therapeutic yield of serum troponin (cTn) and echocardiogram testing in AIS and their associations with outcomes. The authors retrospectively screened for consecutive AIS patients in the Greater Cincinnati/Northern Kentucky region. Hypertroponinemia, defined as elevation in cTn above the 99th percentile, and echocardiographic features of interest were recorded. There were 1999 AIS cases, with mean age of 69 and median NIHSS score of 3. A total of 1706 (85.3%) had a cTn drawn, 1590 (79.5%) had echocardiograms, and 1377 (68.9%) had both. Hypertroponinemia occurred in 20.7%. Important echocardiographic changes occurred in 10.1%, of which cardiomyopathy with low ejection fraction was the most frequent. About 32.5% (96/295) of those with a hypertroponinemia and 15.6% (23/147) of those with echocardiogram findings had no previous history of cardiac disease. Hypertroponinemia was independently associated with echocardiographic findings (OR, 2.9; 95% confidence interval [CI], 2.0–4.2). Hypertroponinemia was also associated with increased mortality at 1 year (35%; OR, 3.45; 95% CI, 2.1–5.6) and 3 years (60%; OR, 2.91; 95% CI, 2.06–4.11), after exclusion of concurrent myocardial infarction. This study highlights the prognostic severity of so-called troponin leaks in AIS, independently of stroke severity. It also prompts consideration of need for further diagnostic investigations in patients with AIS and hypertroponinemia, aiming to reduce early and long-term mortality. See p 1226.
CT Perfusion Selection and Clinical Outcomes After Endovascular Therapy in Large Vessel Occlusion Stroke
In this article, Bouslama et al sought to determine whether CT perfusion (CTP) selection improves endovascular therapy outcomes in acute ischemic stroke, when compared with selection by noncontrast CT (NCCT) alone. To that end, they studied data from a prospective single tertiary center registry. Data from 602 patients with anterior circulation ischemic stroke who underwent stent-retriever thrombectomy were analyzed. Three-hundred sixty-five patients were selected for the procedure based on CTP data, and 237 with NCCT. CTP-selected patients (n=365; 61%) were younger (P=0.02) and had significantly fewer comorbidities such as hypertension, hyperlipidemia, and atrial fibrillation. CTP selection was associated with a favorable shift in the overall distribution of the 90-day modified Rankin scale (P<0.001) and with higher rates of good outcome (modified Rankin scale score of 0–2) at 90 days, when compared with NCCT selection. CTP selection was associated with higher rates of full arterial reperfusion and with lower mortality; these findings remained significant after multivariable adjustments. CTP selection was also better at predicting functional outcomes in patients presenting with stroke after 6 hours, and in those with an ASPECTS score (Alberta Stroke Program Early CT Score) of ≤7. Important study limitations, secondary to its retrospective nature, include selection bias for CTP versus NCCT performance; analysis restricted to patients that received arterial thrombectomy; and analysis by 1 postprocessing CTP. Therefore, although this study suggests the superiority of CTP selection compared with NCCT-based methods in selecting candidates for endovascular therapy with stent retriever, such findings still need to be confirmed in prospective clinical trials. See p 1271.
MIDAS (Modafinil in Debilitating Fatigue After Stroke): A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial
In this study, Bivard et al sought to determine whether modafinil would improve poststroke fatigue. They conducted a prospective, randomized, double-blind, placebo-controlled, crossover single-center phase 2 trial. Included were chronic stroke survivors with significant fatigue, defined as a score ≥60 on the multidimensional fatigue inventory. Patients were randomized to modafinil 200 mg daily or placebo for 6 weeks. They underwent a 1-week washout period and thereafter crossed over to the other treatment arm for another 6 weeks. From 232 screened patients with stroke, 36 were included in the study, of which 33 has ischemic strokes, and 3 had hemorrhagic stroke. The mean age was 63, 61% were male, and median admission NIHSS score (National Institutes of Health Stroke Scale) was 13. The baseline fatigue severity was 72 on multidimensional fatigue inventory. When receiving modafinil, patients had a significant decrease in fatigue (multidimensional fatigue inventory, −7.38; 95% CI, −21.76, −2.99; P<0.001). Patients also reported a significant reduction in symptom severity for every multidimensional fatigue inventory domain. There was improved quality of life (SSQoL [Stroke Specific Quality of Life Scale], 11.81; 95% CI, 2.31, 21.31; P=0.0148) for patients receiving modafinil, when compared with placebo. Adverse event rates were similar between the 2 groups. Hence, this study indicates that 200 mg daily of modafinil may reduce nonresolving fatigue and improve quality of life in chronic stroke survivors. It is hoped that these preliminary findings may be reproduced in a phase 3 clinical trial. See p 1293.
- © 2017 American Heart Association, Inc.
- Prevalence of Positive Troponin and Echocardiogram Findings and Association With Mortality in Acute Ischemic Stroke
- CT Perfusion Selection and Clinical Outcomes After Endovascular Therapy in Large Vessel Occlusion Stroke
- MIDAS (Modafinil in Debilitating Fatigue After Stroke): A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial
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