A Stroke of Genius: Gains Seen on Many Fronts at Meeting

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 - ASA 2015
Source: American Heart Association/American Stroke Association

The American Stroke Association’s 2015 International Stroke Conference held Feb. 11-13 in Nashville, Tenn., likely lifted many spirits with findings that supported new therapies and identified opportunities to improve patient care.

Just add water? Hydration may turn tide in stroke care

Could something as simple as water create a sea change in stroke care? A study unveiled Feb. 12 pointed to dehydration as a factor in poor stroke outcomes, making rehydration a possible pathway for improvement.  

The study used BUN/creatinine ratio and urine specific gravity data to gauge dehydration and diffusion-weighted MR imaging to measure lesion volume 168 patients admitted at a stroke center. For short-term outcomes, 44 percent of the dehydrated patient group had no changes or worse National Institutes of Health Stroke Scale scores compared with 17 percent of the hydrated patient group. By day four, the dehydrated group had a four times increased odds of an unchanged or worse clinical condition.

“I think early hydration is the key,” says presenter Mona Bahouth, MD, a neurologist at Johns Hopkins Hospital in Baltimore. They are continuing to look at the data for longer-term outcomes and if those results hold up they plan to evaluate interventions through a prospective trial. “If it proves positive that rehydrating a patient is helpful to them, then it would be a really cheap and universally available intervention for patients.”

Vitamin D may predict stroke severity

In a retrospective analysis of stroke patients with recorded vitamin D levels, researchers found a nearly fourfold larger stroke risk by two weeks following an event in patients with low vitamin D levels. Low vitamin D also doubled the size of lacunar and nonlacunar strokes.

Insufficient vitamin D levels also appeared to influence the distribution of outcomes, with more than two-thirds of patients with low vitamin D levels showing poorer functional status at three months.

Using infarct size, the team was better able to quantify outcomes related directly to the initial stroke and define initial stroke severity without including outcomes that may be unrelated, such as later death by heart failure.

The next step is to look for validation in a larger group of patients, says presenter Nils Henninger, MD, of the University of Massachusetts Medical School in Worcester. “We find a target population of patients who are at a high risk for stroke and supplement those with vitamin D when the targets are below a certain cut point. Can we modify that risk? … While there are a lot of studies that show that the risk may be higher when vitamin D level is low, there are no studies as yet that show that you can reverse this effect by supplementing vitamin D.”

Insertable monitorcost-effective in cryptogenic stroke patients

Using an insertable cardiac monitor to identify atrial fibrillation in patients with cryptogenic stroke is cost-effective, at least from a UK healthcare system’s perspective.

“The management of cryptogenic stroke patients is currently very difficult and often they don’t get anticoagulated until they have had a second stroke,” says Klaus Witte, MD, a cardiologist at the Leeds Teaching Hospitals National Health Service Trust in the UK and one of the study’s investigators. “The standard of care is aspirin, which we know is effectively pointless in a lot of cases, particularly if there is arrhythmia.”

Their analysis used data from the CRYSTAL AF (Cryptogenic Stroke and Underlying AF) trial, which randomized 441 patients with cryptogenic stroke or transient ischemic attack to either long-term electrocardiographic monitoring with an insertable cardiac monitor (REVEAL XT, Medtronic) or conventional follow-up.

At six months, atrial fibrillation was detected in 8.9 percent of the device group vs. 1.4 percent in the standard-care group. At 12 months, the detection of atrial fibrillation was seven time higher in the insertable cardiac monitor group compared with the control, and it continued to climb up to three years.

The cost-effectiveness model assumed that all patients with detected atrial fibrillation received anticoagulation of either a novel oral anticoagulant (NOAC) or warfarin. For risks, they included cerebrovascular events and treatment-related adverse events.

Patients treated with NOACs tallied an incremental cost-effectiveness ratio (ICER) of $28,308 (£17,184) and those receiving warfarin had an ICER of $21,903 (£13,296). Both anticoagulation approaches fell within