Findings of DAWN trial may influence treatment of stroke

Findings of DAWN trial may influence treatment of stroke

Results of the DAWN trial published in the New England Journal of Medicine shows that clot removal up to 24 hours after stroke led to significantly reduced disability for properly selected patients.

The international multi-center DAWN trial randomized 206 patients of acute stroke who arrived at the hospital within six to 24 hours to either standard medical therapy alone or to endovascular clot removal therapy plus standard care.

It is currently recommended that clot removal should be done only within 6 hours of stroke onset of stroke.

Patients were selected for the trial based on brain imaging (diffusion-weighted MRI or perfusion CT) to assess the extent of irreversible brain damage plus clinical criteria to help decide if thrombectomy would help the patient even if he/she arrives after 6 hours but within 24 hours, rather than just using the 6-hour window as the cut-off.

Almost 50% of patients with stroke due to occlusion of the intracranial internal carotid artery or proximal middle cerebral artery and who had a mismatch between the severity of the clinical deficit and the infarct volume, who underwent clot removal reported significant decrease in disability at 90 days post- treatment. On the other hand, only 13.1% patients who received medical treatment showed such reduction in disability. Decrease in disability means more independence in activities of daily life. Mortality and other safety end-points were similar between the two groups.  

“Time is brain”. The trial abides by this and re-emphasizes the importance of reaching the hospital as early as possible after the onset of stroke. The findings of the trial though may influence management of some selected patients who present to the hospital late, outside the 6-hour window period. “Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy.”

The DAWN trial is published online November 11, 2017 in the New England Journal of Medicine.

About 1.8 million Indians suffer from stroke every year

About 1.8 million Indians suffer from stroke every year

On World Stroke Day, it is important to create awareness on the fact that timely detection and treatment can prevent permanent disability

New Delhi, 28 October 2017: The second most common cause of death globally, next to coronary artery disease, stroke is also the most prevalent cause of chronic adult disability, reveal statistics. India accounts for more than four-fifths of all strokes with about 1.8 million Indians suffering from this condition every year. The IMA opines that stroke is not just limited to the elderly and increasingly, young Indians below 40 years of age are becoming susceptible to this condition primarily due to lifestyle factors.

A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die. It is imperative to detect a stroke early, as with every second that the disease goes untreated, about 32,000 brain cells are damaged.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, ‘Time is brain’. A patient with suspected stroke or ‘brain attack’ should therefore be shifted to hospital at the earliest and given a clot dissolving therapy. A stroke may result from a blocked artery (ischemic stroke) or the leaking or bursting of a blood vessel (hemorrhagic stroke). In others, there could be a temporary disruption of blood flow to the brain (transient ischemic attack, or TIA).About 85% of strokes are ischemic in nature. Some common risk factors for stroke in the country include hypertension, diabetes, smoking, and dyslipidemia. These are further insufficiently controlled due to low awareness levels about the disease. Another major challenge in this direction is that treatment for stroke is still evolving in our country.”

The acronym FAST can be used to recognize the warning signs of stroke: face drooping, arm weakness, speech difficulty, and time to emergency. The disabilities caused due to a stroke can be temporary or permanent, depending on how long the brain lacks blood flow and which part is affected.
Adding further, Dr Aggarwal, said, “Stroke is an emergency and getting timely help and treatment is extremely important. Hence, it is very important to act fast to identify these patients. Early treatment improves the chances of recovery. While one cannot control factors such as race, gender, and genetic predisposition, it is possible to make certain lifestyle changes which will go a long way in reducing a person’s chances of getting a stroke at a young age.”

Some tips to prevent a stroke include the following.
Lower your blood pressure levels as a high BP is one of the leading causes for a stroke.
Losing weight can help prevent other associated complications.
Indulge in about 30 minutes of physical activity every day.
Quit smoking and drink in moderation if you must.
Keep your blood sugar levels under control.
Reduce stress through activities such as meditation and yoga. 

Ignoring warning signs of stroke may be risky

Ignoring warning signs of stroke may be risky A survey conducted by the American Stroke Association has found that one in three American adults experienced a symptom consistent with a warning or “mini” stroke, but almost none took the recommended action. The survey was conducted as part of the American Heart Association/American Stroke Association’s Together to End Stroke and included 2,040 adults. Thir; of these 35% reported having experienced at least one sign of a warning stroke, called a transient ischemic attack (TIA) or mini stroke, where the symptoms are similar to a stroke but last for few minutes and not beyond 24 hours. Rather than immediately call 911, these individuals were more likely to wait, rest or take medicine. • Sudden, severe headache with no known cause was the most common symptom reported (20%). The second most common was sudden trouble walking, dizziness, loss of balance or coordination (14%). • Those who experienced trouble walking, dizziness, loss of balance or coordination, or numbness or weakness of the face, arm or leg were most likely to call 911 (5%). • About 77% of people surveyed had not heard of a TIA. • Though 55% said they would call 911 first if they suspected themselves or someone else was experiencing symptoms of a TIA, but only 3% of people who reported having experienced a TIA-like symptom did. About 15% of strokes are heralded by a TIA. People who have a TIA are significantly more likely to have a stroke within 90 days. The American Stroke Association recommends calling for emergency help immediately, even if symptoms are relieved. The acronym FAST can be used to recognize the warning signs of stroke. • Face drooping • Arm weakness • Speech difficulty • Time to call 911. Warning signals should not be ignored as “time is life” in medical science. Stroke is an emergency and getting timely help and treatment is extremely important. Early treatment improves the chances of recovery. If a patient presents to the emergency with symptoms of mini stroke, then • Rule out brain hemorrhage as soon as possible • Check glucose and correct high or low sugar. If the blood sugar is over 180 mg/dL start insulin. • Maintain normothermia for at least the first several days after an acute stroke • Obtain emergent brain imaging (with CT or MRI) and other important lab studies, including cardiac monitoring during the first 24 hours after the onset of ischemic stroke • For patients with acute ischemic stroke who are not treated with thrombolytic therapy, treat high blood pressure only if the hypertension is extreme (systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg), or if the patient has another clear indication (active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or pre-eclampsia/eclampsia) • For patients with acute ischemic stroke who will receive thrombolytic therapy, antihypertensive treatment is recommended so that systolic BP is ≤185 mmHg and diastolic BP is ≤110 mmHg • Antithrombotic therapy should be initiated within 48 hours of stroke onset. • Continue statins in patients on statin therapy prior to stroke onset. (Source: AHA/ASA News Release, May 1, 2017) Dr KK Aggarwal National President IMA & HCFI

Heat exhaustion and heat stroke should be differentiated promptly

Heat exhaustion and heat stroke should be differentiated promptly Most parts of the country are experiencing high temperatures. With the ongoing heat wave, cases of heat–related disorders are also bound to increase. Heat cramps, heat exhaustion and heat stroke are the three forms of heat-related disorders that occur with prolonged exposure to heat and differ in their severity. Hence, it is important to differentiate between the three conditions. Clinically, both heat exhaustion and heat stroke may manifest as fever, dehydration and other symptoms such as headache, thirst, malaise, nausea or vomiting, rapid pulse etc. The main difference between heat exhaustion and heat stroke is the presence of sweat in the former and absence in the latter.' Normally, the axillae will always be wet even if a person has severe dehydration. If the axillae are dry and the person has high fever, this invariably means that the person has progressed from heat exhaustion to heat stroke and this should be treated as a medical emergency. In heat exhaustion, the core temperature is between 37°C and 40°C. While in heat stroke, the core temperature is very high, > 400C and needs to be lowered within minutes and not hours. Rapid reduction in body temperature can be accomplished by cool or tepid bathing preferably using damp sponges. Submersion should be avoided so that body heat loss by evaporation can occur. Cooling blankets should also be avoided. The absence of sweating, dry armpit, non-passage of urine for 8 hours or presence of high grade fever in summer seasonare ‘red flags’ and medical attention should be sought immediately. Heat cramps are muscle spasms in the arms, legs, or abdomen that result from loss of large amount of salt and water through exercise. The treatment is replacing fluid and salt orally. Dr KK Aggarwal National President IMA & HCFI

BE FAST: A modified assessment tool to identify stroke

BE FAST: A modified assessment tool to identify stroke ‘Time is brain’. A patient with suspected stroke or ‘brain attack’ should therefore be shifted to hospital at the earliest and given a clot dissolving therapy. Jeffrey L. Saver reported in the journal Stroke that “every minute in which a large vessel ischemic stroke is untreated, the average patient loses 1.9 million neurons, 13.8 billion synapses, and 12 km (7 miles) of axonal fibers. And, each hour in which treatment fails to occur, the brain loses as many neurons as it does in almost 3.6 years of normal aging” (Stroke. 2006;36:263-6). The American Stroke Association recommends the mnemonic FAST to recall the signs of stroke and quickly identify victims of stroke; "F" stands for Face drooping; "A" stands for arm weakness i.e. inability to raise arms high, "S" stands for Speech difficulty – slurring of speech and "T" stands for Time – time to call for emergency medical help. A new research has devised a modified version of this simple prehospital stroke assessment tool, ‘BE FAST’ for early identification of patients with occlusion of large vessel, which was presented at the American Stroke Association’s International Stroke Conference 2017, which concludes in Houston, USA today (AHA News, February 22, 2017). The acronym ‘BE FAST’ evaluates: • Balance/coordination • Eye deviation • Facial weakness • Arm/leg weakness • Slurred speech/sensory deficits • Time of onset Researchers examined 455 ischemic stroke patient charts from July 2014 to June 2015, using information about patients’ symptoms and physical findings. The sensitivity i.e. positively recognizes a large vessel occlusion, for the ‘BE FAST’ score was found to be 83%. Stroke is an emergency and getting timely help and treatment is extremely important. Hence, it is very important to act fast to identify these patients. Early treatment improves the chances of recovery.

10 risk factors associated with 90% risk of stroke globally

10 risk factors associated with 90% risk of stroke globally

Dr K K Aggarwal Researchers from McMaster University, Canada have found that 10 potentially modifiable risk factors are collectively associated with about 90% of strokes, 91·5% for ischemic stroke, 87·1% for intracerebral hemorrhage, worldwide in each major region of the world, among ethnic groups, in men and women, and in all ages. The following 10 risk factors were found to be significantly associated with 90% of the risk of stroke: 1. High blood pressure 2. Smoking 3. Waist-to-hip ratio (abdominal obesity) 4. Diet 5. Physical activity 6. Lipids 7. Diabetes mellitus 8. Alcohol intake 9. Stress and depression 10. Heart disorders Hypertension was more associated with intracerebral hemorrhage than with ischemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischemic stroke. The international case-control INTERSTROKE study investigated global and regional effects of potentially modifiable risk factors associated with acute stroke was conducted in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. The findings of the study are published online 15 July 2016 in The Lancet.

Do not give Aspirin still wrongly given to lower AF stroke risk: IMA

Do not give Aspirin still wrongly given to lower AF stroke risk: IMA

New Delhi, 25th June, 2016: Over one-third of patients with atrial fibrillation (AF), who have a moderate to high risk for stroke are prescribed aspirin to lower this risk instead of oral anticoagulants, even though aspirin has no benefit for the prevention of thromboembolism related to AF. A newly published analysis of data from the American College of Cardiology's PINNACLE registry involving AF patients has found that almost 40% of patients were treated with aspirin alone instead of an oral anticoagulant. After multivariable adjustment, patients prescribed aspirin were found to be also more likely to have other risk factors for cardiovascular disease than those prescribed an oral anticoagulant. “There is good evidence now that aspirin is not an anticoagulant, and that it does not prevent stroke due to AF. Understanding the risks involved of wrong treatment, IMA sent out a circular educating its 2.5 lakh members about how Aspirin should not be given to lower AF stroke risk” said Dr SS Agarwal – National President IMA & Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA & President Heart Care Foundation of India. While the American College of Cardiology/American Heart Association (ACC/AHA) still "give tepid support" to the use of aspirin in patients with a low risk for stroke (CHA2DS2-VASc ≤1), other guidelines, including those from the European Society of Cardiology (ESC) and NICE in the United Kingdom, no longer recommend aspirin for AF-related thromboembolism prevention.

Aspirin still wrongly given to lower AF stroke risk

Aspirin still wrongly given to lower AF stroke risk

Dr SS Agarwal, Dr KK Aggarwal Over one-third of patients with atrial fibrillation (AF), who have a moderate to high risk for stroke are prescribed aspirin to lower this risk instead of oral anticoagulants, even though aspirin has no benefit for the prevention of thromboembolism related to AF. A newly published analysis of data from the American College of Cardiology's PINNACLE registry involving AF patients has found that almost 40% of patients were treated with aspirin alone instead of an oral anticoagulant. After multivariable adjustment, patients prescribed aspirin were found to be also more likely to have other risk factors for cardiovascular disease than those prescribed an oral anticoagulant. There is good evidence now that aspirin is not an anticoagulant, and that it does not prevent stroke due to AF. While the American College of Cardiology/American Heart Association (ACC/AHA) still "give tepid support" to the use of aspirin in patients with a low risk for stroke (CHA2DS2-VASc ≤1), other guidelines, including those from the European Society of Cardiology (ESC) and NICE in the United Kingdom, no longer recommend aspirin for AF-related thromboembolism prevention. Aspirin administration places a patient at significant risk for bleeding, while offering virtually no protection from stroke. “Take two aspirin and call me in the morning” is not an appropriate treatment for a patient with AF at risk for thromboembolism, the clot only thickens. (MedPage Today)