Stroke
STROKE: HIGHLIGHTS OF SELECTED ARTICLES
October 2023 Stroke Highlights
Nicole B. Sur, MD
EARLY RECANALIZATION AMONG PATIENTS
UNDERGOING BRIDGING THERAPY WITH
TENECTEPLASE OR ALTEPLASE
In eligible patients presenting with acute large vessel occlusion stroke,
intravenous thrombolysis followed by mechanical thrombectomy is the
recommended treatment to achieve recanalization and ultimately improve
outcomes. Both alteplase and tenecteplase are options for thrombolysis
in acute ischemic stroke, the main difference being that tenecteplase is
more fibrin-specific than alteplase and can be administered as a 1-time
bolus. In this retrospective study from registry-based data, investigators
sought to compare the occurrence of early recanalization (ER) between
alteplase and tenecteplase in acute large vessel occlusion stroke
patients who received thrombolysis and mechanical thrombectomy. ER
was defined as modified Thrombolysis in Cerebral Infarction score 2b-3
on angiography before mechanical thrombectomy or on noninvasive ves-
sel imaging in patients with early neurological improvement. Of 1865
patients included, nearly 20% achieved ER with a nonsignificant higher
rate of recanalization in tenecteplase-treated (19.8%) versus alteplase-
treated (18.5%) patients. There was no significant difference in ER with
Downloaded from http://ahajournals.org by on February 12, 2024
alteplase versus tenecteplase with respect to time from thrombolysis
administration to ER evaluation. Moreover, the occlusion site did not have
a significant effect on ER with alteplase versus tenecteplase. However, in
a subgroup of 1445 patients with susceptibility vessel sign on magnetic
resonance imaging, the probability of ER was nearly 2.5-fold higher in
tenecteplase-treated patients with large clots (susceptibility vessel sign
length ≥10 mm: odds ratio, 2.43 [95% CI, 1.02–5.8]; P=0.04). Although
the benefit of combined therapy with thrombolysis and mechanical
thrombectomy has been recently under debate, these recent studies
have primarily used alteplase for thrombolysis. The present study high-
lights 1 potential advantage of tenecteplase over alteplase in achieving
early recanalization in patients with large vessel occlusion stroke with a
large clot burden. Whether the higher rate of ER translated into improved
outcomes in this patient population was not assessed. See p 2491.
BIOMARKER, IMAGING, AND CLINICAL
FACTORS ASSOCIATED WITH OVERT AND
COVERT STROKE IN PATIENTS WITH ATRIAL
FIBRILLATION
Atrial fibrillation is a significant cause of ischemic stroke and can contrib-
ute to both clinical and silent infarcts. In this prospective cohort study of
patients with atrial fibrillation across 14 sites in Switzerland, investigators
sought to identify clinical, imaging, and biomarker determinants of both
overt and covert brain infarcts over a 2-year follow-up period. Of 1232
patients with atrial fibrillation, the mean age was 71 years, 26% were
women, the mean CHA2DS2-VASc score was 3, and nearly 90% were on
Correspondence to: Nicole B. Sur, MD, Department of Neurology, Stroke Division, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 1358, Miami,
FL 33136. Email nbsur@med.miami.edu
© 2023 American Heart Association, Inc.
Stroke is available at www.ahajournals.org/journal/str
Stroke. 2023;54:2481. DOI: 10.1161/STROKEAHA.123.044954
Section Editor: Nicole B. Sur, MD
oral anticoagulation. After 2 years of follow-up, overt and covert infarcts
occurred in 6.3% of the cohort, of which 76% were covert infarcts.
Patients with overt and covert infarcts were older, and had more vascu-
lar disease, higher CHA2DS2-VASc scores, more white matter lesions,
and more cerebral microbleeds on brain imaging. Interestingly, there was
no significant difference in oral anticoagulation use between patients
with new infarcts on follow-up imaging and those without. In multivari-
able analysis, determinants of new infarct on follow-up brain imaging in
patients with atrial fibrillation included larger white matter lesion volume
and higher levels of N-terminal-pro-brain natriuretic peptide, interleu-
kin-6, creatinine, and growth differentiation factor-15 at baseline. The
study model incorporating clinical factors, biomarkers, and imaging char-
acteristics predicted subsequent stroke more accurately compared with
the CHA2DS2-VASc score. This study highlights the frequency of overt
and covert brain infarcts in patients with atrial fibrillation despite being on
anticoagulation and pinpoints potential underlying mechanisms of new
infarcts, such as small vessel disease and inflammation. See p 2542.
A VIRTUAL MULTIDISCIPLINARY STROKE
CARE CLINIC FOR COMMUNITY-DWELLING
STROKE SURVIVORS: A RANDOMIZED
CONTROLLED TRIAL
After a stroke, the transition from receiving in-hospital acute care to
integrating back into the community can be challenging to navigate for
patients. Poststroke outpatient care is often fragmented and divided
between multiple providers within complex health systems. Telehealth
strategies may be an effective approach to provide multidisciplinary
guidance and poststroke care during this transition period. In this ran-
domized trial across 10 sites in Hong Kong, investigators compared the
effect of a virtual multidisciplinary stroke care clinic for stroke survivors
versus usual care on self-efficacy, self-management behaviors, social
participation, and depression. The intervention included monthly tele-
phone calls from clinic staff, monthly virtual visits with a stroke nurse,
unlimited access to a repository of poststroke educational videos on a
tablet, and a home BP monitoring device. Among 355 study participants,
the mean age was 62 years, 61% were male, 90% had an ischemic
stroke, and ≈83% had mild stroke severity with National Institutes of
Health Stroke Scale score of 0 to 4. At baseline evaluation, participants
in the control group scored higher in all outcomes compared with the
intervention group. However, after 6 months of follow-up, participants
receiving the intervention had a significant increase in self-efficacy and
social participation, similar self-management behaviors, and a significant
reduction in depression compared with the usual care group. This study
highlights the utility of a multidisciplinary virtual telehealth approach to
providing poststroke care and guidance to promote stroke survivor self-
efficacy, social participation, and mood. Whether or not this type of care
model also improves functional outcomes and vascular risk factor con-
trol should be further studied. See p 2482.
October 2023   2481