HomeStrokeVol. 50, No. 2Stroke: Highlights of Selected Articles Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBStroke: Highlights of Selected Articles Originally published28 Jan 2019https://doi.org/10.1161/STROKEAHA.118.024679Stroke. 2019;50:229is related toSafety of Carotid Revascularization in Patients With a History of Coronary Heart DiseaseDo Clinicians Overestimate the Severity of Intracerebral Hemorrhage?Effect of Glyceryl Trinitrate on Hemodynamics in Acute StrokeDo Clinicians Overestimate the Severity of Intracerebral Hemorrhage?In this case-control study, Tilling et al explore the differences in clinicians’ estimation of volume and clinical severity between acute intracerebral hemorrhage (ICH) and ischemic stroke (IS). The premise of the study is the overall negative perception that surrounds ICH, which is often considered to carry a grim prognosis. In turn, this has been shown to affect physician attitudes and management approach, especially with regards to end-of-life decisions. The authors used 33-volume–matched acute ICH and IS cases and asked blinded raters to provide lesion volume and clinical severity estimations and outcome predictions. The average lesion volume was ≈25 mL in both groups. ICH volume was overestimated by an average of 8 mL, whereas IS volume was underestimated by an average of 8 mL. Although unaware of the presenting neurological deficit, raters deemed 41% of ICH cases as severe or very severe, contrary to 17% of IS cases. Unsurprisingly, 47% of ICH cases were assigned a favorable 30-day prognosis compared with 74% of IS cases, a difference that remained significant even after adjusting for estimated lesion volume (odds ratio for ICH, 0.47; 95% CI, 0.28–0.80; P=0.005). It is notable, however, that ICH cases indeed had significantly more severe neurological deficit, with National Institutes of Health Stroke Scale score of 17 versus 9, whereas the actual outcome of the included patients is unknown and therefore the blinded prediction might, in fact, be realistic. Despite its limitations, the study eloquently describes current perceptions of ICH and highlights the need for clinicians to be aware of potential bias that might affect their clinical decision making. See p 344.Safety of Carotid Revascularization in Patients With a History of Coronary Heart DiseaseIn this pooled analysis of 4 randomized clinical trials of carotid artery stenting (CAS) versus carotid endarterectomy (CEA), Volkers et al examined differences in periprocedural risk of stroke or death according to comorbid coronary heart disease (CHD) status and whether age further modifies the effect. The authors’ intention was to further refine prior results that have suggested an age-treatment interaction in favor of CEA for patients >70 years. In the subgroup of patients without CHD, the overall rate of periprocedural complications in CAS versus CEA was 6.9% versus 3.6% with hazard ratio, 1.93 (1.40–2.65). The interaction between age and treatment was significant (P=0.008) and the age-stratified CAS to CEA hazard ratio was 3.62 (1.80–7.29) in those >70 years. In the subgroup of patients with CHD, although the overall rate of complications was higher in those receiving CAS (8.3% versus 4.6%), the CIs of the hazard ratio were wide: 1.96 (0.67–5.73). Although the CAS to CEA hazard ratio was in favor of CEA in those ≥75 years (2.78 [1.32–5.85]), there was no significant interaction of treatment by age in that subgroup (P=0.26). Last, there was no significant 3-way interaction: P value (treatment×age×history of CHD) =0.09. This pooled analysis findings should be interpreted with some caution as the definitions of CHD varied across studies, and important secondary end points such as myocardial infarction could not be examined. Nonetheless, the current analysis highlights that although the age by treatment effect in patients without CHD seems consistently in favor of CEA in those >70 years, the subgroup of patients with CHD merits further study. See p 413.Effect of Glyceryl Trinitrate on Hemodynamics in Acute Stroke: Data From the ENOS TrialIn this prespecified secondary analysis of the Efficacy of Nitric Oxide in Stroke trial, Appleton et al assessed the effects of glyceryl trinitrate on hemodynamic parameters including systolic blood pressure (BP) and diastolic BP, mean arterial pressure, heart rate (HR), and their mathematical derivatives including variability and the rate pressure product=systolic BP×HR. They also examined the association of these hemodynamic parameters with long-term functional and cognitive outcomes. Glyceryl trinitrate administration resulted in decreased systolic BP and diastolic BP by 7 and 3.6 mm Hg, respectively on day 1 of treatment, an effect that was dampened on day 7 (2.9/2.1 mm Hg) indicative of tachyphylaxis expected with the medication. Although the HR was marginally increased, the rate pressure product was decreased owing to a more significant lowering of the systolic BP. Higher baseline BP parameters, HR, and rate pressure product were all associated with unfavorable 90-day outcome. However, this effect was attenuated after excluding patients with diagnosis of atrial fibrillation, remaining significant only for HR and rate pressure product and their variability. Conversely, between-visit variability (day 1–day 7) in all BP parameters remained inversely associated with functional and cognitive performance, even when excluding patients with atrial fibrillation. Although the results of the study are not immediately generalizable, they suggest that besides satisfactory target BP control, the manner of achieving it might be important too. Whether BP variability is indeed, a modifiable treatment target in BP control remains to be tested in a randomized controlled setting. See p 405. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesSafety of Carotid Revascularization in Patients With a History of Coronary Heart DiseaseEline J. Volkers, et al. Stroke. 2019;50:413-418Do Clinicians Overestimate the Severity of Intracerebral Hemorrhage?Elliot J. Tilling, et al. Stroke. 2019;50:344-348Effect of Glyceryl Trinitrate on Hemodynamics in Acute StrokeJason P. Appleton, et al. Stroke. 2019;50:405-412 February 2019Vol 50, Issue 2 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.118.024679PMID: 30802183 Originally publishedJanuary 28, 2019 PDF download Advertisement SubjectsIntracranial HemorrhageIschemic Stroke