HomeStrokeVol. 52, No. 12December 2021 Stroke Highlights Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessResearch ArticlePDF/EPUBDecember 2021 Stroke Highlights Nicole B. Sur, MD Nicole B. SurNicole B. Sur https://orcid.org/0000-0002-3541-3599 Search for more papers by this author Originally published22 Nov 2021https://doi.org/10.1161/STROKEAHA.121.036716Stroke. 2021;52:3749is related toSonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: An Individual Patient Data Meta-AnalysisBaseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 TrialWithdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired ConsciousnessSonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: an Individual Patient Data Meta-analysisSonothrombolysis involves the use of transcranial pulse-wave ultrasound to achieve recanalization in patients with a large vessel occlusion. Preliminary evidence has shown that this technique, when compared with alteplase, may be safe and effective for the treatment of anterior circulation large vessel occlusions. In this meta-analysis and systematic review, investigators pooled individual patient data from 6 randomized clinical trials to further determine the safety and efficacy of sonothrombolysis compared with thrombolysis with alteplase alone in patients with large vessel occlusion. A total of 272 patients with acute ischemic stroke were included in the analysis, with an average age of 68 years, 58% male and high stroke severity. After adjusting for potential confounders, sonothrombolysis was associated with 2-fold higher odds of complete recanalization and nearly 2-fold higher odds of any recanalization compared with intravenous alteplase. In subgroup analysis, younger age and presenting with normal to mildly high blood pressure was associated with higher odds of complete recanalization with sonothrombolysis. Interestingly, there was no difference in clinical or functional outcomes between the 2 groups in the early poststroke period or at 3 months. Sonothrombolysis was associated with numerically higher rate of symptomatic intracranial hemorrhage; however, there was no statistically significant difference compared with the alteplase group. Although these preliminary results are promising in terms of higher recanalization rates with sonothrombolysis, the lack of improved clinical outcomes requires further investigation. See p 3786.Baseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 TrialCognitive impairment has long been associated with stroke; however, whether cognitive impairment develops in patients with asymptomatic carotid stenosis in individuals without stroke has not been formally investigated in a large clinical trial. In this analysis of the first 1000 consecutive patients in CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial), patients underwent neurocognitive batteries to identify baseline cognitive function before receiving the study intervention. Cognitive function for patients in CREST-2 (n=786) were compared with similar patients from a different registry characteristic of the general population and without carotid stenosis. Overall, patients with severe asymptomatic carotid stenosis had lower performance on neurocognitive assessments compared with the control group, even after adjusting for demographics and vascular risk factors associated with cognitive impairment. Overall lower performance was driven mostly by poor performance on the Word List Delay, which reflected impaired memory (versus impaired learning and executive function tested using other batteries). Notably, there was no difference in performance in patients with left versus right-sided stenosis. Proposed mechanisms for the development of cognitive impairment in this setting include chronic cerebral hypoperfusion and impaired vasomotor reactivity. Given the longitudinal study design with follow-up cognitive testing, further insight on the progression of cognitive impairment will be ascertained at the completion of CREST-2. See p 3855.Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired ConsciousnessIntracerebral hemorrhage (ICH) is associated with high mortality and significant disability in survivors. Among other factors, impaired level of consciousness (LOC) at presentation may influence the decision to withdraw life sustaining treatment in these patients. In this study of patients with ICH, investigators evaluated the effect of impaired consciousness on withdrawal of life sustaining treatment and mortality after ICH using data from over 37 600 cases in the Florida Stroke Registry. In the overall study cohort, 33% had impaired LOC and admission and the rate of in-hospital mortality was 18%. Patients with impaired LOC on admission were more likely to be women of older age, with lower Glasgow Coma Scale scores and higher ICH scores. In-hospital mortality and withdrawal of life-sustaining treatment was significantly higher in patients with impaired LOC, 32% and 41%, respectively. Of those in which withdrawal of life sustaining treatment was pursued, the decision was made early, on day 0 or 1 of admission, in about half. After multivariable adjustment, impaired LOC was independently associated with in-hospital mortality. This effect was significantly mediated by the withdrawal of life-sustaining treatment overall, and in the early period (day 0–1). Moreover, 11% of patients with impaired LOC on admission were independent at hospital discharge, and 26% were discharged home or to a rehabilitation facility. This study highlights the effect of LOC and withdrawal of life-sustaining treatment on mortality after ICH and raises the question of whether long-term outcomes and mortality would differ if withdrawal of life-sustaining treatment were avoided and aggressive management pursued in the early post-ICH period. See p 3891. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesSonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: An Individual Patient Data Meta-AnalysisGeorgios Tsivgoulis, et al. Stroke. 2021;52:3786-3795Baseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 TrialRonald M. Lazar, et al. Stroke. 2021;52:3855-3863Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired ConsciousnessAyham Alkhachroum, et al. Stroke. 2021;52:3891-3898 December 2021Vol 52, Issue 12Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.121.036716 Originally publishedNovember 22, 2021 PDF download Advertisement