Domino JS, Baek J, Meurer WJ, et al. Emerging temporal trends in tissue plasminogen activator use. Neurology. 2016;87(21):2184-2191. doi:10.1212/WNL.0000000000003349.
Mexican Americans (MA) have an increased stroke burden when compared to their non-Hispanic white (NHW) counterparts, including increased stroke incidence and poorer neurologic, functional, and cognitive outcomes.
The authors explored the temporal trends in tissue plasminogen activator (tPA) administration for acute ischemic stroke (AIS) in a biethnic community without an academic medical center. Cases of AIS were identified from 7 hospitals in the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based surveillance study from 2000-2012. There were 5,277 AIS cases identified from 4,589 individuals. tPA use was steady at 2% and began increasing in 2006, reaching 11% in subsequent years. Although ethnicity did not modify the temporal trend, Mexican Americans were less likely to receive tPA than non- Hispanic whites due to emerging ethnic differences in later years. The results suggest that increases in tPA use were greater in higher severity patients compared to lower severity patients, and a gap between MAs and NHWs in tPA administration may be emerging. The authors conclude that as physician experience with tPA and its use in community settings increases, follow-up studies should continue to explore temporal trends in tPA as well as identify possible strategies to improve tPA use in MAs.
2 Figures (graphs), 2 Tables
Goldstein LB. IV tPA for acute ischemic stroke. Neurology. 2016;87(21):2178-2179. doi:10.1212/WNL.0000000000003366.
In this editorial on the Domino et al. paper, Dr. Goldstein notes that there were considerable barriers that slowed IV tPA adoption after it was approved by the FDA in 1996. Eight years after FDA approval, IV tPA was being given to only 1%–2% of stroke patients. Transformation of the structure and organization of stroke care delivery were needed, and in part led …
Akoudad S, Wolters FJ, Viswanathan A, et al. Association of Cerebral Microbleeds With Cognitive Decline and Dementia. JAMA Neurol. 2016;73(8):934. doi:10.1001/jamaneurol.2016.1017.
The authors wanted to determine whether microbleed count and location were associated with an increased risk for cognitive impairment and dementia. They evaluated a prospective population-based study set in the general community, and assessed the presence, number, and location of microbleeds at baseline (August 2005 to December 2011) on brain MRI in 4841 participants 45 years or older. Trained research physicians, blinded to clinical data, reviewed the MRs. Cerebral microbleeds were defined as small, round to ovoid areas of focal signal loss on T2- weighted images. Participants underwent neuropsychological testing at 2 time points approximately 6 years apart, and were also followed up for incident dementia. 3257 participants underwent baseline and follow-up cognitive testing. Microbleed prevalence was 15.3%. The presence of more than 4 microbleeds was associated with cognitive decline. The presence of microbleeds was associated with an increased risk for dementia after adjustment for age, sex, and educational level, including Alzheimer dementia.
The strengths of this study, according to the authors, is the longitudinal population based design with a large sample size, the use of an extensive neuropsychological test battery, and the virtually complete screening for incident dementia. Limitations include multiple statistical tests, increasing the chance of type I errors. Second, selection bias may have influenced the results, because healthier people without subjective memory complaints were more likely to receive follow-up cognitive testing. Most importantly perhaps, the microbleed number may not reflect the true biological number because microbleed detection strongly depends on technical imaging methods used. T2W images were used, and as we know, SWI is far superior for the detection of these lesions.
Manoso MW, Moore TA, Agel J, Bellabarba C, Bransford RJ. Floating