'Vacuum' Device Is a Clot Buster

Feb. 22, 2008 (New Orleans) -- A tiny vacuum-cleaner-like device can help stroke patients when standard clot-busting drugs fail, researchers report.

Called Penumbra, the recently approved device suctions out clots that can cause an ischemic stroke.

The most common type of stroke, ischemic stroke occurs when blood flow to an area of the brain is compromised by a blood clot. This leads to the death of brain cells and brain damage.

Penumbra restored blood flow in 82% of 125 patients studied, says Cameron McDougall, MD, chief of endovascular neurosurgery at the Barrow Neurological Institute in Phoenix.

"There were no serious adverse events associated with the procedure, and nearly 60% of patients were better neurologically by the time they left the hospital," he tells WebMD.

Also, one in four patients had no to minimal disability three months later.

The findings were presented at the American Stroke Association's (ASA) International Stroke Conference.

Penumbra Helps When tPA Fails

About 780,000 Americans suffer a stroke each year and more than 150,000 of them die. Survivors often face serious disability.

For patients who suffer an ischemic stroke, tissue plasminogen activator, or tPA, can mean the difference between permanent brain damage and a return to normal activities. TPA breaks up the clot, restoring blood flow to the brain.

But tPA has to be administered in the first three hours after symptoms strike, and the vast majority of people fail to get to the hospital in time. Plus, it only works in about 40% of patients who get it.

Penumbra could help both these groups of people, McDougall says.

A catheter is inserted through a small puncture in the groin. Under X-ray guidance, it is advanced through the blood vessels until it reaches the closest edge of the blockage. A wire is advanced to dislodge the clot, which is sucked into the catheter.

McDougall says that originally, the system had a plan B -- a clot-grabbing device that doctors could use if the vacuum failed. "But we never really needed it," he says.

Not everyone benefited from the new device. By three months after the procedure, about one in three of the patients had died, many due to bleeding in the brain.

Given the severity of their illness, "this was not an unexpected result," says Philip Gorelick, MD, head of the committee that chose which studies would be presented at the meeting and chairman of neurology at the University of Illinois in Chicago.

They "had ischemic stroke that was pretty severe for a clinical trial," he tells WebMD.

Penumbra isn't the only clot-dislodging device. Doctors can also use a corkscrew-shaped wire called the Merci Retriever to pull out clots.

According to McDougall, the two devices compare "favorably." But the only way to really know is to pit one against the other in a clinical trial, Gorelick says.

The new study was sponsored by Penumbra Inc.

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More Strokes in U.S. Than in Europe

Feb. 22, 2008 (New Orleans) -- Stroke is more prevalent in the United States than in Europe -- and higher rates of obesity, diabetes, and lifetime smoking in the U.S. play a major role, researchers report.

Barriers to care in the U.S. -- chiefly a lack of universal health care coverage and minimal focus on prevention -- also contribute to its higher prevalence of stroke, says study head Mauricio Avendano, PhD, a research fellow in public health at the Erasmus Medical Center in Rotterdam, Netherlands.

The researchers looked at what is known as stroke prevalence -- the number of people who have a disease at any given point in time.

Compared with European men, American men had a 61% higher chance of having had a stroke in their lifetime, Avendano says. U.S. women had almost twice the odds of having had a stroke as European women.

"Most of this gap is among relatively poor Americans who were, in our data, much more likely to have a stroke than poor Europeans, whereas the gap in stroke prevalence is less marked between rich Americans and rich Europeans," Avendano says.

The study was presented at the American Stroke Association's (ASA) International Stroke Conference 2008.

Stroke Deaths Down in U.S.

ASA spokesman Larry Goldstein, MD, a stroke expert at Duke University in Durham, N.C., says looking at stroke prevalence may give a blurred snapshot of what's going on the U.S.

That's because prevalence goes up as the chance of dying of a disease goes down. "If everyone has a disease and everyone survives, then prevalence is 100%," he tells WebMD.

The fact that the U.S. has made great strides in reducing deaths due to stroke -- there's been a 25% drop in recent years -- may play a role in its higher prevalence, Goldstein says.

That said, "there are a lot of data linking lower socioeconomic status and lack of access of care to a variety of ill health effects, including stroke," he says.

African-Americans Have Highest Stroke Odds

The researchers analyzed 2004 data from the U.S. Health and Retirement Survey (HRS); the Survey of Health, Aging and Retirement in Europe (SHARE); and the English Longitudinal Study of Aging (ELSA). These surveys include twice-yearly interviews among people age 50 and older.

Altogether, there were data on 13,667 people in the U.S. and 30,120 individuals in 11 European countries.

Among the findings:

• Overall, women were about 25% less likely to have had a stroke, on average, than men.
• When age was taken into account, stroke was most prevalent in the U.S. and least prevalent in the southern Mediterranean European countries of Spain, Italy and Greece, as well as Switzerland.
• African-Americans had the highest odds of having a stroke of any group studied -- they were nearly three times more likely to have had a stroke in their lifetime than "other Americans," the dubious winner of the second-place prize.
• In the U.S., stroke prevalence is higher in the southern and western states.

Within Europe, "there was a north-south gradient, with the northern countries, especially Denmark and Sweden, having the highest prevalence of stroke," Avendano says.

Avendano says that while rates of lifetime smoking are higher in the U.S. than in Europe, "the proportion of current smokers is lower in the U.S. So going forward we could see a positive effect of that trend."

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Strokes Up in China as Economy Booms

Feb. 29, 2008 -- A new study shows the most common type of stroke increased almost 9% annually over a 20-year period in China as its economy boomed. At the same time, deaths from strokes decreased.

Ischemic strokes, the most common type of stroke, are caused by blood clots.

"The changes in patterns of stroke have raised new challenges and the need to adjust priorities to prevent stroke in China," researcher Dong Zhao says in a news release.

Dong notes that "risk factors have become a new problem and challenge for public health in China."

The study, funded by the Chinese government and the World Health Organization and published in the journal Stroke, looked at nearly 14,600 strokes among people ages 25-74 in seven districts throughout Beijing from 1984 to 2004.

Unhealthy Lifestyle to Blame?

Risk factors for stroke include obesity, elevated cholesterol, diabetes, high blood pressure, and smoking. The researchers write that other studies that approximately cover the same time period show that:

• More and more people became obese or overweight, especially those who live in rural areas.
• From 1983 to 2002, fat and daily cholesterol intake shot up in urban areas and nearly tripled in the countryside.
• Cholesterol levels in the blood increased 24% from 1984 to 1999.
• Diabetes skyrocketed 97% from 1994 to 2002.

Dong says cigarette smoking changed very little during the time of the study.

The study shows that the decrease in fatal strokes is likely due to improved health care such as control of high blood pressure and stroke treatment.

The researchers note that stroke is a top killer in China, estimated to be the "second or third leading cause of death, even with dramatic economic development in recent years."

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Getting Back to Work After a Stroke

March 27, 2008 -- A stroke can have a major impact on every aspect of a person's life, including his or her job. New research shows that only about half of stroke survivors are able to return to work, and continuing disability and depression are major causes.

The weakness, speech, and movement problems that often occur after a stroke can lead to a lengthy disability period for many patients. Often stroke survivors also develop depression and other psychiatric problems. All of these factors can contribute to the decision not to return to work.

To assess the impact of stroke on employment, researchers in Australia and New Zealand looked at 210 previously working patients (average age 55) who had had a first stroke between 2002 and 2003. Researchers assessed patients soon after their stroke, then again at one and six months afterward.

Fifty-three percent of patients were able to return to full-time work within a few months of their stroke, the researchers reported in the journal Stroke. "It can be quite heartening to families and clinicians that more than half of stroke patients go back to work," study researcher Nick Glozier, MD, PhD, associate principal director of The George Institute for International Health in Sydney, Australia, says in a news release. "But physicians should continually assess patients' mood after stroke, because it's an important predictor of whether patients will go back to work."

Depression did have a significant independent impact on work status after a stroke. Forty-five percent of patients who didn't return to work at six months were depressed, compared with 33% of those who did go back to work. Only 30% of those patients with depression following stroke reported receiving treatment for this.

"If family members pick up on someone being depressed after a stroke, ask the physician to assess them and intervene if necessary," Glozier advises. "Post-stroke depression can be successfully treated, and treatment can help the patients, their families, and society."

Other important determinants in whether patients could get back to work were the severity of the stroke and the patients' ability to care for themselves independently. Seventy-one percent of those who were working six months after a stroke were rated "independent" on a scale of self-care abilities called the Barthel Index, compared with only 32% of those who didn't go back to work. Glozier says people who are functioning well after a stroke should consider vocational rehabilitation, which can help them make the transition back into the workforce.

The authors say the next step in research is to look at ways to prevent and manage stroke-related depression to help improve patients' quality of life.

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Preventing Strokes: Stents vs. Surgery

April 9, 2008 -- A less invasive alternative to surgery for clearing neck arteries of plaque proved as effective as surgical treatment for preventing strokes in high-risk patients in a three-year follow-up study.

Carotid artery stenting was compared to open-neck surgery in 260 patients considered less than optimal surgical candidates at high risk for strokes.

Stenting is routinely used to open plaque-clogged coronary arteries, which cause heart attacks. But it is still largely considered an experimental treatment for opening the clogged neck arteries that lead to strokes.

The newly published findings are the first to show long-term outcomes for neck stenting to be comparable to surgery in high-risk patients, University of Michigan interventional cardiologist Hitinder S. Gurm, MD, tells WebMD.

The study appears in the April 10 issue of the New England Journal of Medicine. The research was funded by Johnson & Johnson's Cordis, which makes the stent used in the study.

"This is the first data we have to suggest that these two procedures have similar long-term benefits," Gurm says. "But the findings only apply to high-risk patients. The trials examining lower-risk populations are going on now, and we hope to know more over the next few years."

Stent vs. Surgery

The patients who took part in the study were treated at 29 hospitals around the U.S. All were considered at increased risk for complications with surgery because of advanced age (over 80), co-morbid conditions (heart failure, advanced coronary artery disease, lung disease) or a history of prior neck surgery or radiation. Most also had symptoms associated with carotid artery narrowing.

Roughly half were treated with surgery, known as carotid endarterectomy, which involves opening the blocked carotid artery surgically to manually clear out accumulated plaque.

The other half got stents -- tiny wire mesh tubes threaded into the neck artery from an incision in the arm or groin. A filter designed to capture plaque and other debris freed from the arterial walls during the procedure was also used during stent implantation.

Of the participants available for follow-up, 41 of 143 stent-treated patients and 45 of the 117 patients treated with surgery had suffered a heart attack, a stroke, or had died within three years.

Most of the deaths were from cardiac or other non-stroke-related causes.

Strokes accounted for about a third of the adverse events recorded, but most were not serious enough to be life-threatening.

Follow-up Needed

The findings suggest that outcomes with surgery and stenting are similar among high-risk patients, but that doesn't mean that stenting will always be the best choice for this group, Gurm says. Importantly, this trial did not include a set of patients treated with medications alone.

"The first thing a patient who has a high surgical risk should discuss with their doctor is whether they really need either procedure," he tells WebMD.

If the answer is yes, the next consideration should be the doctor's prior experience with surgery or stenting.

"There are those that do both, but most people working in this field are either good at surgery or good at stenting," he says.

UCLA Medical Center vascular surgeon Wesley S. Moore, MD, tells WebMD that three years of follow-up is not enough to prove that stenting and surgery are equal for the treatment of high-risk patients with carotid artery blockage.

He adds that there is some evidence that neck arteries cleared using stents become clogged again more quickly than those cleared by surgical means.

"This may not show up in three years, but we can't really say if this is the case at four and even five years," he says.

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Wealth Lowers Stroke Risk in Middle Age

April 24, 2008 -- Having more money and assets just prior to retirement may lower your risk of stroke, but those perks may not last very long, according to a new study.

Researchers found greater wealth was linked to a lower risk of stroke among Americans between the ages of 50 and 64.

For example, middle-aged adults with the lowest 10% of wealth had about two times the risk of stroke compared with those in the 75th-89th percentile, which researchers say translates to the wealthy but not super-rich.

But the protective effect of wealth on stroke risk completely disappeared after age 65.

"We expected wealth to be a strong predictor of stroke in the elderly," researcher Mauricio Avendano, PhD, of the Erasmus Medical Center in Rotterdam, Netherlands, says in a news release. "We were surprised to see that it was not associated with stroke beyond age 65."

Wealth: A New Stroke Risk Factor?

Although previous studies have identified lower socioeconomic status as a risk factor for stroke, researchers say this is the first study to look at how factors that affect socioeconomic status, such as education, income, and overall wealth, evolve throughout middle and old age.

In their study, published in Stroke: Journal of the American Heart Association, researchers analyzed data from the Health and Retirement study, which followed a group of nearly 20,000 Americans aged 50 or older for an average of 8.5 years.

During the follow-up period, 1,542 participants had a stroke. The results showed that higher education reduced stroke risk at ages 50 to 64 but not after adjusting for wealth and income.

Both wealth and income were independent risk factors for stroke at ages 50 to 64. But wealth, including the total of all financial and housing assets minus the liabilities, was a much stronger risk factor, with increasing wealth linked to decreasing stroke risk.

"Wealth more comprehensively reflects both lifelong earnings and intergenerational transfers, and increases access to medical care and other material and psychosocial resources," Avendano says.

Beyond age 65, however, neither wealth, income, nor education was significant predictors of stroke risk.

"We confirmed that lower wealth, education, and income are associated with increased stroke up to age 65, and wealth is the strongest predictor of stroke among the factors we looked at," Avendano says. "After age 65, the association of education, income, and wealth with stroke are very weak, and wealth did not clearly predict stroke."

Researchers say selective survival may explain some of these effects: individuals with lower wealth die earlier than their richer counterparts, and those that survive into old age are the healthiest.

"Further research is needed to understand why the effect of wealth, income, and education on stroke is less clear beyond age 65 and the role of selective survival," Avendano says.

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Few Aware of Stroke Warning Symptoms

May 8, 2008 -- Do you think sudden chest pain is a symptom of a stroke? If you answered yes, you're not only wrong, you're not alone.

A telephone survey of more than 71,000 adults in 13 states and Washington, D.C., has revealed that shockingly few people know the warning signs of a stroke. The CDC analyzed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey and found that only 16.4% of persons surveyed correctly recognized all five stroke warning symptoms, knew to call 911, and could identify an incorrect symptom of stroke.

According to the CDC, the five warning symptoms of a stroke are:

• Sudden weakness or numbness of the arms, legs, or face, especially on one side.
• Sudden vision problem in one or both eyes.
• Sudden dizziness, loss of balance or coordination, or difficulty walking.
• Sudden confusion or trouble speaking.
• Sudden severe headache with no known cause.

Promptly recognizing stroke warning symptoms and seeking immediate emergency care can mean the difference between life and death or disability. Patients whose stroke is caused by an interruption of the blood supply to the brain (blood clot) can be treated with clot-busting drugs, but such medicines should be given within three hours of symptom onset. Other type of strokes may require immediate surgery to prevent serious disability or death.

In general, most respondents (92.6%) knew that sudden numbness, especially on one side of the body, was a stroke warning symptom, but considerably fewer (68.8%) were aware that sudden trouble seeing was a warning symptom.

Other survey findings:

• Only 60.4% knew a severe headache with no known cause was a symptom of stroke.
• 86.5% of respondents correctly identified sudden confusion or trouble speaking as a symptom.
• Slightly fewer (83.4%) knew sudden trouble walking, dizziness, or loss of balance meant a stroke might be happening.
• Less than half of those surveyed could identify all five stroke warning symptoms.

However, the BRFSS survey showed that correct answers varied by race, ethnicity, gender, education level, and geographic region. In addition to the District of Columbia, states included in the survey were Alabama, Florida, Iowa, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, Oklahoma, Tennessee, Virginia, and West Virginia.

Minnesota residents appeared to be the most stroke savvy, topping the list of the most informed across several categories. They were more likely to say they'd call 911 if they thought someone was having a heart attack or stroke compared to those in other areas. Mississippi residents ranked lowest on that list, coming in at 77.7%.

Whites, women, and persons with a college degree were more likely to know all five stroke warning symptoms and the importance of calling 911 than blacks, Hispanics, men, and those who had not received a high school diploma.

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