STROKE: The Cutting Edge: 2017 i STROKE THE CUTTING EDGE Copyright © 2017 AHC Media, a Relias Learning company Reproduction, distribution, or translation without express written permission is strictly prohibited. STROKE: The Cutting Edge is published by AHC Media, a Relias Learning company Executive Editor: Leslie G. Coplin AHC Media Editorial Group Manager: Terrey L. Hatcher Senior Accreditations Officer: Lee Landenberger AHC Media, LLC 111 Corning Road, Suite 250 Cary, NC 27518 (800) 688-2421 ISBN: 978-1-941481-36-3 The articles within this publication were previously published in the following AHC Media publications: Clinical Cardiology Alert ED Management Internal Medicine Alert Neurology Alert OB/GYN Clinical Alert ii STROKE: The Cutting Edge: 2017 ACCREDITATION INFORMATION ACCREDITATION STATEMENT Relias Learning is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Relias Learning, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Provider approved by the California Board of Registered Nursing, Provider #CEP13791, for 8 Contact Hours. CREDIT DESIGNATION Relias Learning designates this enduring material for a maximum of 8.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity has been approved for 8.0 nursing contact hours using a 60-minute contact hour. ACTIVITY OBJECTIVES After reading STROKE: The Cutting Edge: 2017, the participant will be able to: 1. Discuss current scientific research and data regarding the diagnosis and treatment of stroke; 2. Discuss the pathogenesis and treatment of stroke; 3. Explain the basic science of brain function as it applies to stroke; 4. Cite new information regarding new drugs for stroke and new uses for traditional drugs; 5. Identify nonclinical issues of importance for health care providers who treat stroke patients. 6. Discuss advances in neurointerventional treatment. Physicians and nurses participate in this CME/CE activity by reading the articles, using the provided references for further research, and studying the relevant questions at the end of the book. Participants will then be directed to a website, where they will complete an online assessment to show what they’ve learned. They must score 100 on the assessment in order to complete the activity, but they are allowed to answer the questions multiple times if needed. After they have successfully completed the assessment, they will be directed to an online activity evaluation form. Once that is submitted, they will receive their credit letter. TARGET AUDIENCE This activity is intended for for neurologists, emergency medicine physicians and nurses, Joint Commission-certified stroke center personnel, psychiatrists, and ENTs. EXPIRATION DATE March 31, 2020 PHYSICIAN EDITOR Matthew Fink, MD Louis and Gertrude Feil Professor in Clinical Neurology and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital PEER REVIEWER Amre M. Nouh, MD Director of the Stroke Center, Hartford Hospital; Assistant Professor and Associate Residency Program Director, Department of Neurology, University of Connecticut NURSE PLANNER Donna Avanecean, MS, RN, FNP-C, CNRN, DNP-c Movement Disorders/DBS Program, Department of Neurosurgery, Yale University FINANCIAL DISCLOSURES In order to reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Fink, Dr. Nouh, and Dr. Avanecean report no financial relationships relevant to this field of study. Editorial and Production: Ms. Coplin, Ms. Hatcher, and Mr. Landenberger report no financial relationships relevant to this field of study. Authors: Financial disclosure information for authors can be found at the beginning of their respective articles. This publication does not receive commercial support. STROKE: The Cutting Edge: 2017 iii TABLE OF CONTENTS Module 1: Prevention and Risk Factor Reduction (1 hour) Preventing 90% of Stroke with 10 Modifiable Risk Factors ................................................. 1 A New Risk Score for Stroke in Atrial Fibrillation ................................................................. 2 Effects of Aspirin on Risk of Early Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke .......................................................... 4 Headaches in the Elderly: A Non-specific Marker for Stroke Risk ....................................... 6 Migraine with Aura and Systemic Right-to-Left Shunt: Risk for Stroke? ............................. 8 Contraception, Migraines, and Stroke ............................................................................... 10 Arterial Ischemic Stroke Prevention and Risk Factor Management ................................... 13 Proceedings from the 2017 International Stroke Conference ........................................... 31 Stroke Alert: A Review of Current Stroke Literature.......................................................... 33 CME Test: Module 1 ........................................................................................................... 35 Module 2: Prehospital and Emergency Care (1 hour) Functional Outcomes in Acute Ischemic Stroke Patients Receiving Prehospital Thrombolysis in Mobile Stroke Units ............................................................... 38 New Mobile Stroke Unit Programs Aim to Improve Outcomes ........................................ 40 Proceedings from the 2017 International Stroke Conference ........................................... 44 Stroke Alert: A Review of Current Stroke Literature.......................................................... 45 CME Test: Module 2 ........................................................................................................... 46 Module 3: Neuroimaging for Stroke (1 hour) Blood-brain Barrier Breakdown in RCVS ............................................................................ 48 Proceedings from the 2017 International Stroke Conference ........................................... 50 CME Test: Module 3 ........................................................................................................... 51 Module 4: Large Vessel Ischemic Stroke Treatment (1 hour) Intravenous Glyburide to Reduce Brain Swelling in Large Hemispheric Infarction ........... 53 Proceedings from the 2017 International Stroke Conference ........................................... 55 Stroke Alert: A Review of Current Stroke Literature.......................................................... 57 CME Test: Module 4 ........................................................................................................... 59 Module 5: Acute Endovascular Treatment (1 hour) Proceedings from the 2017 International Stroke Conference ........................................... 60 A Review of Current Stroke Literature ............................................................................... 62 CME Test: Module 5 ........................................................................................................... 63 iv STROKE: The Cutting Edge: 2017 TABLE OF CONTENTS Module 6: In-hospital Management of Stroke (1 hour) RESCUEicp: A Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension ............................................................................. 65 Proceedings from the 2017 International Stroke Conference ........................................... 67 A Review of Current Stroke Literature ............................................................................... 69 CME Test: Module 6 ........................................................................................................... 71 Module 7: Aneurysms and AVMs (1 hour) Proceedings from the 2017 International Stroke Conference ........................................... 73 A Review of Current Stroke Literature ............................................................................... 74 CME Test: Module 7 ........................................................................................................... 75 Module 8: Stroke Rehabilitation (1 hour) Stroke: Rehabilitation and Recovery .................................................................................. 77 Proceedings from the 2017 International Stroke Conference ........................................... 87 CME Test: Module 8 .......................................................................................................... 88. STROKE: The Cutting Edge | Module 1: Prevention and Risk Factor Reduction v STROKE: THE CUTTING EDGE Module 1: Prevention and Risk Factor Reduction vi Module 1: Prevention and Risk Factor Reduction | STROKE: The Cutting Edge ABSTRACT & COMMENTARY Preventing 90% of Stroke with 10 Modifiable Risk Factors By Joseph E. Scherger, MD, MPH, Vice President, Primary Care, Eisenhower Medical Center; Clinical Professor, Keck School of Medicine, University of Southern California. Dr. Scherger reports no financial relationships relevant to this field of study. SYNOPSIS: Controlling 10 modifiable risk factors would prevent 90.7% of strokes, according to results from a 32-country study. SOURCE: O’Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of modifiable risk factors associated with acute stroke in 32 countries.