Name: Burton J. Tabaac, MD Hometown: Philadelphia, PA Current Position: Comprehensive Stroke Director, Renown Health, and Clinical Assistant Professor of Neurology at the University of Nevada Reno
Q: What made you interested in a career in stroke?
A: The acuity and pace of emergent stroke care is unmatched in
the field of medicine. In staying current with clinical trials, and by
following updates to AHA/ASA guidelines, vascular and interventional
neurologists can deliver the most forefront and up-to-date evidence-based
medicine as it pertains to management, treatment, prevention, and
rehabilitation. I share in the passion and dedication to this field, supported
by a vast, dedicated, and engaged community of providers.
Cerebral microbleeds (CMB) have
long presented a clinical challenge in the treatment of acute ischemic stroke.
Patients with a high burden of CBMs are at a higher risk of intraparenchymal hemorrhage;
however, thoroughly evaluating this burden in each treatment-eligible patient
is time-intensive and can delay otherwise life-saving therapy. The authors
in this article, led by Dr. Ludwig Schlemm, MD, of Berlin,
dove into this dilemma and evaluated risk/benefit profiles of treatment with
intravenous thrombolysis (IVT) in patients with both high (> 10) and
low (<10) CMB burden presenting with acute ischemic stroke. Their attention
was mainly on outcomes in these patients.
The authors used existing data from recent meta-analyses and prospective cohort studies in their statistical analysis. In total, they used data from seven studies. The primary outcome measure was the effect of IVT in patients with high CMB burden and low CMB burden. This was measured using a weighted modified Rankin Score (mRS). In a complicated, yet thorough, 13-step algorithm, results were divided into multiple categories and compared against several pathways. This breakdown is nicely depicted in Figure 1 of the article. Briefly, the authors used estimated 90-day mRS of patients with acute ischemic stroke and presumed average CMB burden who did not receive IVT and those who did. They also included treatment delay as a factor in this model. Then, they analyzed the mRS outcomes of patients who received IVT with high CMB burden and low CMB burden. They further compared the outcomes of patients with both high and low CMB burden who did not receive IVT.
The authors have evaluated
randomized control trials (RCT) and meta-analysis of observational studies
(real-world studies) to compare the effects of non-vitamin K antagonist oral
anticoagulation (NOACs) with warfarin in atrial fibrillation (AF) in the Asian
population. The incidence of AF and complications associated with it are higher
in the Asian population. Four worldwide RCT studies (1-4) compared NOACs with
warfarin. NOACs demonstrated noninferiority in efficacy and reasonable safety.
Specifically, in the Asian population, Wang et al. (5) have demonstrated that
standard NOACs are safer and more effective in Asians. When a lower dose of
NOACs was used in the Asian population, it still showed similar efficacy and
safety. However, the Asian Pacific Heart Rhythm Society still recommends a
standard dose of NOACs for the Asian population. Nevertheless, real-world
efficacy and safety of NOACs in the Asian population is still unclear.
A conversation with Christopher
D. Anderson, MD, MMSC, Assistant Professor of Neurology, Harvard Medical
School, Director or Acute Stroke Services at Massachusetts General Hospital,
Faculty in the Center for Genomic Medicine and Associate Member at the Broad
Institute.
Interviewed by Rachel
Forman, MD, vascular neurology fellow, Massachusetts General Hospital.
Dr. Forman: First of
all, thank you for taking the time to sit down with me and discuss this
important topic. How did this article come to fruition?
Dr. Anderson: This feature is part
of a larger set of articles on cerebral small vessel disease (SVD) that was
submitted as a group, and the genetics of SVD is a specific consideration that
sheds a lot of light on the pathogenesis of the disease. I think it merited its
own exploration as part of this issue.
Dr. Forman: Can you
expand on the categorization of SVD into arteriosclerosis and amyloidosis?
Dr.
Anderson:
As it stands, these days SVD is subcategorized into amyloid-related and
hypertensive or SVD-related. You can think of SVD as an arteriolar process that
arises from the perforating arteries of the deep structures and is categorized
by lipohyalinosis and
sometimes perivascular necrosis. This is really pathologically distinct from
the amyloid-related disease, which tends to be on the other side of the brain
out in the cortical surface and the sub-cortical structures and is
characterized by the classic apple green birefringent amyloid-related disease
that results in this arteriopathy. This can co-exist often with SVD and certainly
seems to be accelerated by the concurrent presence of SVD, but genetically at
least, has a relatively distinct set of risk factors.
Double antiplatelet therapy (DAT)
with Clopidogrel plus Aspirin for TIA and minor ischemic stroke has been widely
supported by several clinical trials, allowing its indication in clinical
practice guidelines. However, differences in DAT employment duration between
studies may increase bleeding risk by canceling the benefit for ischemic events
recurrence.
To clarify the optimal DAT duration
after TIA or minor ischemic stroke, the authors from the CHANCE and POINT trials
performed a pooled analysis of both randomized clinical trials. Primary
efficacy outcome was defined as a major ischemic event (ischemic stroke,
myocardial infarction or death from ischemic vascular causes), and primary
safety outcome was major hemorrhage.
Several studies in recent years have linked the type
of stent used during carotid artery stenting (CAS) to the early recurrence of
stroke in the early days (peri-procedural period). However, there are currently
no data on the relationship between the type of device and the incidence of
stroke and restenosis of the stent in the long term.
This study analyzes the restenosis rate and
incidence of new strokes among patients treated with CAS using open-cell stent
versus closed-cell stent during follow-up, at least 4 years.
Name: Lin Kooi Ong, PhD (Medical Biochemistry) Hometown: Bandar Sunway, Selangor, Malaysia Current Position: Lecturer, Monash University Malaysia; Conjoint Fellow, The University of Newcastle
Q: What made you interested in a career in stroke?
A: I am fascinated about the brain, and I also want to
contribute to people’s lives. I have family members and friends who suffer from
stroke and neurodegenerative disorders. I feel that this is a rewarding career
to investigate how the brain works and how to fix it when it fails.
An interview with Prof. Adnan Siddiqui, MD, PhD,
Professor of Neurosurgery and Radiology, University at Buffalo, about
aspiration thrombectomy versus stent retriever thrombectomy as a first-line
approach for large vessel occlusion strokes.
Interviewed by Dr. Robert Regenhardt, MD, PhD,
Fellow, Massachusetts General Hospital.
Dr. Regenhardt: The endovascular thrombectomy (EVT) trials from the last few years have revolutionized the approach to the treatment of acute stroke from large vessel occlusion (LVO). For most patients enrolled in these trials, stent retriever devices were used for EVT. Indeed, the current stroke guidelines specifically recommend the use of stent retrievers for EVT to treat eligible patients. Therefore, the robust, randomized COMPASS trial may lead to practice changes at many institutions, encouraging interventionalists to perform a direct aspiration first pass technique (ADAPT). Would you mind describing your approach and experience with ADAPT?
Prof. Siddiqui:
At Buffalo, we were some of the original stenting for stroke trialists. Dr. [J]
Mocco was part of that group, and he took that with him after he completed his
fellowship at Buffalo. We realized the value of putting a stent across a clot,
like cardiologists do for STEMIs. However, when you drop a stent into someone,
you need to put them on aspirin and Plavix. And, unlike in the heart, most of
the time there is no underlying plaque. The lesion causing the occlusion often
is an embolus that traveled from somewhere else to the brain. As part of that
original stenting for stroke trial, towards the end, we were using a stent
called Enterprise. Enterprise came in a long size and you could actually
partially deploy it and drag it back. Lo and behold, we would retrieve the
stent and out came the clot. And so that was the genesis of the whole stent
retriever concept, and that caught on like wildfire.
Name: Richard Jackson, MD Hometown: Radford , VA Current Position: Glens Falls Hospital Stroke Director
Q: What made you interested in a career in stroke?
A: My father was a general neurologist who believed that a generalist
could treat anyone with the right resources and knowledge. He even starting the
tPA program in my hometown. I, too, became a generalist, but I realized after three
years that with the rapidly changing treatments and a large need in most
communities, my current level of knowledge would not be enough in the near
future.
Q: What has been your career path into this field?
A: I started out as a generalist and created programs in Botox and
confusion locally, but starting a primary stroke center showed me that to treat
people on that size scale, specialized training would be required. The need,
coupled with a previous interest in vascular neurology and neuroimaging, helped
shape the decision to return to fellowship.
The
benefit of mechanical thrombectomy (MT) compared to IV thrombolysis (tPA) for
the treatment of an acute posterior cerebral artery (PCA) occlusion is
uncertain. Patients with a PCA occlusion can have a low NIH stroke scale (NIHSS),
a population that is underrepresented in mechanical thrombectomy trials. The
PCA territory provides vascularization to the thalamus, the hub of cerebral
connections not only for motor and sensory pathways, but also for cognition.
Impaired cognition is not represented on the NIHSS, which further
underestimates the deficits of a PCA occlusion. The authors of “Thrombectomy
and Thrombolysis of Isolated Posterior Cerebral Artery Occlusion” sought to
understand the impact of revascularization with MT, tPA, or conservative
treatment and assessed the outcomes of visual field deficit, cognitive
impairment, and disability.
This
retrospective observational study included all acute stroke patients with
radiographic evidence of a P1, P2, or fetal PCA occlusion. Analysis was
separated into three treatment groups: conservative therapy (no tPA), tPA, and
MT. The following outcomes were assessed: visual field normalization on
confrontation, 90-day modified Rankin Scale (mRS), and cognitive function.
Cognitive function was evaluated by a neuropsychologist in the subacute
hospital, and a favorable outcome was defined as less than or equal to 2
impaired cognitive domains.
Mohammad Anadani, MD*
Elizabeth M. Aradine, DO
Rohan Arora, MD
Bahar M. Beaver, MD*
Anusha Boyanpally, MD
Alan C. Cameron, MB ChB, BSc (Hons), MRCP*
Pamela Cheng, DO
Kat Dakay, DO*
Danielle de Sa Boasquevisque, MD*
Reyes de Torres Chacon, MD
Victor J. Del Brutto, MD*
Rachel Forman, MD
Alejandro Fuerte, MD*
Parneet Grewal, MD
Deepak Gulati, MD*
Jennifer Harris, MD
Mausaminben Hathidara, MD
Kathryn S. Hayward, PhD, PT
Yan Hou, MD, PhD
Richard Jackson, MD*
Wayneho Kam, MD
Gurmeen Kaur, MBBS*
Muhammad Taimoor Khan, MD
Abbas Kharal, MD, MPH*
Grace Y. Kuo, MD, MS, BA
Stephanie Lyden, MD, BS
Piyush Ojha, MBBS, MD, DM
Adeola Olowu, MD
Lin Kooi Ong, PhD*
Raffaele Ornello, MD*
Matthew Maximillian Padrick, MD, BA
Lina Palaiodimou, MD*
Robert W. Regenhardt, MD, PhD*
Shashank Shekhar, MD, MS*
Kristina Shkirkova, BSc
Ravinder-Jeet Singh, MBBS, DM*
Burton J. Tabaac, MD*
Melissa Trotman-Lucas, PhD
Tamaya Van Criekinge, PT
Elena Zapata-Arriaza, MD*
Charlotte Zerna, MD, MSc
*Senior Blogger
