American Heart Association

Meet the Blogger: Burton J. Tabaac, MD

Burton J. Tabaac

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.

By |January 17th, 2020|clinical|0 Comments

The Acute Ischemic Stroke Patient with Cerebral Microbleeds — When is IV Thrombolysis Beneficial?

Bahar M. Beaver, MD

Schlemm L, Endres M, Werring DJ, Nolte CH. Benefit of Intravenous Thrombolysis in Acute Ischemic Stroke Patients With High Cerebral Microbleed Burden. Stroke. 2020;51:232–239.

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.

Schematic diagram of the algorithm.

Figure 1. Schematic diagram of the algorithm.
By |January 15th, 2020|clinical|0 Comments

Article Commentary: “Non–Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Asians With Atrial Fibrillation”

Anusha Boyanpally, MD

Xue Z, Zhang H. Non–Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Asians With Atrial Fibrillation: Meta-Analysis of Randomized Trials and Real-World Studies. Stroke. 2019;50:2819–2828.

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.

By |January 14th, 2020|clinical|0 Comments

Author Interview: Dr. Christopher D. Anderson, MD, MMSC, on “Genetics of Cerebral Small Vessel Disease”

Christopher D. Anderson
Dr. Christopher D. Anderson

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.

They will be discussing the article “Genetics of Cerebral Small Vessel Disease,” published in the January 2020 issue of Stroke.

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. 

By |January 13th, 2020|clinical|0 Comments

A CHANCE for Double Antiplatelet Therapy in Minor Stroke: That’s the POINT

Elena Zapata-Arriaza, MD
@ElenaZaps

Pan Y, Elm JJ, Li H, Easton JD, Wang Y, Farrant M, et al. Outcomes Associated With Clopidogrel-Aspirin Use in Minor Stroke or Transient Ischemic Attack: A Pooled Analysis of Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events (CHANCE) and Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trials. JAMA Neurol. 2019;76:1466-1473.

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.

By |January 10th, 2020|clinical|0 Comments

Article Commentary: “Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study”

Reyes de Torres Chacon, MD

Müller MD, Gregson J, McCabe DJH, Nederkoorn PJ, van der Worp HB, de Borst GJ, et al. Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study. Stroke. 2019;50:3013–3020.

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.

By |January 8th, 2020|clinical|0 Comments

Meet the Blogger: Lin Kooi Ong, PhD

Lin Kooi Ong

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.

By |January 7th, 2020|clinical|0 Comments

Author Interview: Prof. Adnan Siddiqui, MD, PhD, on the COMPASS Trial

Prof. Adnan Siddiqui
Prof. Adnan Siddiqui

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. 

They will be discussing the article “Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial,” published in The Lancet.

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.

Meet the Blogger: Richard Jackson, MD

Richard Jackson

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.

By |January 3rd, 2020|clinical|0 Comments

IV tPA or Mechanical Thrombectomy: Is One Better for Acute Posterior Cerebral Artery Occlusions?

Elizabeth M. Aradine, DO

Strambo D, Bartonlini B, Beaud V, Marto JP, Sirimarco G, Dunet V, et al. Thrombectomy and Thrombolysis of Isolated Posterior Cerebral Artery Occlusion: Cognitive, Visual, and Disability Outcomes. Stroke. 2019.

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.

By |December 31st, 2019|clinical|0 Comments