American Heart Association

Monthly Archives: January 2018

ISC Session: Driving Stroke Systems Change: Innovative Solutions to Global Resource Challenges

International Stroke Conference
January 24–26

Danny R. Rose, Jr., MD

Improving stroke systems of care around the globe is a complex challenge that truly captures the “international” aspect of the International Stroke Conference. Each country faces its own unique set of challenges and opportunities based on available resources, geography, government and many other factors. The four talks were split evenly between discussing challenges for high income and low/middle income countries, with representation from Canada, Germany, India and Brazil.

The first talk was by Dr. Gordon Gubitz, MD, from Dalhousie University in Nova Scotia, Canada, discussing the implementation of stroke systems of care in Canada’s national single-payer healthcare system. Dr. Gubitz stressed that the foundation of the success of the Canadian model was developing nurturing relationships between physicians, researchers and advocacy groups, informed by best practice. The Canadian healthcare system is Medicare, a publically funded program that has been in place since 1971. The federal government provides funds that are distributed and utilized at the provincial level, according to the needs of each individual province or territory. This was largely due to the recognition that there is a wide disparity in geography, population density, infrastructure and other things between very rural areas like the Northwest Territories and a populous province like Ontario.

By |January 31st, 2018|Conference|1 Comment

ISC Session: Plaque Inflammation is Associated with Early Cerebral Ischemic Events in Symptomatic Carotid Stenosis

International Stroke Conference
January 24–26

Richa Sharma, MD, MPH

This was a very interesting presentation about a stroke etiology that we need to study further, namely symptomatic carotid plaque not resulting in severe stenosis. Currently, there is no compelling evidence for intervention more than medical management. However, the presenter, Vijay Sharma, argued that there are certain characteristics that make a plaque at risk for embolizing even if it does not meet NASCET criteria for severe stenosis. The researchers embarked on identifying imaging characteristics that are associated with a higher risk of embolization of these plaques. They utilized FDG-PET/CT and high-resolution, fat-suppressed MRI as modalities to help different plaque risk. A prospective study included patients with carotid plaque resulting in 50 to 70% stenosis, which was ipsilateral to a recent infarct which occurred within 30 days. These patients underwent FDG-PET to identify any regions of inflammation in the plaque since this may be an initiating event for plaque rupture. They also underwent MRI with high-resolution of the carotid, which yielded a ratio of the T1 hyperintensity of the plaque to the intensity of the ipsilateral sternocleidomastoid. The MRI presumably detects the lipid-rich necrotic core of the plaque and intraplaque hematoma. The endpoint of the study was whether the patients developed a recurrent stroke within a 90-day follow-up period. Interestingly, 11% of these patients suffered from a recurrent ischemic stroke (N=11), and these patients on average had higher T1 carotid-sternocleidomastoid ratios (p<0.0001) and higher SUV values by PET in the carotid plaque (p<0.0001). In multivariable modeling, a higher T1 carotid-sternocleidomastoid ratio and higher SUV values independently predicted recurrent ischemic stroke.

By |January 30th, 2018|Conference|0 Comments

The Future of Remote Ischemic Conditioning: An Interview with Dr. David Hess

International Stroke Conference
January 24–26

A conversation with David Hess, MD, vascular neurologist and Dean of the Medical College of Georgia, on Remote Ischemic Conditioning at the Internal Stroke Conference 2018.

Interviewed by Alexis N. Simpkins, MD, PhD, University of Florida.

Remote ischemic conditioning (RIC) was the focus of several talks and posters at the 2018 International Stroke Conference, focusing on the utility of RIC in a range of cerebrovascular disease from acute ischemic stroke, to small vessel disease, to subarachnoid hemorrhage. Remote ischemic conditioning involves temporarily decreasing blood flow typically to a limb such as the arm and then reperfusing the limb serially with the goal of creating a milieu in the blood that will mimic an ischemia tolerate state. The data presented summarized the most common adverse events and intolerances (skin petechia and pain in the extremity), feasibility in the clinical setting, and probably mechanism of action of RIC. Dr. David Hess participated in a question-and-answer interview following the conference about the future of RIC in the field of stroke.

ISC Session: Closing Main Event — Exciting Neuroprotection Results

International Stroke Conference
January 24–26

Alexis N. Simpkins, MD, PhD

Session: Closing Main Event.
Date: Friday, January 26, 2018

Speaker: Patrick D. Lyden, MD, FAAN, FAHA, FANA, Carmen and Louis Warschaw Chair in Neurology, Cedars-Sinai Medical Center

At the closing remarks session, Dr. Patrick D. Lyden presented the first clinical trial use of a neuroprotectant post the new era of the embolectomy trials. The NeuroNEXT NN104 (RHAPSODY) Study was a phase II multi-center, double-blinded clinical trial in which a 3K3A-activated protein C (APC) was tested for safety. A secondary outcome measure included assessment of hemorrhagic transformation. The 3K3A-APC is both neuroprotective and vascular protective with preclinical evidence that suggests that it improves neurologic outcome and reduces risk of hemorrhagic transformation. In this study, patients received intravenous tPA and/or endovascular therapy, followed by 3K3A-APC within 2 hours of the acute intervention divided into 5 doses. Of the 110 patients enrolled, 45% of the patients received thrombolysis and endovascular therapy, and 54% were given tPA alone. There were 5 doses that were tested in the clinical trial using the continuous reassessment method, and the maximum dose was well tolerated. Hemorrhagic transformation was assessed on MRI 30 days post treatment.

By |January 29th, 2018|Conference|1 Comment

ISC Crossfire Debate: Should Anticoagulation Therapy Not Be Started in Patients with Anticoagulation-related Lobar Intracerebral Hemorrhage?

International Stroke Conference
January 24–26

Abbas Kharal, MD, MPH

The topic of whether or not anticoagulation should be restarted after an anticoagulation-related lobar intracerebral hemorrhage (ICH) remains a hot debate among neurologists around the world. Although with the advent of better imaging-based risk predictors for lobar ICH, including cerebral microbleeeds and sulcal siderosis on MRI, raising concern for cerebral amyloid angiopathy and posing higher recurrent ICH risks, there are also accordingly more safer options available now for oral anticoagulation, e.g. direct thrombin inhibitors and surgical alternatives like left atrial appendage closure, which may help lower mitigate the risks of recurrent lobar intracerebral hemorrhage. However, there still remains insufficient data to help definitively guide our management decisions when deciding whether or not it is truly safe to resume anticoagulation in such high-risk patients with a prior anticoagulation-related intracerebral hemorrhage.

An interesting crossfire debate was held on this very topic at the International Stroke Conference’s closing event between Dr. Stephan Mayer from Henry Ford Hospital, who spoke glamorously in favor of not resuming AC in such patients, and Dr. Alessandro Biffi from Massachusetts General Hospital, a world renowned cerebrovascular epidemiologist who has published extensively on the topic of intracerebral hemorrhage and anticoagulation risks, who spoke against the notion of holding oral anticoagulation in all patients with AC-related lobar ICH. Dr. Mayer raised concerns about the high risk of recurrent ICH being approximately 10.4% per year based on previously published data from Dr. Biffi and colleagues, which, when paired with the presumed increase in mortality associated with it from previously published data, appears to outweigh any potential benefits of resuming anticoagulation in such patients. Dr. Mayer went on to conclude that resuming anticoagulation in such patients would be “nuts!”

ISC Session: Acute Neuroimaging Oral Abstracts II — An interview with Dr. Steven Warach

International Stroke Conference
January 24–26

Alexis N. Simpkins, MD, PhD

Session: Acute Neuroimaging Oral Abstracts II.
Date: Thursday, January 25, 2018

Speaker: Steven Warach, MD, PhD, University of Texas Dell Medical School, University of Texas

Now that the time window for endovascular interventions in acute stroke patients has been extended up to 24 hours, it is important to evaluate the proportion of patients that would potentially be eligible during this window in the general population and determine factors that may predict whether a patient will have an acceptable imaging profile. Dr. Steven Warach presented data analyzed from the LESION database that provided some interesting findings on both fronts. After the presentation, I was able to ask Dr. Warach some follow-up questions about his findings.

By |January 29th, 2018|Conference|0 Comments

ISC Session Summary: Reperfusion Therapy in the Extended Time Window: A New Reality

International Stroke Conference
January 24–26

Neal S. Parikh, MD
@NealSParikhMD

It was no surprise that the conference room assigned to this session was woefully inadequate in size. Stroke neurologists filled the seats, the carpet, and the aisles. The results of DEFUSE 3 and the updated acute ischemic stroke treatment guidelines had been released the prior day, and the world of acute stroke care had been changed. Stroke protocols, regional EMS triage protocols, and the entire systems of care require drastic changes to help us offer extended-window endovascular therapy to our patients.

In this session, we heard from leaders in the field. Raul Nogueira and Gregory Albers provided complementary information regarding the differences between their trials: DAWN and DEFUSE 3. The key differences pertain to the duration of the extended window, the stroke severity cut-off, ages of the patients included, and core sizes.  The key takeaway was that individuals in DEFUSE 3 who were DAWN-ineligible derived similar benefits from extended-window endovascular therapy as compared to DAWN-eligible patients. This suggests that, within the first 16 hours, the more forgiving DEFUSE 3 inclusion criteria can be applied. Further analyses comparing these trials will be forthcoming.

By |January 29th, 2018|Conference|1 Comment

ISC Session: Sickle Cell Disease and Stroke in Populations of African Ancestry

International Stroke Conference
January 24–26

Deepak Gulati, MD

Stroke is a leading cause of morbidity and mortality among children with sickle cell disease. It was an interesting discussion by national and international speakers during one of the dedicated sessions at ISC 2018 on epidemiology of stroke, genetics, use of transcranial Doppler and hydroxyurea trial in sickle cell disease. Sickle cell disease is an inherited monogenetic disorder with a polygenic phenotype. Stroke affects 10–30% of children with sickle cell disease.

Dr. Rufus Akinyemi, MBBS, from the University of Ibadan in Nigeria, provided an update on the epidemiology of stroke in Africa. Non-communicable diseases contribute as much as 80% to medical admissions in some African hospitals. There are numerous studies providing varying number for stroke prevalence in Africa, ranging from 58 to 1,331/100,000. In one of the studies (Interstroke study), the one-month case fatality rate for stroke was 22% in Africa. Hemorrhagic strokes are reported to be more common in Africa. There has also been observed a relationship between HIV infection and stroke, but the pathogenesis is not entirely clear. One of the major concerns is the gaps in the stroke knowledge in health care workers and treatment choice influenced by cultural and religious beliefs. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. ARISES (African Rigorous Innovative Stroke Surveillance) aims to conduct a 3-year surveillance of stroke cases in selected urban and rural sites in Nigeria, which have an existing demographic surveillance system. There is a great need for rigorous and reliable data to inform implementation efforts for prevention and control of stroke in Africa.

By |January 29th, 2018|Conference|0 Comments

Addressing the Controversy: Report from the ISC Guidelines Q&A

International Stroke Conference
January 24–26

Kevin S. Attenhofer, MD

Following a mixed reception at the reveal of the new 2018 AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke, selected members of the guidelines panel spent time Thursday with conference-goers to field questions. The session was in such demand that the fire marshal had to start turning people away at the door, leading to the creation of a second session in the afternoon. All told, the panel spent about 3 hours answering questions from stroke practitioners in the trenches.

In this post, I highlight 6 of the most contentious topics brought up by clinicians. I have attempted to summarize the lengthy and passionate discussion between the panel and the crowd. The panel frequently reminded the crowd that these guidelines are here to help guide clinical practice when the clinician has a question, not dictate it. These are much more streamlined guidelines than previous versions, as the authors feel they have “trimmed the fat” to make them more usable and accessible.

By |January 26th, 2018|Conference|0 Comments

ISC Session: Acute Ischemic Stroke Guidelines

International Stroke Conference
January 24–26

Alexis N. Simpkins, MD, PhD

Session: Acute Ischemic Stroke Guidelines
Date: Wednesday, January 24, 2018

Speakers: William Powers, MD, FAHA, University of North Carolina; Opeolu Adeoya, MD, University of Cincinnati; Alejandro Rabinstein, MD, Mayo Clinic; Thabele Leslie-Mazwi, MD, Massachusetts General Hospital

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018

The new American Heart Association acute ischemic stroke guidelines were presented at the 2018 International Stroke Conference in Los Angeles. There were several new notable recommendations and updates, which are now published. Some of the updates emphasized during the presentation addressed mild stroke symptoms in the 3-4.5 hour time window for intravenous alteplase, indications for tenecteplase, risk of intracerebral hemorrhage with intravenous thrombolysis in patients with cerebral microbleeds, anti-thrombotic use within 24 hours of intravenous thrombolysis, triage of patients in the field by EMS to tPA capable versus tPA/mechanical thrombectomy capable hospitals, and tPA eligibility in adult patients with sickle cell disease.

By |January 25th, 2018|Conference|9 Comments