American Heart Association

Monthly Archives: January 2018

ISC Session: Unruptured Aneurysms: Novel Insights and Treatment Concepts

International Stroke Conference
January 24–26

Kaustubh Limaye, MD

Management of unruptured aneurysms continues to be a clinical conundrum. This session at ISC 2018 was geared toward identifying better strategies for identifying patients at higher risk of rupture and selecting appropriate management modalities.

The session started with a talk by Dr. Mervyn Vergouwen, who discussed risk factors for aneurysm growth and rupture. He discussed the prevalence of aneurysm to be 3% of the world population. “Growth predicts rupture,” he said. What to do: treat or wait and scan? Weigh risk of rupture and risk of treatment. He discussed the PHACES and ELAPSS studies, highlighting the important features and also the important predictors of aneurysm rupture that were excluded from these studies, like data on smoking, familial history and aneurysm morphology. “Risk predicting scores are the beginning and not the end,” he said. Multiple factors, rather than just diameter or location, should be included in deciding treatment.

By |January 25th, 2018|Conference|0 Comments

“Telestroke 3.0. Beyond Acute Ischemic Stroke”: Leveraging Technology for Stroke Management

International Stroke Conference
January 24–26

Deepak Gulati, MD

During “Telestroke 3.0. Beyond Acute Ischemic Stroke,” one of the last symposium sessions on day one of ISC 2018 in Los Angeles, many national and international speakers discussed the innovative use of telestroke beyond acute ischemic stroke care in different settings.

The first presentation was on “Telestroke Networks Providing Community Education: Stroke ECHO” by Dr. Chung from the University of Utah. He discussed the project ECHO — Extension for Community Healthcare Outcomes — which is a rural, resource-limited focus initiative by the University of Utah. It is an extensive network with spokes in other states and countries, including Canada and West Africa. There is a growing demand of vascular neurologists nationally and internationally. Project ECHO is based on a case review model, and the initial focus is on acute stroke care while addressing multiple changing practice updates, along with CME and outreach beyond spoke ED’s. The future opportunities with the telestroke include pre-hospital and post-hospital long term care, expanding educational and clinical needs, and inter-disciplinary partnerships.

By |January 25th, 2018|Conference|0 Comments

The Fellows in Training (FIT) Initiative

International Stroke Conference
January 24–26

Gurmeen Kaur, MBBS

This year at ISC 2018 in Los Angeles, the American Heart Association/American Stroke Association put together a new program called the Fellows in Training program (FIT). In addition to introducing attendees to the International Stroke Conference and the AHA/ASA, the workshop was meant to provide stroke fellows with tools and training that will benefit them in their professional career, as well as opportunities to interact with thought leaders and potential mentors in the national and international stroke community.

Around 50 fellows from vascular neurology programs around the country were a part of the workshop, which began with an introduction and several talks on how to identify your mission statement, good ways to present your data, and introducing changes in healthcare by understanding business, quality improvement and leadership models and roles. Day 1 also included a talk on how to build a practice and various practice models and their limitations. This was an excellent way of introducing fellows and early career attendees to academic, hospital-owned and physician-owned practice models to help this young group select their first jobs. The final session of the day was a networking event for all the participating fellows and faculty.

By |January 25th, 2018|Conference|0 Comments

Sweet Tooth for Stroke: Looking at Diabetes from Bench to Bedside

International Stroke Conference
January 24–26

Kevin S. Attenhofer, MD

Diabetes is not just a matter of the sugar! Like stroke, diabetes is a vascular disease. This morning, Drs. Wuwei Feng, Karen C. Johnston, Kunjan Dave, and Adviye Ergul presented an intriguing series of lectures looking into some of the subtleties of pathophysiology and management of diabetes in the acute stroke patient. This is a particularly important topic here in the United States, where 1 in 4 patients carry this diagnosis — an independent risk factor for stroke that is modifiable!

By |January 24th, 2018|Conference|0 Comments

ISC Session: Role of Neuroimaging in Stroke Prevention, Treatment and Recovery

International Stroke Conference
January 24–26

Deepak Gulati, MD

During one of the first symposium sessions on day one at ISC 2018 in Los Angeles, speakers discussed a few interesting topics, including the role of MR imaging and high resolution MR (vessel wall) imaging in acute stroke.

The first presentation was on “MRI Guided Treatment of Patients With Resolved or Minimal Symptoms” by Dr. Richard Leigh from NINDS. There are always few cases in daily practice when there is a diagnostic dilemma, whether it is a stroke mimic or making treatment decisions for patients with high risk of bleeding or an unclear time window. When performed as first modality in the setting of acute stroke, MRI can provide additional information in patients with resolving or resolved NIHSS or where the risk/benefit of thrombolysis is in debate. MRI could also identify blood flow abnormalities that are concerning for clinical decline and prevent treatment of patients with a high burden or worrisome pattern of microbleeds. However, there are practical difficulties in performing DWI-MRI in a timely manner, including scheduling issues, the patient’s condition, pacemaker, patient movements, etc., even though it has been reported that 11% of hospitals with MRI on site had performed MRI on any stroke patient within 6 hours of onset.  MRI rapid stroke protocol usually takes approximately 8 minutes.

By |January 24th, 2018|Conference|0 Comments

Therapeutic Management of Aspirin Failure – Does Changing the Antiplatelet Regimen Help?

Philip Chang, MD

Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Antiplatelet Regimen for Patients with Breakthrough Strokes While on Aspirin. Stroke. 2017

When your patient has a stroke while on an antiplatelet regimen, a common practice is to switch it. If they were on aspirin, change to clopidogrel. If on clopidogrel, one may think of switching to aspirin plus dipyridamole. While there has been much theory about aspirin failure, or aspirin resistance, there has been scant evidence to suggest that switching antiplatelet agents may benefit patients. Clinicians have switched antiplatelet regimens under the common philosophy, “Insanity is doing the same thing over and over again and expecting different results.” This is with the underlying theory that patients who experience recurrent stroke while on aspirin must have developed aspirin resistance, and blocking another antiplatelet pathway (like ADP) will confer some protective benefit. However, this theory has never been proven or disproven by a clinical study. This article by Lee et al is a great step into this clinical conundrum.

Association Between Prehospital Blood Pressure and Extent of Bleeding in Patients with Acute Intracerebral Hemorrhage

Andrea Morotti, MD

Rodriguez-Luna D, Rodriguez-Villatoro N, Juega JM, Boned S, Muchada M, Sanjuan E, et al. Prehospital Systolic Blood Pressure Is Related to Intracerebral Hemorrhage Volume on Admission. Stroke. 2018

Elevated blood pressure has been consistently associated with active bleeding and unfavorable prognosis in acute intracerebral hemorrhage (ICH). Dr. Rodriguez-Luna and colleagues investigated whether systolic blood pressure (SBP) in the prehospital phase correlates with admission SBP and extent of bleeding measured as baseline ICH volume. To explore this association, a prospectively collected cohort of ICH patients was retrospectively analyzed. A total of 219 patients qualified for the analysis (mean age 76, 54% males), with mean baseline ICH volume of 25 mL. Prehospital SBP was strongly correlated with admission SBP (r=0.552; P<0.001) and baseline ICH volume (ρ=0.189; P=0.006), as shown in the Figure.

Scatterplots showing the relationship between prehospital systolic blood pressure (SBP) and time from symptom onset (A), SBP on admission (B), and intracerebral hemorrhage (ICH) volume on admission (C).

Figure: Scatterplots showing the relationship between prehospital systolic blood pressure (SBP) and time from symptom onset (A), SBP on admission (B), and intracerebral hemorrhage (ICH) volume on admission (C).

Hitting the Sack After Brain Attack: The Relationship Between Sleep, Preconditioning and Stroke

Danny R. Rose, Jr. MD

Pincherle A, Pace M, Sarasso S, Facchin L, Dreier JP, Bassetti CL. Sleep, Preconditioning and Stroke. Stroke. 2017

Sleep is a complex yet fundamental physiological state with wide-reaching implications for a variety of disease states that are still incompletely understood. The study of the various deleterious effects of sleep deprivation and benefits of physiologic sleep are ripe for application to the pathophysiology of stroke, which itself involves the study of the negative and positive effects of physiologic stressors and the importance of recovery and regeneration. Coauthors Pincherle and Pace et al. recently published a comprehensive review of current research in human and animal models about the effects of sleep as well as preconditioning in the context of acute ischemic stroke.

Sleep disorders are exceedingly prevalent; it is estimated that up to one third of adults do not get adequate sleep. Sleep deprivation (SD)/fragmentation induces autonomic nervous system dysfunction, increases inflammation and induces procoagulant factors and oxidative stress. In acute stroke, animal models show that sleep deprivation increases apoptosis and impairs neuroplasticity and neurogenesis. In human studies, sleep-disordered breathing (SDB) has been significantly associated with hypertension, atherosclerosis and cardiac arrhythmia. In addition, SDB was identified as an independent stroke predictor in one meta-analysis (OR 2.24, CI 1.57-3.19), and was shown to have a dose-response relationship in stroke/TIA survivors with respect to recurrent stroke/TIA and all-cause mortality in a separate review. Intermittent hypoxia, intrathoracic pressure changes, sympathetic activation, blood pressure lability, endothelial dysfunction and proinflammatory factors are all likely contributing factors associated with SDB.

By |January 17th, 2018|clinical|0 Comments

Eating Healthy: Tips for Stroke Prevention

Rohan Arora, MD

Larsson SC. Dietary Approaches for Stroke Prevention. Stroke. 2017

This review by Susanna Larsson focuses on the current evidence from randomized controlled trials and prospective studies on dietary modifications that could help with stroke prevention.

The article is very important since diet is one of the modifiable factors that can help with reducing the risk of stroke and promote cardiovascular health. The stroke survivors or their family members are of utmost curiosity to change their diet after seeing a family member suffer from stroke.

Bridging Therapy for Endovascular Thrombectomy: A Role for Direct Mechanical Thrombectomy?

Mark R. Etherton, MD PhD

Bellwald S, Weber R, Dobrocky T, Nordmeyer H, Jung S, Hadisurya J, et al. Direct Mechanical Intervention Versus Bridging Therapy in Stroke patients Eligible for Intravenous Thrombolysis. Stroke. 2017

In this entry, I discuss the matched pairs analysis of IV tPA eligible patients with large-vessel occlusion (LVO) of the anterior circulation that underwent endovascular thrombectomy (EVT) with or without pre-treatment with IV tPA.

The clinical importance of understanding the role of bridging therapy in patients with LVO is critical for efficaciously triaging this population to stroke centers. The hypothetical scenario is, how should emergency medical services appropriately triage a patient with suspicion for LVO with regards to transfer to a primary stroke center with tPA capabilities or a comprehensive stroke center with EVT capabilities that is further away? This scenario epitomizes why there is great interest in understanding the contribution that bridging therapy with tPA has on outcomes in patients with LVO of the anterior circulation.