American Heart Association

Monthly Archives: February 2019

ISC Session: “Stroke Telehealth: Controversies and Solutions”

International Stroke Conference
February 6–8, 2019

Deepak Gulati, MD

During the joint symposium on the last day of the ISC 2019 on Telestroke, multiple experts with different backgrounds addressed the challenges associated with Telestroke. Telestroke turns 20 in 2019, which reflects 2 decades of progress. It was more of proof of concepts in early 2000 while showing benefit of Telestroke in rural areas. Telestroke plays a predominant role in the ‘Drip and Ship’ model in the United States, whereas the focus has been on Telestroke-supported stroke units in Europe. In the U.S., the Congress also authorized the payment for Medicare FFS Telestroke regardless of patient location in the “Furthering Access to Stroke Telemedicine” FAST Act. The future of Telestroke research will be on value (~quality/cost) vs churn, true econometric analyses, adoption within health system, scalability, disparities in access, continuum of care and Telestroke on call expertise vs AI. Based on data provided, there appears to be a connection between door-to-needle time with the number of consults from spoke hospitals. 50% of the Telestroke consults are usually acute stroke, and the rate of IVtpa administration increases with the number of consults performed. It’s expected to have the involvement of artificial intelligence in the future to deal with increasing demand of Telestroke.

ISC Session: “Chronic Kidney Disease and Stroke”

International Stroke Conference
February 6–8, 2019

Richard Jackson, MD

I’m writing to you from ISC reporting on another difficult topic: chronic kidney disease (CKD) and stroke.  From past experience, both with traditional vascular CKD and Fabry’s disease, I know that there is a higher incidence of ICH in CKD; however, I’ve never been able to find a source that goes deep into the subject matter. Enter “Neuro-Nephrology,” a new word I had never heard before introduced to me at this mini-series. I had no idea this was a word, let alone an emerging field. I have always thought that stroke needs a subspecialty field for each subset of disease for proper study.  So, welcome to the fray, Neuro-Nephrology.

First Lecture: Epidemiology of CKD and Stroke by Angela Webster, MBBS, MM(Clin Epid), PhD, FRCP, FRACP

Mortality in ESRD is 10%/year all cause and a higher incidence of ICH. Interestingly, she presented the data that most ESRD with strokes don’t go to Stroke Units despite the proven benefits of the units and the proven benefit of the units in ESRD.

She then move on to cognition and showed data that Attention and Memory worsen early in CKD and are dose dependent with decreases in GFR peaking in HD with worsening further still in the non-dialyzed. Interestingly, but not surprisingly, there is improvement after transplant.

ISC Stroke Journal Symposium: “Imaging Approaches to Patient Selection for Thrombectomy”

International Stroke Conference
February 6–8, 2019

Kat Dakay, DO

Much discussion has taken place about the role of advanced imaging in patient selection for mechanical thrombectomy. In this symposium, Dr. Marc Fisher, Editor-in-Chief of Stroke, moderated a lecture series focused on what imaging to perform in order to select patients for thrombectomy. The lectures were given by Dr. Fisher, Dr. Bruce Campbell (Melbourne Brain Institute, University of Melbourne), Dr. Michael Hill (University of Calgary), Dr. Maarten Lansberg (Stanford), and Dr. Pooja Khatri (University of Cincinnati).

Some themes that came up in the four lectures:

Advanced neuroimaging such as MR perfusion or CT perfusion can help make thrombectomy decisions, and may be especially important in patients presenting in the extended time window as per DAWN and DEFUSE.

  • Dr. Lansberg discussed how CT perfusion can extend the time window, and identify patients who may be a high risk for hemorrhage.
  • He also cited a meta-analysis titled “Neurons Over Nephrons” published in 2017 that dispelled the notion that CTA/CTP was associated with acute renal injury to help alleviate concerns regarding iodinated contrast exposure.

ISC Session: “The Justin Zivin Memorial Session: The Tried and Tested vs the New Kid on the Block: The tPA vs tNK Debate”

International Stroke Conference
February 6–8, 2019

Burton J. Tabaac, MD
@burtontabaac

Presenter: Mark Parsons, MD, PhD, FRACP — “tNK Is Ready for Prime Time”

This speaker argued that tenecteplase is the future of IV lysis. Tenecteplase is a genetically modified version of alteplase with an increased half life. Notably, tNK has been successfully used for myocardial infarction for decades, essentially replacing tPA. A phase II randomized trial comparing tNK and tPA (NEJM 2012) identified patients with LVO (large vessel occlusion) who benefited from reperfusion with tNK as compared to a relative lack of reperfusion with tPA. A phase 3 study currently being completed, TASTE, is comparing tNK and tPA. There is evidence to show that tNK has been more useful in drip and ship cases because tenecteplase does not require an hour long infusion following a bolus dose (as is required with tPA). Notably, using tNK instead of tPA will significantly reduce cost and decrease the risk of hemorrhage, and is more effective prior to thrombectomy.

ISC Session: “Vulnerable Carotid Plaque Imaging and Management: A New Dawn?”

International Stroke Conference
February 6–8, 2019

Richard Jackson, MD

I’m writing to you from ISC reporting on an extremely well-planned lecture series on symptomatic carotid artery identification by imaging. I’ve always thought this topic extremely vague as the imaging technology progressed, the medical treatment progressed, but the evaluation and treatment remained surgical with guidelines from the 1990s and most of the research spread across multiple sub-specialties. This same sentiment was echoed today in each mini-series lecture. There’s no easy way to summarize each mini lecture except to keep it in its original format and hit the relevant highlights, which are numerous to say the least.

First Lecture: “Ultrasound Imaging of Carotid Wall and Plaque” by J David Spence
His focus is clearly the identification of vulnerable plaques by ultrasound, and he was a proponent of upcoming volumetric plaque morphology assessment. He quotes the prevalence of asymptomatic carotid stenosis in the >60 year old population at 10% and identifies vulnerable plaques using TCD with emboli detection and plaque characteristics as echo-lucency, hemorrhage, and plaque ulcerations. Of interest was a paper he showed in which TMAO and lecithins produced by intestinal flora worsened carotid stenosis. As GFR decreased, including with age, the metabolites increased, possibly explaining the age relationship to carotid stenosis. Also of interest were the timelines in which carotid stenosis responded to medication. He presented his own carotid plaque and showed a transition from hypoechoic to hyperechoic in 3 months with atorvastatin, and then presented a paper in which ezetimibe doubled the effectiveness of statin therapy.

“What Do I Do with this Aneurysm?” — ISC Symposium Highlights the Challenges and Complexity of Treatment Decisions

International Stroke Conference
February 6–8, 2019

Kat Dakay, DO

One of the talks I was most looking forward to at ISC 2019 was the invited symposium titled “What Do I Do with this Aneurysm?” As advanced imaging allows for the detection of smaller and smaller aneurysms, many of them incidental, this is becoming a more challenging and pertinent topic.

This symposium, moderated by Dr. Sepideh Amin-Hanjani, MD, co-director of neurovascular surgery at the University of Illinois, was a lively discussion incorporating both neuroendovascular and open neurosurgical approaches to aneurysm treatment.

First, Dr. Mervyn Vergouwen, MD, PhD, from UMC Utrecht, began the symposium with a lecture titled “What Aneurysms Should I Treat?” He discussed patient-specific factors such as patient preference and life expectancy/comorbidities, as well as the challenging task of weighing the risk of aneurysmal rupture versus the risk of aneurysm treatment complications. One scoring system mentioned during the lecture was the PHASES score (published in Lancet Neurology in 2014 by Greving et al.), a score developed to approximate the five-year risk of rupture in an unruptured aneurysm; this score takes into account both patient-specific characteristics such as age and hypertension, as well as aneurysm-specific characteristics such as size and location. He discussed also considering the risk of the treatment approach — e.g., stent-assisted coiling versus coiling alone — when deciding whether to treat or observe an asymptomatic aneurysm.

ISC Session: “I Know the Best Way to Select Patients and Perform Stroke Thrombectomy” (Debate)

International Stroke Conference
February 6–8, 2019

Burton J. Tabaac, MD
@burtontabaac

First Presenter: Xin Cheng, MD, PhD
This insightful discussion focused on the identification of intracranial atherosclerotic disease (ICAD) and its relationship to large vessel occlusion (LVO). The speaker pointedly detailed the differences in truncal type vs. branching type anatomies. This difference in dynamic may be correlated with baseline NIHSS and size of penumbra, with larger penumbra suggesting better collateral circulation. This portion of the talk was aided by neuroimaging to demonstrate the presence of a “susceptibility vessel sign” (SVS) on GRE/SWI MRI sequencing. If present, SVS suggests an embolic etiology, whereas the absence of SVS suggests ICAD.

The current treatment of ICAD-LVO lacks consensus amongst the scientific community. Notably, patients with ICAD were observed to experience much longer procedure times compared to patients with LVO of embolic origin. The presenter posed the question, “Is endovascular treatment, or even thrombosis, necessary in this subset of patients?” ICAD-LVO is highly common in Asian populations, and there are no definitive clinical and/or imaging profiles for ICAD-LVO patients. It remains to be clear how treatment and patient selection criteria will change, the take-away being that intervention is safe, but it is unclear if it is beneficial.

Middle Meningeal Artery Embolization for Chronic Recurrent Subdural Hematoma

Tapan Mehta, MBBS, MPH

Chronic subdural hematoma (SDH) can be challenging to manage. Although, surgical evacuation with craniotomy or burr hole are very effective interventions, the recurrence rates are reported to be more than 30% with a great variability. The incidence of chronic SDH in the age group 70-79 increases to 7.35/100,000 per year from an overall average population incidence of 1.72/100,000. Along with an increasing life expectancy, the incidence of cardiovascular diseases requiring antiplatelet and anticoagulant medications is also increasing. Patients who develop chronic subdural hematoma and stop antiplatelet/anticoagulant medications are not only at a higher risk for ischemic cardiovascular events, they also are typically high risk neurosurgical candidates for hematoma evacuation procedures. An alternative minimally invasive intervention could significantly impact this population.

Subdural hematoma (SDH) formation occurs due to the tearing of bridging veins. Chronic subdural hematomas are shown to develop an outer membrane with neovascularization along with the dura. Histopathological studies have shown ongoing inflammation at the site of chronic SDH and presence of angiogenic factors. The neovascularization with presence of very small arteries (50 mu) connecting to dural branches of the middle meningeal artery (MMA) have also been demonstrated. Theoretically, embolization of MMA would decrease the “leaking” of these vessels. Several retrospective studies have reported the possibility of usefulness of MMA embolization in specific setting of chronic subdural hematoma. Link et al. demonstrated that among the 50 cases treated with MMA embolization, 91.1% patients with chronic SDH (previously untreated or recurrent after surgical evacuation) were able to avoid surgery with clinical improvement and decrease in size of the hematoma. Ban et al., in a prospective cohort study of 541 chronic subdural hematoma patients (72 patients receiving MMA embolization and 469 receiving conventional treatment), demonstrated that the treatment failure rate in the MMA embolization group was lower than the conventional treatment group (1.4% vs 27.5%, adjusted odds ratio 0.056; 95% confidence interval: 0.011 – 0.286; P = .001). There are several similar case reports and case series published with good outcomes as of now.

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