American Heart Association

Monthly Archives: February 2020

ISC 2020: “Paola de Rango Memorial Session. Sex Differences in Stroke (a Go Red for Women Session)”

International Stroke Conference
February 19–21, 2020

Charlotte Zerna, MD, MSc
@CharlotteZerna

Go Red For Women was created in 2004 and is a comprehensive platform designed to increase women’s health awareness and focus on research into women’s cardiovascular health, and it is meant to empower female patients to take charge of their own heart and brain health to improve outcomes. This year’s International Stroke Conference featured multiple sessions under the Go Red For Women track. The inaugural Paolo de Rango Memorial Session about sex differences in stroke was moderated by Nada El Husseini (Durham, NC) and Amytis Towfighi (Los Angeles, CA).

Salvador Cruz-Flores (El Paso, TX) emphasized that differences have to be avoidable, unjust, and unfair to constitute a disparity and can occur in any one group when compared to the most advantaged group. These differences systematically place socially disadvantaged groups at further disadvantage in regards to their health. Such disparities or social determinants of health are, for example, the adoption of health-promoting behavior and exposure to unhealthy/stressful living and working conditions, as well as access to health care and other public services. Measuring health disparity necessitates an indicator variable for one’s health, an indicator variable for one’s social position, and the ability to compare the health indicators across social position strata. A recent study by Rinaldo and colleagues was able to show the racial and ethnic disparities in the utilization of acute treatment for ischemic stroke in the United States.1 Intravenous alteplase was offered to 4.3% more white patients compared to black/Hispanic patients. About 10% more were also admitted to an endovascular-capable center, and 2.8% more received endovascular treatment.

ISC 2020 Session: “The New Frontiers in Thrombolysis of Patients with Acute Ischemic Stroke (25th Anniversary of NINDS Trial)”

International Stroke Conference
February 19–21, 2020

Mausaminben Hathidara, MD
@mausameen

This session was divided in topics as below, each discussing different aspects associated with making decisions for tPA for extended window, proper patient selection for mild strokes and the dilemma for patients with relative contraindication, as well as thrombolysis in women with ischemic stroke.

The story from bench to bedside by Patrick Lyden

In 1995, the NINIDS trial proved the efficacy of tPA and reasonable safety. Per pilot study analysis, the dose 0.9 mg/Kg demonstrated the best efficacy, therefore, was chosen for the NINDS trial up to 3 hours from symptoms onset, which showed that patients in the treatment arm were 30% more likely to have minimal or no disability at 3 months with reasonable safety (symptomatic ICH 6.4%) for intra-cerebral. Before the NINDS trial, there were several studies that looked into tPA for acute ischemic strokes, including ECASS I and ECASS II, which did not show successful results due to different time window and dosing selection.

ISC 2020 Session: “Is Less More? Controversies in Imaging Endovascular Treatment Candidates”

International Stroke Conference
February 19–21, 2020

Parneet Grewal, MD                           

Moderators: Dr. Ashutosh Jadhav and Dr. Robin Novakovic

This session at the International Stroke Conference 2020 in Los Angeles included extensive discussion about various imaging modalities that are being used to select patients as candidates for endovascular treatment (EVT) in the real world, along with their pitfalls. The discussion was led by Dr. Albert J. Yoo, Dr. Achala Vagal, and Dr. Bernard Yan. There were also case scenarios presented by Dr. Richard Aviv of challenging CT angiography (CTA) cases.

Early time, late time, large core, small core: Non-con CT is all you need (Dr. Albert J. Yoo)

In his presentation, Dr. Yoo discussed the importance of non-contrast CT head in selecting patients for EVT and urged the clinicians to consider CT head and CTA as the only imaging modalities that are needed prior to making decisions for EVT. The EVT candidate patients are broadly divided into early window (0-6 hours) and late window (> 6-24 hours) based on their time of presentation, as well as into small core and large core based on the size of ischemic infarct. All the major landmark trials in the early window, such as MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME and REVASCAT, utilized CT head/CTA for patient selection with EXTEND IA and SWIFT PRIME also using CT perfusion (CTP) imaging. All the trials demonstrated improved perfusion and functional outcome for patients with large vessel occlusion who underwent EVT but had different criteria for patient selection. A study by Tawil et al. on comparing eligibility for different trial protocols to estimate the number of patients eligible for treatment showed that 53% of the patient population met criteria for MR CLEAN, which decreased to only 17% for EXTEND IA. Secondary analysis of the MR CLEAN trial has also shown that the patients who were ineligible per EXTEND IA criterion also benefitted from the EVT, which means that excluding patients in the early window using CTP might lead us to miss a subset of the population which can still benefit from thrombectomy.

ISC 2020 Session: “Widening the Lens of Telestroke: From the ED Across the Stroke Continuum”

International Stroke Conference
February 19–21, 2020

Burton J. Tabaac, MD

With a room filled with astute and engaged listeners, this talk was aimed at featuring some of the most preeminent minds in the field of vascular neurology to comment on particular intricacies as pertains to telestroke.  The session was subdivided into four sections, with each delving into a specific approach and perspective on the spectrum of telemedicine.

The first talk, titled “Expansion of Telestroke Networks” was illustriously given at the lectern by Dr. Jennifer Majersik. This presentation highlighted post-hyperacute care options for community hospitals without neurologists, underscored the value of inpatient stroke follow up via telestroke, and outlined suggested requirements to conduct post-acute stoke follow up. The acute telestroke consult relies on three main questions: 1. Is the patient likely having an acute ischemic stroke? 2. Is a large vessel occlusion (LVO) present / Is the patient a candidate for mechanical thrombectomy? 3. Would the patient benefit from transfer to a higher level of care? Majersik details, “The goal of the telestroke consult is to provide accurate and fast revascularization for patients with acute ischemic stroke, and stroke care does not end after this goal is met.” The neurologist should aim to assist with avoidance of complications, consider the underlying stroke etiology, and discuss initiation of targeted secondary preventative therapies. Majersik succinctly concluded the talk by suggesting the following telestroke follow up requirements: the local availability of stroke diagnostic tools (MRI, ECHO, vessel imaging, and potentially non-stroke diagnostics such as EEG), the local availability of rehabilitation services, personnel training (nursing, other physicians, teleprompter), as well as administrative assistance (EMR, scheduling, financial agreement(s) between hospitals, and adequate neurologist staffing).

ISC 2020 Session: “Expanding Indications for Thrombectomy”

International Stroke Conference
February 19–21, 2020

Robert Regenhardt, MD, PhD
@rwregen

The session “Expanding Indications for Thrombectomy” at the International Stroke Conference 2020 included several debates about which patients should be treated with thrombectomy (EVT). Moderated by Thabele Leslie-Mazwi and Marc Ribo, topics included whether to treat patients with mild symptoms, tandem occlusions, and large cores.

Pooja Khatri argued to treat patients with mild symptoms. She first defined mild as NIHSS 0-5, as these patients were largely not included in the landmark RCTs. 20-40% of patients with mild symptoms will decline. Dr. Khatri made the point that NIHSS doesn’t modify the treatment effect of EVT; it may be reasonable to expect benefit even with lower NIHSS. While non-randomized data are mixed, a recent meta-analysis showed a non-significant benefit with treatment.

ISC 2020: LINQing Real-World Data to Evidence-Based Medicine: A Glimpse of Preliminary Results of Long-Term Atrial Fibrillation Monitoring from the Reveal LINQ Real-World Registry Analysis

International Stroke Conference
February 19–21, 2020

Abbas Kharal, MD, MPH

Some interesting preliminary data about stroke etiologies was revealed at the Stroke Etiology Oral Abstracts sessions at the first day of the International Stroke Conference 2020 held at the Los Angeles Convention Center on February 19, 2020. 

Preliminary results from the Reveal LINQ Real World Registry data were disclosed on the incidence rate of atrial fibrillation (AF) in cryptogenic stroke and TIA patients enrolled to date in the registry. Presence of AF was defined as an episode of AF ≥2 min over 1 year of monitoring. 192 patients (61±14 years, 61% male, mean CHA2DS2-VASc score 3.8±1.4) from 29 centers in 8 countries were included. During an average follow-up of 19±6 months, AF was detected in 19% patients, similar to that previously reported in CRYSTAL AF1 data when monitored for 2 years. As a result of longer-term monitoring and higher sensitivity of AF detection, therapeutic anticoagulation was initiated in 29 (15%) patients during follow-up, while 14 of 45 initially on anticoagulation discontinued the treatment due to lack of AF detected.

ISC 2020: Pre-Conference Symposium III: HEADS-UP: Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving (AM Session)

International Stroke Conference
Pre-Conference Symposia: February 18, 2020
Sessions: February 19–21, 2020

Rachel Forman, MD
@bustinclots247

I had the privilege to attend this important symposium shedding light on different aspects of stroke disparities. As someone who is passionate about stroke community education and addressing healthcare disparities, it was really incredible to be able to listen in person to people I have admired throughout my training.  The symposium was moderated by Drs. Bruce Ovbiagele and Amytis Towfighi. 

The first talk was by Dr. Mitchell Elkind (Columbia University), who began by describing disparities: “… a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.” He also mentioned that approximately 1/3 of people in the United States, or more than 100 million people, identify as belonging to a racial or ethnic minority population. Another interesting point from the discussion is that Hispanic and Asian men and women are less likely to use EMS versus white men and women, and that black women are less likely than white women to use EMS (Journal of the American Heart Association, Smith 2015). We were then introduced to his work with the Northern Manhattan Study (NOMAS): a study of the population in Washington Heights (beginning in 1990) that has enrolled over 4,400 people from the surrounding community with neurological conditions. This work is ongoing and exciting (and, importantly, includes a diverse patient population).

Article Commentary: “Movement Behavior Patterns in People With First-Ever Stroke”

Tamaya Van Criekinge, PT
@TamayaVC

Wondergem R, Veenhof C, Wouters EMJ, de Bie RA, Visser-Meily JMA, Pisters MF. Movement Behavior Patterns in People With First-Ever Stroke. Stroke. 2019;50:3553–3560.

Are you reaching the recommended daily step goal of 10,000 steps for achieving a desirable level of physical activity? During routine daily activities, this is already considered a difficult task, and it becomes harder when having to deal with activity impairments. People living with stroke spend only half of the recommended time being active as compared to healthy individuals and are subsequently at high risk of developing sedentary behavior. Since prolonged sedentary behavior can damage your physical and mental health, it is important to gain insight into these unhealthy movement behavior patterns of people living with stroke. As the authors suggest, this provides health care providers with important information regarding the identification of the right persons with specific behaviors for targeted interventions.

Meet the Blogger: Elena Zapata-Arriaza, MD

Elena Zapata-Arriaza

Name: Elena Zapata-Arriaza, MD
Hometown: Sevilla, Andalucía, Spain
Current Position: Interventional Neuroradiologist in the Radiology Department in Virgen del Rocio University Hospital; Stroke Neurologist Researcher in the Institute of Biomedical Research of Seville (IBiS)

Q: What made you interested in a career in stroke?

A: Near the end of my residency in neurology, there were fundamental changes in the acute treatment of ischemic stroke, which changed the paradigm of disease management, as well as the role of the neurologist in the stroke. The possibility of expanding the therapeutic options, whose indication depended on the combination of clinical-radiological knowledge, motivated me to focus more on the stroke, in which the neurologist became an active part of its outcome. Likewise, the wide variety of topics to investigate about stroke, together with the existence of quality researchers in my center who trusted me to develop studies on stroke-associated pneumonia, further boosted my interest in the field.

By |February 11th, 2020|clinical|0 Comments

Thrombus Migration in Large Vessel Occlusion: Is it Good or Bad?

Ravinder-Jeet Singh, MBBS, DM

Alves HC, Treurniet KM, Jansen IGH, Yoo AJ, Dutra BG, Zhang G, et al. Thrombus Migration Paradox in Patients with Acute Ischemic Stroke. Stroke. 2019; 50:3156-3163.

Thrombus is a dynamic structure with constantly changing size, morphology and location over time, to variable extent in each patient, before recanalization occurs. Recently, there is interest in understanding dynamic clot features, especially regarding thrombus movement — defined as change in the occlusion site — between initial (typically CT angiogram) and follow-up vascular imaging (usually catheter angiogram for mechanical thrombectomy). Whether thrombus migration before recanalization is of any clinical or functional significance remains under investigation. The thrombus migration was studied in the past.1 It underlies a clinical phenomenon called “spectacular shrinking deficit,” in which a patient with major hemispheric syndrome shows rapid (over minutes to hours) and dramatic improvement or disappearance of most clinical deficits.1 Use of regular “vascular imaging” now allows investigating the concept in reverse order, i.e., the incidence thrombus migration and correlate it with clinical change or functional outcome. Different factors determine the dynamic behavior of the clot, including source of thrombus (etiology of stroke), composition of the thrombus, initial thrombus location within arterial tree (for example, proximal vs distal occlusion), angioarchitecture around the thrombus and use of intravenous thrombolysis (IVT).1-4