American Heart Association

Monthly Archives: March 2021

ISC 2021 Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate)

Robert W. Regenhardt, MD, PhD
@rwregen

International Stroke Conference 2021
March 17–19, 2021
Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate) (33, On Demand)

The session “Challenging EVT Decision Making: When, Where, and Who to Treat” (Debate) highlights some of the most difficult management decisions regarding EVT.

Dr. Sandra Narayanan built the case “Low NIHSS proximal occlusions should undergo thrombectomy.” She started by reviewing the magnitude of the question. An LVO is present in 18% of patients with NIHSS 0-4 and 39% of those with NIHSS 5-8. Furthermore, 15% of LVO stroke patients have minor symptoms. Deterioration can happen in early or delayed fashion; about 40% deteriorate early. Current guidelines suggest that treating patients with low NIHSS is reasonable. Indeed, several studies show a benefit. The Grady experience (JNIS 2017; 9:917-921) described 32 patients with NIHSS<6. Analyses of this cohort, while small, suggested a benefit of EVT. 22 were treated with medical management, of which 9 declined requiring EVT. The median time from arrival to deterioration was 5.2 hours. Subsequently, a larger study of 6 CSCs (Stroke 2018;49: 2391-2397) described 300 patients with NIHSS<6; 11.3% of those treated with medical management later declined. At 90 days, mRS 0-2 was observed in 84% of those treated with EVT, 70% of those with medical management, and 55% of those who underwent rescue EVT. Those who are allowed to deteriorate tend to have worse outcomes. The risks versus benefits should be carefully weighed up front because waiting more than 3 hours appears to impact outcomes. There is growing data that patients at risk for decline can be selected by collaterals, orthostatic challenges, perfusion imaging, and NIHSS eloquence/disability. Three randomized controlled trials are forthcoming: ENDOLOW, IN EXTREMIS, and TEMPO 2.

ISC 2021 Session: Prognostication and Early Withdrawal of Care in Ischemic Stroke and ICH

Melanie R. F. Greenway, MD
@MRFGreenwayMD

International Stroke Conference 2021
March 17–19, 2021
Session: Prognostication and Early Withdrawal of Care in Ischemic Stroke and ICH (116)
Moderators: Aneesh Singhal, MD, and James Meschia, MD
Presenters: Gustavo Saposnik, MD, MPH, PhD, FRCPC; H B Van Der Worp, MD; Claire Creutzfeldt, MD; J Claude Hemphill III, MD, MAS; Wendy Ziai, MD, MPH

Moderated by Dr. Aneesh Singhal from Massachusetts General Hospital and Dr. James Meschia from Mayo Clinic, this session on prognostication in ischemic stroke and intracranial hemorrhage was informative, interactive, and diverse. Topics ranged from accurate prognostication to coaching physicians on important care discussions with patients and families. A must-watch session for those who were unable to watch it live, in my opinion.

Dr. Gustavo Saposnik of St. Michael’s Hospital and the University of Toronto started the session by (painfully) reminding us that poker players and meteorologists are much more accurate in predicting outcomes than physicians. With routine feedback, they are able to refine their practice with data less prone to outcome bias. From there, he took us on a tour of the many validated risk scores available, and their limitations, and encouraged the audience to use risk scores to supplement prognostication rather than “eyeballing” the assessment.

ISC 2021 Session: New Frontiers in Endovascular Therapy

Robert W. Regenhardt, MD, PhD
@rwregen

International Stroke Conference 2021
March 17–19, 2021
Session: New Frontiers in Endovascular Therapy (122, On Demand)

The session “New Frontiers in Endovascular Therapy” had a great line-up of panelists discussing hot topics in neuroendovascular therapies.  

Dr. Jenny Tsai spoke on a “Combined open vascular and endovascular approach for complex cerebrovascular cases.” She emphasized that open microsurgery has many advantages. In fact, open surgery and endovascular approaches can complement each other. A combined approach may be preferable in several scenarios: 1. Challenging anatomy and disease processes. 2. Limited access by individual approaches. 3. Complimentary treatment effects. Tsai emphasized that combined approaches can sometimes be simpler. In the past, combined approaches have been utilized especially for AVM and vascular tumor treatments, where embolization can be offered in stages before open surgery. However, joint approaches do not always require staging. More centers are developing hybrid combined open and endovascular rooms.

ISC 2021 Symposium: Enriched Environments and Recovery

Burton J. Tabaac, MD
@burtontabaac

International Stroke Conference 2021
March 17–19, 2021
Symposium: Enriched Environments and Recovery (121)

Preclinical work has shown the importance of enriched environments on post-stroke recovery. Enriched environments are designed to enhance sensory, motor, and cognitive stimulation by providing equipment, stimulation, open spaces, and a desire to want to engage in rehabilitative interventions. In rodent experiments, enriched environments include toys, ramps, tubes, mirrors, ropes, and the ability to interact with other animals. Rodents exposed to enriched environments early (but not late) post-stroke showed improved motor performance even on tasks for which they did not receive specific training. The proposed mechanisms of action are plethoric and may relate to multiple molecular pathways. Translating an enriched environment to human patients may take several forms, including access to iPads, books, puzzles, games, music, and interaction with other people. Additionally, one could imagine enrichment using virtual/augmented environments with video games and other technology that would not only increase dose and enjoyment.

ISC 2021 Session: Mismatch Misalignments for Extended-window IV-thrombolysis for Non-Large Vessel Occlusion Strokes (Debate)

Yasmin Aziz, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Mismatch Misalignments for Extended-window IV-thrombolysis for Non-Large Vessel Occlusion Strokes (Debate)
Moderator: Dr. Gotz Thomalla

Can thrombolytics be given safely and efficaciously beyond 4.5 hours? That was the debate topic for one of ISC’s first live debates to kick off Wednesday morning. 

Dr. Shlee Song: DWI-FLAIR Mismatch Rules!

The arguments began with Dr. Song, who focused on DWI-FLAIR mismatch. After a brief introduction with the MR WITNESS trial results, she then discussed how patients with DWI-FLAIR mismatch treated with alteplase had better outcomes at 90 days in the WAKE UP study. She also made the point that while efficient MRI scanning of acute stroke patients can be cumbersome, in addition to treating more patients, we can also avoid potential side effects of treating with conventional CT/CTA methods (i.e., contrast nephropathy and ICH in the event of unseen microhemorrhages only visible on MR).

ISC 2021: Novel Imaging Techniques in ICAD — Beyond the Stenosis

Song J. Kim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Advanced Imaging in Intracranial Atherosclerotic Disease: Misnomer or Game-Changer? (24, OnDemand)

A common stroke mechanism accounting for 20-30% of the ischemic strokes worldwide, intracranial atherosclerotic disease (ICAD) is a diagnosis that primarily relies on visualization of luminal narrowing on CTA/MRA. This session expanded upon cutting-edge advances in imaging of ICAD, specifically in revealing plaque morphology, collateral status, and cerebrovascular reserve distal to the stenosis of the culprit lesion.

Before the panel delved into discussion of the advanced imaging, Dr. Achala Vagal provided a comprehensive overview highlighting the limitations of the current conventional lumen-based imaging: failure to detect on-stenosing plaque, compensatory remodeling, and the status of distal flow and collateralization.

ISC 2021: COVID-19 and Acute Ischemic Stroke: Adding Fuel to the Fire

Isabella Canavero, MD

International Stroke Conference 2021
March 17–19, 2021
Presentation LB15

Srivastava PK, Zhang S, Xian Y, Xu H, Rutan C, Alger HM, Walchok J, Williams J, de Lemos JA, Decker-Palmer MR, et al. Acute Ischemic Stroke in Patients With COVID-19: An Analysis From Get With The Guidelines–Stroke. Stroke. 2021.

Actually, both COVID-19 and stroke represent pandemic diseases: To date, they account for the most frequent illnesses worldwide. In addition, upcoming evidence from medical literature suggests that the ultimate overlap of COVID-19 with the everlasting stroke “pandemic” has led to increasing rates of adverse outcomes.

In this paper, Srivastava et al. investigated clinical features and outcomes of patients with acute ischemic stroke and COVID-19 in the United States in the first 4-months period of the COVID-19 outbreak, by using data from the Get With The Guidelines-Stroke network. Nearly 42,000 acute ischemic stroke patients, hospitalized in 458 GWTG-Stroke hospitals, were identified: Of them, about 1,150 were also affected by COVID-19. Comparing acute ischemic stroke patients with or without COVID-19, younger age, Black, Hispanic and Asian ethnicity, higher NIHSS scores, and large vessel occlusions were found to be significantly more represented in the COVID-19 subgroup, supporting the negative impact of the infection on stroke outcome. Furthermore, acute ischemic stroke patients with COVID-19 were featured by longer times to evaluation and treatment, and worse morbidity and mortality compared to COVID-19-free patients.

ISC 2021: COVID-19 Pandemic: Collateral Damage in Stroke Quality of Care

Elena Zapata-Arriaza, MD
@ElenaZaps

International Stroke Conference 2021
March 17–19, 2021
Poster P846

Balucani C, Carhuapoma JR, Canner JK, Faigle R, Johnson B, Aycock A, Phipps MS, Schrier C, Yarbrough K, Toral L, et al. Exploring the Collateral Damage of the COVID-19 Pandemic on Stroke Care: A Statewide Analysis. Stroke. 2021.

The morbidity and mortality effects of COVID-19 are well demonstrated and are a global health priority. The collateral effects of the pandemic on other pathologies that will continue to harm when SARS-CoV-2 becomes endemic have growing evidence. Balucani et al. have performed a retrospective analysis of an existing prospective stroke registry reported by stroke centers in the state of Maryland, between March 1 and September 30, 2020 (pandemic) and the same time period in 2019 (pre-pandemic), in order to explore the effect of the COVID-19 pandemic on transient ischemic attack (TIA) and stroke care.

ISC 2021: Article Commentary: “Association Between Stroke and Subsequent Risk of Suicide”

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P237

Vyas MV, Wang JZ, Gao MM, Hackam DG. Association Between Stroke and Subsequent Risk of Suicide: A Systematic Review and Meta-Analysis. Stroke. 2021.

“What remains in diseases after the crisis is apt to produce relapses.”
— Hippocrates, Aphorisms

This article very well summarizes the impact of stroke on mental health. Stroke survivors, overall, struggle with the adjustment not only due to the illness itself, but the overall impact of it on their lifestyle. Stroke survivors are more likely to be unemployed, have greater lost productivity, and have higher disability from physical, cognitive and mental sequalae of stroke, which may confer the observed higher risk of suicide.

ISC 2021 Session: Substance Abuse in Stroke

Setareh Salehi Omran, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Substance Abuse in Stroke (153, OnDemand)

The session “Substance Abuse in Stroke” at the International Stroke Conference 2021 included several presentations on the risk of stroke from a wide range of substances, including cannabis, tobacco cigarettes, e-cigarettes, alcohol, methamphetamine, and cocaine.

Marijuana and Synthetic Cannabinoid by Dr. Stephen Sidney:

Dr. Sidney discussed the potential mechanisms of cerebrovascular disease associated with cannabis use. Cannabis can lead to cerebrovascular disease through direct toxic effects on the vascular bed, altered hemodynamics (increased heart rate, increased supine blood pressure, postural hypotension), incident atrial fibrillation and atrial flutter, and endothelial dysfunction. Several studies have shown an association between cannabis exposure and increased risk of stroke. However, these studies have several major limitations, including cross-sectional study design, inability to stratify analysis by confounders (cigarette smoking, cocaine use), and lack of granular clinical information pertaining to the stroke and cannabis use (dose, composition, possible contaminants, various modes of consumption).

As it stands, it is unclear whether cannabis use is associated with stroke. It is important for clinicians to notify patients of limited data on cannabis use and stroke risk, and to advise against cannabis use in patients with known cardiovascular disease.