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Focal CTP Abnormalities in TIA

Deepak Gulati, MD

Meyer IA, Cereda CW, Correia PN, Zerlauth JP, Puccinelli F, Rotzinger DC, et al. Factors Associated With Focal Computed Tomographic Perfusion Abnormalities in Supratentorial Transient Ischemic Attacks. Stroke. 2017

TIAs are associated with an increased risk of debilitating recurrent stroke along with increased risk for cardiovascular morbidity and mortality. Several studies have demonstrated poor agreement regarding TIA diagnosis among Emergency Department (ED) physicians, neurologists, and even stroke specialists. Although many biomarkers for TIA diagnosis are promising, none has been proven to be sufficiently reliable for diagnosis of TIA. Substantial international variation exists in clinical practice and policies for hospital admission for patients with TIA. International guidelines also differ in their recommendations for brain and vascular imaging after TIA, with imaging either immediately or several days after symptom onset, and brain imaging by either CT or MRI recommended. It has been reported that CTP shows focal perfusion deficits in up to a third of suspected patients with TIA and could also predict functional outcome at 3 months. It has been shown that limiting urgent assessment to patients with a score of 4 or more on ABCD2 would miss approximately 20% of those with early recurrent strokes. There appears to be a need for more research focus on dynamic imaging modalities like CTP or MRP, in addition to clinical information for better diagnosis and management of TIA.

By |February 16th, 2018|clinical|0 Comments

Statins and Intracerebral Hemorrhage — Causation or Coincidence?

Kevin S. Attenhofer, MD

Gaist D, Goldstein LB, Cea Soriano L, García Rodríguez LA. Statins and the Risk of Intracerebral Hemorrhage in Patients With Previous Ischemic Stroke or Transient Ischemic Attack. Stroke. 2017

Statins are some of the most commonly prescribed drugs in the fields of cardio- and cerebrovascular disease. In the last two decades, randomized controlled trials have shown that statin therapy reduces the risk of major vascular events in high-risk populations. Definitions of these populations have changed over the years, but currently the AHA/ASA stroke guidelines recommend statins in all patients for secondary stroke prevention.

Despite the ubiquitous usage of statins, it has been noted that some data (from the Heart Protection Study (HPS) and the Stroke Prevention with Aggressive Reductions of Cholesterol Levels (SPARCL)) suggests that the benefits of high-dose atorvastatin treatment was partially offset by an increase in hemorrhagic stroke. The association of statins and intracerebral hemorrhage (ICH) has remained controversial ever since. Subsequent meta-analyses and case control studies — some of which included data from SPARCL — found no associated increase in the risk of ICH in patients on statin therapy.

Author Interview: Dr. Greg Albers, on DEFUSE 3 and its Implications for Systems of Stroke Care in the U.S.

Dr. Greg Albers

Dr. Greg Albers

A conversation with Dr. Greg Albers, professor of neurology at Stanford and the principal investigator for DEFUSE 3.

Interviewed by Dr. Kaustubh Limaye, assistant professor of neurology in the division of cerebrovascular diseases at the University of Iowa, at the International Stroke Conference 2018 following the presentation of the final results of DEFUSE 3 and a simultaneous publication in the New England Journal of Medicine.

Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. New England Journal of Medicine. 2018

Dr. Limaye: Dr. Albers, first accept my hearty congratulations on the phenomenal success of the DEFUSE 3 trial.

Dr. Albers: Thank you so much.

Dr. Limaye: Just like everybody else, I was patiently waiting to hear what the results were going to be. All of us are delighted looking at the strong treatment effect that DEFUSE 3 showed in this extended time window. Thanks again for taking time out from your busy schedule. I’m sure this conference was extremely busy for you.

Dr. Albers: It’s been a very exciting week. We’ve been anticipating this for some time, and it’s wonderful to see this come to fruition.

Highlights from the International Stroke Conference 2018

International Stroke Conference
January 24–26

Philip Chang, MD

This year’s International Stroke Conference revealed big advances and changes to the acute ischemic stroke guidelines. I had a great time at the Los Angeles Convention Center and learned a lot, as new exciting trials revolutionized the acute ischemic stroke treatment landscape, most notably tripling the reperfusion time windows. As with every conference, there were tons of different lectures and abstracts to go to, but I’ll highlight what I found the most interesting, and key take-home points from the conference.

By |February 9th, 2018|Conference|0 Comments

ISC Session: The Efficacy and Safety of Cilostazol in Subarachnoid Hemorrhage

International Stroke Conference
January 24–26

Pouya Tahsili-Fahadan, MD

Vasospasm and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH) are a major cause of morbidity and mortality. The only proven medication to improve outcomes after SAH is nimodipine.

Cilostazol is a phosphodiesterase III inhibitor that has been shown to decrease vasospasm and DCI in animal studies, as well as in small clinical series. The proposed mechanisms include increase in endothelial release of nitric oxide (NO) and inhibition of platelet derived growth factor (PDGF), vascular smooth muscle proliferation, and expression of adhesion molecules on endothelium.

Dr. Muhammad F. Ishfaq presented the results of a meta-analysis of previous studies on the effects of cilostazol on vasospasm and DCI. A total of 6 studies were included in the meta-analysis after reviewing 33 studies (three studies were randomized clinical trials). The primary end-point was incidence of DCI secondary to vasospasm. Secondary end-points included: angiographic vasospasm, new stroke, mortality, and major disability (defined as modified Rankin scale 4-6 at discharge and follow-up exams).

By |February 2nd, 2018|Conference|0 Comments

ISC Session: Tough Decisions in ICH

International Stroke Conference
January 24–26

Danny R. Rose, Jr., MD

New advances in our understanding of intracerebral hemorrhage in recent years have led to new questions, as well as revisiting previously held notions about treatment and prevention.  The talks in this session covered coagulopathy reversal, anticoagulant usage in patients with a history of ICH, the relationship between statins and ICH and anti-edema therapy.

Dr. Thorsten Steiner, MD, PhD, began the session by discussing drug-induced coagulopathy reversal in ICH. The primary purpose of such therapies is to prevent hematoma expansion, which occurs in 30% of cases in the first 4 hours after ICH and is associated with increased morbidity and mortality. Anticoagulants increase this rate to upwards of 54% for vitamin K antagonists (VKAs) and 38% with direct-acting oral anticoagulants (DOACs). Timing is an important thing to consider in this scenario, given the half-life of VKAs are around 2 days, while DOACs are all around 14 hours, with peak effect somewhere between 3–4 hours. Specifically, many patients on DOACs may present in a time window when reversal would have little to no effect given the lack of active drug at the time. It is important to consider things that may cause variations in half-life for DOACs, including body size, inhibiting/inducing medications, and renal function (most important for dabigatran).

By |February 1st, 2018|Conference|0 Comments

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|0 Comments

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|0 Comments