American Heart Association

author interview

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.

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.

Author Interview: Ramin Zand, MD, and Vida Abedi, PhD

A conversation with Ramin Zand, MD, Neurology Director of Clinical Stroke Operations, Northeastern Regional Stroke Director, Geisinger Health System, and Associate Professor of Neurology, University of Tennessee Health Science Center, and Vida Abedi, PhD, Research Scientist, Geisinger Health System, and Adjunct Professor, Virginia Tech, about using an artificial neural network to screen for stroke.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper “Novel Screening Tool for Stroke Using Artificial Neural Network,” published in the June issue of Stroke.

Dr. Merino: Could you please briefly summarize the key findings and put them in context of what was known before you did the study (i.e. an “elevator pitch” about your research)?

Vida Abedi, PhD

Vida Abedi, PhD

Drs. Zand and Abedi: We have developed ​a new computational method based on artificial intelligence to screen for the stroke in an emergency setting. Previous studies have shown that up to 25% of strokes can be initially misdiagnosed in the emergency department. The failure to recognize stroke in the emergency department is a missed opportunity for intervention. The goal of our study was to test if a supervised learning method could recognize and differentiate stroke from stroke mimics based on the patient demographics, risk factors, and certain clinical elements. Our results showed that in 6 out of the 10 data sets, the precision of our tool for the diagnosis of stroke was >90%. We believe that these methods can serve as a clinical decision support system and assist the emergency providers with early recognition of stroke.

Ramin Zand, MD

Ramin Zand, MD

Sleep Apnea and Stroke: Interview with Antonio Culebras, MD

Antonio Culebras

Antonio Culebras

A conversation with Antonio Culebras, MD, Professor of Neurology, SUNY Upstate Medical University, about the association between sleep apnea and stroke.

Interviewed by Gurmeen Kaur, MBBS, Vascular Neurology Fellow, Icahn School of Medicine at Mount Sinai.

Dr. Kaur: What can you tell us about the association between sleep apnea and atrial fibrillation? What is the strength of the evidence supporting this association?

Dr. Culebras: Obstructive sleep apnea is a risk factor for stroke because of its association with systemic hypertension and other risk factors for stroke, including atrial fibrillation. The Stroke Risk in Atrial Fibrillation Working Group 2007 demonstrated a 5–10% increase in risk of stroke in patients with atrial fibrillation.

Gami et al studied a cohort of over 3000 patients over 65 years who underwent polysomnography. Over a 5-year follow-up period, nocturnal oxygen desaturations emerged as a predictor for new onset atrial fibrillation. In a study of 47 women and 111 men with subacute ischemic stroke admitted for neurorehabilitation (Chen et al, 2017), mean nocturnal desaturation was significantly associated with atrial fibrillation after adjusting for age, neck circumference, Barthel index, and high-density lipoprotein level. Poli et al also concluded that there is a strong correlation between age and sleep apnea that drives the increased frequency of stroke related to atrial fibrillation.

Author Interview: Søren Bache, MD

Søren Bache

Søren Bache

A conversation with Søren Bache, MD, from the Neurointensive Care Unit, Department of Neuroanaesthesiology and Centre for Genomic Medicine, Rigshospitalet, University of Copenhagen, Denmark, about microRNA changes after subarachnoid hemorrhage.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “MicroRNA Changes in Cerebrospinal Fluid After Subarachnoid Hemorrhage,” published in the September 2017 issue of Stroke.

​Dr. Merino: Thank you for agreeing to the interview. First, I would like you to explain some things about delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) for our readers: How common is it? How soon after SAH does it develop? How does it affect outcome after SAH?

Dr. Bache: The reported prevalence of DCI after SAH varies, but newer randomized clinical trials have found a risk of 21–38% in patients who survive the initial bleeding and aneurism-securing surgery. The variation in calculated risk may be due to discrepancies both in case definition (i.e. the numerator) and in the definition of which patients are entered into the denominator. Today, most researchers base their case definition of DCI on the criteria suggested by Vergouwen et al. (Vergouwen MD, et al. Stroke. 2010). Before this consensus work, the definition varied even more, and many used their own criteria for DCI, delayed ischemic neurological deficits (DIND) or cerebral vasospasm. However, not all patients are conscious enough to be assessed clinically for a deterioration in consciousness, and such patients may be either included or excluded in the total number of patients; hence, the variation in the denominator. Based on Vergouwen’s criteria, in our center, we found a prevalence of 23% in 450 patients admitted from 2009–12 with SAH (unpublished data). These patients all receive prophylactic nimodipine, which lowers the risk of DCI; therefore, one should expect publications from the pre-nimodipine era to report a higher prevalence of DCI (Dorhout Mees SM, et al. Cochrane Database of Systematic Reviews. 2007).

Delayed cerebral ischemia occurs a median of 6–7 days after hemorrhage, but this varies, with a typical reported range from 3 to 14 days. DCI may be reversible, but in some cases it progresses to permanent brain injury, thereby affecting outcome.

Author Interview: George Ntaios, MD

George Ntaios

George Ntaios

A conversation with George Ntaios, MD, MSc (ESO Stroke Medicine), PhD, Assistant Professor of Internal Medicine, Department of Medicine, University of Thessaly

Interviewed by Stephen Makin, PhD, Clinical Lecturer at Glasgow University

They will be discussing the paper, “Real-World Setting Comparison of Nonvitamin-K Antagonist Oral Anticoagulants Versus Vitamin-K Antagonists for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Meta-Analysis,” being published in the September 2017 issue of Stroke.

Dr. Makin: Thank you for taking the time to talk to us.

Prof. Ntaios: Thank you for the invitation to discuss our study.

Dr. Makin: Could I begin by asking you to summarize your study and its findings?

Prof. Ntaios: We aimed to summarize all available evidence from high-quality real-world observational studies about the efficacy and safety of non-vitamin-K-oral-anticoagulants (NOACs) compared to vitamin-K-antagonists (VKAs) in patients with atrial fibrillation (AF). Based on 28 identified studies, we found that dabigatran, rivaroxaban and apixaban, as compared to VKAs, are associated with lower risk of intracranial haemorrhage and similar risk of ischemic stroke and ischemic stroke or systemic embolism; apixaban and dabigatran with lower risk of mortality; apixaban with fewer gastrointestinal and major haemorrhages; dabigatran and rivaroxaban with higher risk of gastrointestinal haemorrhage; and dabigatran and rivaroxaban with a similar rate of myocardial infarction.

Author Interview: Robert G. Kowalski, MD, MS

Robert G. Kowalski

Robert G. Kowalski

A conversation with Robert G. Kowalski, MD, MS, Principal Investigator, Craig Hospital, and Assistant Clinical Professor of Neurology and PM&R, University of Colorado School of Medicine, about stroke following traumatic brain injury.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “Acute Ischemic Stroke After Moderate to Severe Traumatic Brain Injury: Incidence and Impact on Outcome,” published in the July issue of Stroke.

Dr. Merino: Thank you for agreeing to the interview. Can you first briefly describe the methods and main findings of the analysis published in Stroke?

Dr. Kowalski: The study was a research collaboration between the Centers for Disease Control and Prevention (CDC) and the Traumatic Brain Injury Model Systems (TBIMS) program. It was led by researchers at Craig Hospital in Englewood, CO. Investigators studied more than 6,400 traumatic brain injury (TBI) patients over a 7.5-year period to evaluate risk factors for onset, incidence, and predictors of outcome in ischemic stroke occurring acutely after TBI. We found that 2.5% of individuals who experience a moderate to severe TBI also suffer an acute ischemic stroke (AIS) at the time of the injury. In half of these cases, the individuals experiencing stroke concurrent with brain trauma were age 40 or younger. Additionally, the study found the risk of acute ischemic stroke immediately following traumatic brain injury was 10 times the risk of ischemic stroke in the general population.

Author Interview: Philippa Lavallée, MD

A conversation with Philippa Lavallée, MD, Department of Neurology and Stroke Centre, Bichat University Hospital, about the importance of atypical symptoms in patients with TIA.

Interviewed by José G. Merino, MD, FAHA, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “Clinical Significance of Isolated Atypical Transient Symptoms in a Cohort With Transient Ischemic Attack,” published in the June 2017 issue of Stroke.

Dr. Merino: Could you please briefly summarize the key findings and put them into context of what was known before you did the study?

Dr. Lavallée: Conventional wisdom considers that some transient symptoms such as diplopia, vertigo, dysarthria and even a sensory deficit limited to one limb or the face are not compatible with the diagnosis of TIA when they occur in isolation. Daily experience in the stroke unit and TIA clinic shows that it is not true. In our study, we enrolled 1,850 patients seen in our TIA clinic who had transient symptoms and found that 10% of the patients with stroke or TIA had one of these isolated atypical symptoms and that 10% of the patients with atypical symptoms had an acute infarct on brain MRI and 18% had an underlying disease that placed them at high risk of stroke recurrence.

Author Interview: Seung-Hoon Lee, MD, PhD

Seung-Hoon Lee

Seung-Hoon Lee

A conversation with Seung-Hoon Lee, MD, PhD, Professor of Neurology, Seoul National University Hospital, about the role of the susceptibility vessel sign on SWI to predict stroke subtype and recanalization.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “Prediction of Stroke Subtype and Recanalization Using Susceptibility Vessel Sign on Susceptibility-Weighted Magnetic Resonance Imaging,” published in the June 2017 issue of Stroke.

Dr. Merino: Could you please briefly describe the study and summarize the key findings, putting them into context of what was known before you did the study?

Dr. Lee: I’m glad to talk about our research in this interview. Thrombi in the cerebral arteries appear hypointense on susceptibility-weighted MRI (SWMRI). We call them “the susceptibility vessel sign” (SVS). The methodological strength of this study is that SWI MRI is much more sensitive than GRE and thus can quantify the size of the SVS. In this study, we analyzed the relationship between the size of the SVS, the stroke mechanism, and whether successful recanalization occurred in patients receiving endovascular treatment. Cardiac emboli are large but fragile because they are rich in RBCs but have scant platelets. We hypothesized that because the SVS reflects the red blood cell component of the clot, patients with larger SVS are more likely to have a cardioembolic source and thus more likely to have successful recanalization. We found that as the SVS size increased, the probability of cardioembolic stroke was higher, but that SVS size did not show any positive or negative correlation with successful recanalization. This is probably due to the high recanalization rate with the stent-retrievers, irrespective of stroke etiology. No association between SVS size and recanalization can be partly explained by clot fragility in cardioembolic stroke.

Author Interview: Alexandros Rentzos, MD, and Pia Löwhagen Hendén, MD, PhD

Alexandros Rentzos, MD, and Pia Löwhagen Hendén, MD, PhD

Alexandros Rentzos, MD, and Pia Löwhagen Hendén, MD, PhD

A conversation with Alexandros Rentzos, MD, Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, and Pia Löwhagen Hendén, MD, PhD, Anesthesiology and Intensive Care department, Sahlgrenska University Hospital, about the role of anesthesia and conscious sedation for patients undergoing embolectomy for stroke.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The AnStroke Trial (Anesthesia During Stroke),” published in the June 2017 issue of Stroke.

Dr. Merino: Could you please summarize the key findings of your study and put them in context of what was known on the topic?

Drs. Rentzos and Löwhagen: Since a number of retrospective studies showed that general anesthesia during endovascular stroke treatment was associated with poor neurological outcome, conscious sedation became the main method in most neurointerventional centers after 2010. However, the retrospective studies were limited by important selection bias, such as inclusion of posterior strokes (in some of the series) and, importantly, more severe stroke in patients treated under GA. Furthermore, most retrospective studies on anesthesia technique did not describe the anesthesia technique, nor the anesthetic management!

At our institute, we have used mainly general anesthesia since 1991 when we started with endovascular stroke treatment, and, in our experience, patients treated with GA did not have worse neurological outcome. That is why we started the randomized trial AnStroke in 2013. The results were presented in ESOC 2017 in Prague on May 18. In our trial, general anesthesia did not lead to worse neurological outcome compared to conscious sedation.