American Heart Association

author interview

Author Interview: Drs. Diogo Haussen, MD, and Yasir Saleem, MD, on “Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically”

Diogo Haussen
Dr. Diogo Haussen
Dr. Yasir Saleem
Dr. Yasir Saleem

A conversation with Diogo Haussen, MD, Assistant Professor of Neurology, Emory School of Medicine/Grady Memorial Hospital, and Yasir Saleem, MD, Assistant Professor of Neurology, Baylor College of Medicine, on the approach to patients with large vessel occlusion (LVO) and mild symptoms.

Interviewed by Jennifer Harris, MD, stroke fellow, Columbia University, and Rachel Forman, MD, stroke fellow, Massachusetts General Hospital.

They will be discussing the article “Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically,” published in the May 2020 issue of Stroke.

Drs. Harris and Forman: Thank you for taking the time to speak with us on this important topic.  

Drs. Haussen and Saleem: Thank you for reaching out. It is a pleasure interacting with you.

Drs. Harris and Forman: As stroke fellows, we run into this scenario from time to time, and it is often a challenging decision that generates good discussion. What was the background for you in wanting to study this specific topic?

Drs. Haussen and Saleem: A common reason for neurological deterioration in patients presenting with mild strokes is the underlying presence of a large vessel occlusion. Importantly, neurological worsening in this setting has been associated with worse clinical outcomes. However, not all individuals with large vessel occlusion and mild presentation end up worsening. We have observed, in our original experience (Haussen DC et al. JNIS 2017 Oct;9(10):917-921), that >40% of patients with LVO medically managed had some degree of neurological deterioration. We wanted to evaluate the potential variables that could potentially predict neurological worsening within patients presenting with minor stroke symptoms and large vessel occlusion.

Author Interview: Dr. Eric Jouvent, MD, PhD, on “Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy”

Dr. Eric Jouvent
Dr. Eric Jouvent

A conversation with Dr. Eric Jouvent, MD, PhD, Professor of Neurology at Paris University. He is involved in acute stroke care in the stroke unit in Lariboisière Hospital in Paris. He holds a PhD in image processing.

Interviewed by Dr. Stephanie Lyden, MD, BS, a vascular neurology fellow at the University of Utah.

They will be discussing the article “Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy: Lessons From Neuroimaging.” Published in the January 2020 issue of Stroke, it is part of a Focused Updates in Cerebrovascular Disease series of articles on topics related to cerebral small vessel diseases.

Dr. Lyden: First of all, thank you for taking the time to discuss this important topic. What led you to become interested in studying CADASIL?

Dr. Jouvent: It was not really a choice at first. Residency in France is different than in the United States, where we first choose a city and then we move from department to department in that city. At the end of that time period, you hope to match in a department or with a team. At the end of my cycle, I matched with a team headed by Dr. Bousser, who identified the first family with CADASIL, in part because I was not only interested in stroke, but also in cognitive and behavioral alterations and in advanced MRI techniques, which are key aspects in small vessel diseases. This was how I started to become involved in CADASIL research.

Author Interview: Profs. Eric E. Smith and Hugh Markus on “New Treatment Approaches to Modify the Course of Cerebral Small Vessel Diseases”

Professor Eric E. Smith and Professor Hugh Markus
Prof. Eric E. Smith and Prof. Hugh Markus

A conversation with Professor Eric E. Smith, MD, Ph.D., Professor of Neurology, Cumming School of Medicine, University of Calgary, Canada, and Professor Hugh Markus, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.

Interviewed by Shashank Shekhar, MD, MS, Assistant Professor, Division of Vascular Neurology, University of Mississippi Medical Center, USA; @ArtofStroke.

They will be discussing the article “New Treatment Approaches to Modify the Course of Cerebral Small Vessel Diseases,” published in the January 2020 issue of Stroke. The article is part of a Focused Updates in Cerebrovascular Disease series of articles on topics related to cerebral small vessel diseases.

Dr. Shekhar: I would like to thank Prof. Smith and Prof. Markus for agreeing to do this interview. In this interesting review paper, you have discussed in detail the new treatment approaches to modify the course of small vessel disease. Could you tell the readers why you decided to write about this topic?

Prof. Smith: Cerebral small vessel disease is a common condition of aging. We now know that it can cause cognitive decline and stroke. When I chaired a writing group for the American Heart Association that produced a scientific statement on stroke prevention in persons with silent cerebrovascular disease (Smith et al, Stroke 2017; 48:e44-e71), one of the interesting things we found is that there were few clinical trials that focused on small vessel disease. There are no medications specifically indicated for cerebral small vessel disease. The time seemed ripe to review progress in this area, and indeed we found emerging evidence for new treatment strategies in early phase trials.

Prof. Markus: Cerebral small vessel disease is an enormous health problem — it causes a quarter of all strokes and is the most common cause of vascular dementia. Despite this, there are few, if any, treatments for established disease, and it remains one of the great therapeutic challenges in stroke. We wanted to summarize where we were and describe a pathway forwards.

Author Interview: Prof. Adnan Siddiqui, MD, PhD, on the COMPASS Trial

Prof. Adnan Siddiqui
Prof. Adnan Siddiqui

An interview with Prof. Adnan Siddiqui, MD, PhD, Professor of Neurosurgery and Radiology, University at Buffalo, about aspiration thrombectomy versus stent retriever thrombectomy as a first-line approach for large vessel occlusion strokes.

Interviewed by Dr. Robert Regenhardt, MD, PhD, Fellow, Massachusetts General Hospital. 

They will be discussing the article “Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial,” published in The Lancet.

Dr. Regenhardt: The endovascular thrombectomy (EVT) trials from the last few years have revolutionized the approach to the treatment of acute stroke from large vessel occlusion (LVO). For most patients enrolled in these trials, stent retriever devices were used for EVT. Indeed, the current stroke guidelines specifically recommend the use of stent retrievers for EVT to treat eligible patients. Therefore, the robust, randomized COMPASS trial may lead to practice changes at many institutions, encouraging interventionalists to perform a direct aspiration first pass technique (ADAPT). Would you mind describing your approach and experience with ADAPT?

Prof. Siddiqui: At Buffalo, we were some of the original stenting for stroke trialists. Dr. [J] Mocco was part of that group, and he took that with him after he completed his fellowship at Buffalo. We realized the value of putting a stent across a clot, like cardiologists do for STEMIs. However, when you drop a stent into someone, you need to put them on aspirin and Plavix. And, unlike in the heart, most of the time there is no underlying plaque. The lesion causing the occlusion often is an embolus that traveled from somewhere else to the brain. As part of that original stenting for stroke trial, towards the end, we were using a stent called Enterprise. Enterprise came in a long size and you could actually partially deploy it and drag it back. Lo and behold, we would retrieve the stent and out came the clot. And so that was the genesis of the whole stent retriever concept, and that caught on like wildfire.

Author Interview: Prof. Kazuo Kitagawa, MD, PhD, on “Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke”

Prof. Kazuo Kitagawa
Prof. Kazuo Kitagawa

An interview with Prof. Kazuo Kitagawa, MD, PhD, Department of Neurology, Tokyo Women’s Medical University, Tokyo, Japan, about the optimal blood pressure goal for secondary stroke prevention.

Interviewed by Dr. Mohammad Anadani, MD, neurocritical care fellow, Washington University, St. Louis, MO.

They will be discussing the article “Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke: A Randomized Clinical Trial and Meta-analysis,” published in JAMA Neurology.

Dr. Anadani: First, I want to thank Prof. Kitagawa for agreeing to the interview. Prof. Kitagawa is the lead investigator of the RESPECT trial, which investigated the optimal blood pressure goal for secondary stroke prevention.

Could you please share with the readers the rationale behind the RESPECT trial and summarize the key findings of the trial?

Dr. Kitagawa: Although the SPRINT trial recently demonstrated that a systolic blood pressure (BP) target of <120 mmHg was superior to <140 mmHg for preventing vascular events, no evidence was published about what is the optimal blood pressure target in the secondary stroke prevention.

In the RESPECT Study that included 1263 patients with a history of stroke, intensive blood pressure control to less than 120/80 mmHg tended to reduce stroke recurrence compared with standard blood pressure control (<140/90 mmHg). When this finding was pooled with the results of prior trials of intensive blood pressure control for secondary stroke prevention in an updated systematic review, intensive blood pressure treatment significantly reduced stroke recurrence by 22%. In conclusion, intensive blood pressure control to less than 130/80 mmHg is recommended for secondary stroke prevention.

Author Interview: Dr. Diogo Haussen, MD, and Dr. Thomas Madaelil, MD, on “Multimodality Imaging in Carotid Web”

Dr. Diogo Haussen, left, and Dr. Thomas Madaelil

Dr. Diogo Haussen, left, and Dr. Thomas Madaelil

A conversation with Dr. Diogo Haussen, MD (Assistant Professor of Neurology, Emory School of Medicine/Grady Memorial Hospital), and Dr. Thomas Madaelil, MD (Neurointerventional Fellow, Emory School of Medicine), on imaging and clinical significance of carotid web.

Interviewed by Sami Al Kasab, MD (StrokeNet fellow, University of Iowa Hospitals and Clinics).

They will be discussing the paper “Multimodality Imaging in Carotid Web,” published in Frontiers in Neurology.

Dr. Al Kasab: I read with great enthusiasm your recent article comparing different imaging modalities to diagnose a carotid web. Can you please summarize the key findings of your study, and how your results can be applied to our clinical practice?

Drs. Haussen and Madaelil: Thank you for your interest in our manuscript. Acute ischemic stroke is commonly a devastating condition, especially when occurring in young adults. Occasionally, we can get tangled when we cast wide nets for the diagnostic work-up in patients with cryptogenic stroke. Carotid web is a condition that can be overlooked when neurovascular studies are reviewed during this diagnostic work-up period, and it may actually be more common that previously thought. Our study is aimed to help shed light on the performance of different imaging modalities in the diagnosis of carotid web, which is particularly important since there were no previously published comparative studies. We observed that computed tomographic angiogram (CTA) shared very high rates of inter-rater agreement with digital subtraction angiogram (DSA), while the CTA agreement with ultrasonography was much more limited. Therefore, non-invasive multiplanar imaging modalities, such as CTA, should be considered in the evaluation of young patients with otherwise no identified stroke cause considering the possibility of an underlying carotid web.

Author Interview: Drs. Thabele (Bay) Leslie-Mazwi, MD, and Gregory W. Albers, MD, on “DEFUSE 3 Non-DAWN Patients: A Closer Look at Late Window Thrombectomy Selection”

Dr. Thabele (Bay) Leslie-Mazwi, left, and Dr. Gregory W. Albers

Dr. Thabele (Bay) Leslie-Mazwi, left, and Dr. Gregory W. Albers

An interview with Dr. Thabele (Bay) Leslie-Mazwi, MD, Director of Endovascular Stroke Services, Massachusetts General Hospital; Assistant Professor of Neurology, Harvard University; and Dr. Gregory W. Albers, MD, Director, Stanford Stroke Center; Professor of Neurology, Stanford University.

Interviewed by Kristina Shkirkova, BSc, Doctoral Student in Neuroscience, Department of Neurosurgery, Zilkha Neurogenetic Institute, University of Southern California.

They will be discussing the article “DEFUSE 3 Non-DAWN Patients: A Closer Look at Late Window Thrombectomy Selection,” published in the March 2019 issue of Stroke.

Ms. Shkirkova: Please briefly summarize the design and findings of your study.

Drs. Leslie-Mazwi and Albers: We evaluated DEFUSE 3 patients who would have been excluded from the DAWN trial based on DAWN eligibility criteria, with the goal of assessing treatment effect in that DEFUSE 3 subgroup (DEFUSE 3 Non-DAWN). The main reasons for DEFUSE 3 Non-DAWN were NIHSS 6-9, core too large (based on age and volume of established infarct), and mRS of 2. Patients with mRS 2 were included with the NIH stroke scale 6-9 group, as detailed in our paper, and so we analyzed the DEFUSE 3 Non-DAWN patients NIHSS 6-9 and core-too-large patients to assess treatment effect in that subgroup.

Patients with pretreatment core infarct volumes <70ml but too large for inclusion by DAWN criteria demonstrated robust benefit from endovascular therapy. Data supporting a beneficial treatment effect across the full range of NIHSS scores was documented in the entire DEFUSE 3 population. In our small subgroup of patients with NIHSS 6-9, we found a trend towards benefit.

Author Interview: Prof. Craig Anderson, MD, PhD, on “Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED)”

Prof. Craig Anderson

Prof. Craig Anderson

An interview with Prof. Craig Anderson, MD, PhD, Professor of Neurology and Epidemiology, University of New South Wales, about blood pressure management after intravenous thrombolysis treatment.

Interviewed by Dr. Mohammad Anadani, MD, Neurology Resident, Medical University of South Carolina.

They will be discussing the paper Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial, published in the February 2019 issue of The Lancet.

Dr. Anadani: First, I want to thank Prof. Anderson for agreeing to the interview. Prof. Anderson’s research has a significant impact on the stroke field and especially on our understanding of the relationship between blood pressure and outcome after hemorrhagic and ischemic stroke. Prof. Anderson was the lead investigator of the INTERACT 2 trial and the ENCHANTED trial. In this interview, we will discuss the results of the ENCHANTED trial and its implication on clinical practice.

Author Interview: Dr. Raul Nogueira, MD, on “Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions”

Dr. Raul Nogueira

Dr. Raul Nogueira

A conversation with Raul Nogueira, MD, Professor of Neurology, Neurosurgery and Radiology,Emory University School of Medicine, Director of Neuroendovascular Service, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, on endovascular thrombectomy for acute ischemic stroke with mild symptoms.

Interviewed by Mark R. Etherton, MD, PhD, Assistant in Neurology, Massachusetts General Hospital, Instructor, Harvard Medical School.

They will be discussing the paper “Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions: A Multicenter Matched Analysis,” published in the October 2018 issue of Stroke.

Dr. Etherton: This is a very interesting paper that I think raises some good questions about the triage and management approaches to patients with large vessel occlusions and low severity ischemic strokes as assessed with the NIHSS. Could you speak a little bit regarding your management approaches to this patient population, including if any differences whether the stroke was involving the anterior or posterior circulation?

Dr. Nogueira: The first thing you have to acknowledge is there is not a lot of data to answer this question. The data is mostly retrospective in nature. There are methodological issues with these retrospective approaches in that you have to analyze them as intention-to-treat. So you have to separate out the cohorts as immediate treatment versus no immediate treatment. In reality, you really have three groups: immediate mechanical thrombectomy (MT), immediate medical therapy, and immediate medical therapy with subsequent deterioration and rescue MT. You cannot group this last group with the MT group because your initial intent was to treat this group medically. This is the equivalent of cross-over in a clinical trial which creates methodological problems.

Author Interview: Prof. Turgut Tatlisumak, MD, PhD, on “Nontraumatic intracerebral haemorrhage in young adults”

Prof. Turgut Tatlisumak

Prof. Turgut Tatlisumak

A conversation with Turgut Tatlisumak, MD, PhD, from the Department of Clinical Neuroscience and Neurology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.

Interviewed by Shashank Shekhar (@ArtofStroke), MD, MS, Assistant Professor, Division of Vascular Neurology, University of Mississippi Medical Center.

They will be discussing the article “Nontraumatic intracerebral haemorrhage in young adults,” published in Nature Reviews Neurology.

Dr. Shekhar: First, I would like to thank Prof. Tatlisumak for agreeing to do this interview. This is an interesting review paper in which you have discussed in detail nontraumatic intracerebral hemorrhage (ICH) in young adults. Could you tell the readers why you decided to write about hemorrhage in young adults?

Prof. Tatlisumak: We have long been investigating stroke in young adults, but most of our attention went to ischemic strokes. I wished to extend our research to ICH in young adults and found only few original patient series. Sometime later, I noticed that there is not a single review on this topic, and there is an unmet need. Then we set up a small group of experts sharing the tasks. That is how we started.