American Heart Association

author interview

Author Interview: Dr. Masafumi Ihara on “Oral Carriage of Streptococcus mutans Harboring the cnm Gene Relates to an Increased Incidence of Cerebral Microbleeds”

Dr. Masafumi Ihara, left, and Dr. Saurav Das

An  interview with Dr. Masafumi Ihara, MD, PhD; Head, Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan.

Interviewed by Dr. Saurav Das, MD; Fellow in Vascular Neurology, Washington University School of Medicine, St. Louis.

They will be discussing the article “Oral Carriage of Streptococcus mutans Harboring the cnm Gene Relates to an Increased Incidence of Cerebral Microbleeds,” published in the December 2020 issue of Stroke.

Dr. Das: Dr. Ihara, on behalf of the Blogging Stroke team, it is my pleasure to welcome you to this author interview about your publication in Stroke regarding the association between CNM gene-positive Streptococcus mutans and increased incidence of cerebral microbleeds. Given Streptococcus mutans is a common pathogen associated with dental caries, it is a potential treatment target to prevent increase in cerebral microbleeds.

Many of our readers come from a stroke background and may not be as familiar with oral pathology. It will be of interest to start by discussing some common oral pathogens implicated in cerebrovascular disease. Also, what is specific about Streptococcus mutans, and particularly the ones positive for CNM gene?

Dr. Ihara: More than 500 bacterial species have been estimated to exist in the oral cavity, and many remain to be identified and characterized. Of all the known pathogenic oral bacteria, a few have been linked to cerebrovascular diseases. Our co-investigator Prof. Nakano reported that certain strains of Streptococcus mutans (S. mutans) are potential risk factors for intracerebral hemorrhage in stroke-prone spontaneously hypertensive rats and mice with photochemically induced middle cerebral artery occlusion.1 This corresponds with findings showing periodontal infections to be risk factors for stroke, and that S. mutans is detected in 100% of samples of atherosclerotic plaques. S. mutans is a major pathogen in dental caries that can cause bacteremia by dental procedures, such as tooth extraction and periodontal surgery, or even tooth brushing in daily life. S. mutans is well known to be responsible for infective endocarditis. The hemorrhage-causing S. mutans strains express collagen-binding protein Cnm on their cell surface, enabling them to attach to exposed collagen fibers on the surface of damaged blood vessels and prevent platelet activation, thereby, leading to hemorrhages. Another dental bacterium, Porphyromonas gingivalis (P. gingivalis), is also found in atherosclerotic plaques and has been linked to the increased risk of ischemic stroke. P. gingivalis adheres to and infects endothelial cells not only to increase the expression of endothelial adhesion molecules and promote monocyte/macrophage infiltration, but also to produce cysteine proteinase gingipains, which activate protease-activated receptors-1 and -4 on platelets to induce platelet aggregation. Thus, infection from P. gingivalis could cause small vessel disease pathology through thrombotic occlusion and BBB disruption through inflammation.

World Stroke Day: Interview with Dr. Anna Bersano on the Impact of the COVID-19 Pandemic on Stroke Care in Italy

Dr. Anna Bersano
Dr. Anna Bersano

An interview with Dr. Anna Bersano, MD, PhD, at the Cerebrovascular Unit of Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy, about the impact of the COVID-19 pandemic on stroke care in Italy.

Interviewed by Francesca Tinelli, MCs, rare cerebrovascular disease fellow at Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

Dr. Tinelli: First of all, I present you Dr. Anna Bersano, the neurologist I work with, and I would like to thank Anna for agreeing to do this interview. 

Anna is a stroke neurologist with long-term expertise in cerebrovascular diseases, particularly in genetics of monogenic and complex stroke diseases, combining research with an active practice as a vascular care neurologist. She coordinated several studies on genetics of stroke, such as the Lombardia GENS study on stroke monogenic disease and the SVE-LA study on genetics of small vessel disease and lacunar stroke. Recently, she implemented an Italian network for the study of Moyamoya disease named GE-NO-MA (Genetics of Moyamoya Disease) and an Italian network for the study of Cerebral Amyloid Angiopathy (SENECA project). 

Dr. Bersano: Thank you for discussing this relevant and critical topic in the current situation.

Dr. Tinelli: What is the correlation between SARS-CoV2 and cerebrovascular diseases?

Dr. Bersano: It is well known that SARS-CoV2 invades human respiratory epithelial cells through its S-protein and ACE2 receptor on human cell surface. Then, the virus can spread from the respiratory tract to the central nervous system, causing possible neurological complications. A recent study on 214 Chinese COVID-19 patients reported acute cerebrovascular events in 5.7% of COVID-19 patients. However, the exact relationship between SARS-CoV2 and stroke is unclear. Patients affected by COVID-19 have been observed to have a higher risk of cerebrovascular events, probably due to the activation of coagulation and inflammatory pathways, which lead to cardiovascular and thrombotic complications, or to cardioembolic causes.

Author Interview: Dr. Bruce Ovbiagele on “HEADS-UP: Understanding and Problem-Solving: Seeking Hands-Down Solutions to Major Inequities in Stroke”

A conversation with Dr. Bruce Ovbiagele, MD, MSc, MAS, MBA, Professor of Neurology, University of California, San Francisco.

Interviewed by Dr. Saurav Das, MD, Fellow in Vascular Neurology, Washington University School of Medicine, St. Louis.

They will be discussing the article “HEADS-UP: Understanding and Problem-Solving: Seeking Hands-Down Solutions to Major Inequities in Stroke,” published in November 2020 issue of Stroke. The article is part of a Focused Updates series of articles on topics related to health equity.

Dr. Das: Dr. Ovbiagele, at the outset, I want to thank you on behalf of the Blogging Stroke team for organizing this timely and reflective series of articles. I read with enthusiasm your introduction to the series. Thanks for finding time for this interview.

Dr. Ovbiagele, COVID-19 and the killings of unarmed Black individuals by police recently have brought to the forefront discussions about pre-existing racial disparities in stroke care. However, the idea of HEADS-UP was envisaged even before these extenuating circumstances. Please throw some light on the origins of the idea.

Dr. Ovbiagele: My co-chair, Dr. Amy Towfighi, and I have been involved in stroke disparities research for a while (Amy doing work with the Latinx population in Los Angeles, and I doing work with people of African ancestry in South Carolina and Sub-Saharan Africa), and had lamented about both the lack of successful interventions and a clear pipeline of next generation stroke disparities researchers. We observed that with changing U.S. demographics and anticipated worsening of stroke inequities, stroke disparities research and publications seemed to mostly focus on repeatedly pointing out the existence and magnitude of racial/ethnic disparities, that the stroke disparities community was not routinely connected or integrated in a sustainable way, and that early career individuals interested in stroke disparities did not appear to have an established avenue through which to nurture that interest into a successful independent academic career. We thought that if we could bring key stakeholders together in a forum that routinely informs and inspires established and budding stroke disparities researchers to better solutions and greater heights, we might be able to accelerate the pace of discoverers and discoveries. We approached the American Stroke Association, National Institute of Neurological Disorders and Stroke, and several of our esteemed research colleagues about the idea, and then collectively planned and implemented the inaugural Symposium.

Pictured, from left to right, at the International Stroke Conference 2020, are Dr. Amy Towfighi, Dr. Bruce Ovbiagele, Dr. Ralph Sacco, and Ms. Adrienne Kenton, daughter of Dr. Edgar Kenton III, after whom the Kenton Award is named.
Pictured, from left to right, at the International Stroke Conference 2020, are Dr. Amy Towfighi, Dr. Bruce Ovbiagele, Dr. Ralph Sacco, and Ms. Adrienne Kenton, daughter of Dr. Edgar Kenton III, after whom the Kenton Award is named. Photo provided, with permission, by Dr. Ovbiagele.

Dr. Das: Dr. Ovbiagele, you have summarized in your introduction a series of key papers from the 2020 HEADS-UP symposium in Los Angeles, California. These papers explore biological and social determinants of disparities and explore multi-level interventions. However, neither of these categories have explored “racism,” individual or systemic, as a study variable in stroke research. What are your thoughts, and will this be addressed in the HEADS-UP symposium in 2021?

Author Interview: Prof. Marc Ribo on “Deep Learning Based Software to Identify Large Vessel Occlusion on Noncontrast Computed Tomography”

Prof. Marc Ribo
Prof. Marc Ribo

An interview with Prof. Marc Ribo, MD, PhD, Assistant Professor at the Stroke Unit/Department of Neurology at the Hospital Vall d’Hebron, Barcelona, Spain.

Interviewed by Dr. Vera Sharashidze, MD, Vascular Neurology Fellow, University of Miami.

They will be discussing the article “Deep Learning Based Software to Identify Large Vessel Occlusion on Noncontrast Computed Tomography,” published in the October 2020 issue of Stroke.

Dr. Sharashidze: First of all, thank you for taking time to discuss this very interesting article. What led you to become interested in this topic?

Prof. Ribo: My first interest in AI analysis of acute stroke imaging began when I met by coincidence with an expert engineer who wanted to use his skills to help stroke patients.

Author Interview: Dr. Mayank Goyal on “Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging”

Dr. Mayank Goyal and Dr. Saurav Das
Dr. Mayank Goyal, left, and Dr. Saurav Das

A conversation with Mayank Goyal, MD, PhD, Professor of Radiology and Clinical Neurosciences, University of Calgary.

Interviewed by Saurav Das, MD, Fellow in Vascular Neurology, Washington University School of Medicine, St. Louis.

They will be discussing the topical review “Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging,” published in October 2020 issue of Stroke

Dr. Das: Dr. Goyal, the Blogging Stroke team is happy to have you for an author interview today. Thanks for this provocative paper, which disrupts several currently accepted ideas that guide decision-making in stroke patients to make way for new innovation.

Let’s start by discussing the context in which this paper was conceptualized. The paper has a line-up of great authors, many considered visionaries in vascular neurology, across countries. Please tell us more about how this collaboration came into being.

Dr. Goyal: I have been thinking about the problem of defining ischemic core on baseline imaging for a long time. I noticed patients with a really bad-looking baseline CT, patients in which you would be inclined to call the whole MCA territory “core.” But when these patients went on to endovascular treatment and we managed to re-open the occluded vessel quickly, many of those did well, and their follow-up MRI scans showed that much of the parenchyma thought to be “core” was not actually damaged. More importantly, many of these patients did well clinically, resulting in a clinical-imaging mismatch. In addition, I was quite convinced that the so called “core” on CT perfusion was quite an exaggeration of the truth. In some ways, when many of the trials were being designed, they came in the aftermath of the Interventional Management of Stroke (IMS) 3 trial, and hence, people were over-conservative in their selection criteria. I then started talking to several of my collaborators and friends from all over the world, to see whether they felt the same way. This is when this collaboration was formed.

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.