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Meet the Blogger: Rohan Arora, MD, FAHA

Rohan Arora

Name: Rohan Arora, MD, FAHA
Hometown: New Delhi, India
Current Position: Director of Stroke Program at LIJ Forest Hills, New York; Program Director, Vascular Neurology Fellowship, Zucker School of Medicine at Hofstra, Northwell, NY        

Q: What made you interested in a career in stroke?       

A: Finding myself in a position where my knowledge and expertise can save an individual from having permanent disability due to stroke is my constant motivation to practice this field. It could be a quick phone call/a telemedicine consult or long hours of ICU care; everything counts.

Q: What has been your career path into this field?

A: My focus is providing cutting edge clinical care, especially to young stroke patients, and enrolling patients in NIH-funded clinical studies and clinical trials. I am interested in finding novel methods to encourage people for a low-stress healthy lifestyle; that is one of the most commonly encountered risk factors for stroke and cerebrovascular disease.

By |March 25th, 2020|clinical|0 Comments

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: Dr. Marco Pasi, MD, on “Clinical Relevance of Cerebral Small Vessel Diseases”

Dr. Marco Pasi and Prof. Charlotte Cordonnier
Dr. Marco Pasi and Prof. Charlotte Cordonnier

An interview with Dr. Marco Pasi, MD, Stroke Clinical Fellow at Université de Lille, CHU Lille, Inserm U1172, France, on his article “Clinical Relevance of Cerebral Small Vessel Diseases.” The article, co-authored by Prof. Charlotte Cordonnier, was published in the January 2020 issue of Stroke as part of a Focused Updates in Cerebrovascular Disease series of articles on topics related to cerebral small vessel diseases.

Interviewed by Dr. Parneet Grewal, MD, Vascular Neurology Fellow at Rush University Medical Center, Chicago, Illinois.

Dr. Grewal: First, I would like to thank Dr. Pasi and Pr. Cordonnier for agreeing to do this interview. This is an interesting paper which discusses in detail the main manifestations of cerebral small vessel disease (SVD) along with their impact. Can you please summarize the key findings of your paper and their application to clinical practice?

Dr. Pasi: Cerebral small vessel diseases (SVD) have gained increased interest in the last decades as they play a crucial role in a large variety of conditions, such as aging, stroke, cognitive impairment, and other age-related disabilities. The term SVDis used with various meanings according to the context, but from a neuropathological perspective, SVD describes a group of pathologies that affect the perforating arteries and arterioles located in the brain parenchyma or in the leptomeningeal vessels. Sporadic SVD is characterized by two main forms that mainly differ for their localization within the brain. The first one is arteriolosclerosis, also known as hypertensive-SVD, which has a predilection for the deep lenticulostriate arteries that are vulnerable to poorly controlled and long-standing hypertension or diabetes. The second most common form is cerebral amyloid angiopathy that is a pathological process characterized by the progressive accumulation of ß-amyloid protein in the wall of small cortical and leptomeningeal arterioles and arteries. It is clinically relevant to distinguish these two forms of SVD because they differ in terms of hemorrhagic risk with important consequences when antithrombotic decisions need to be taken. In our review, we aimed to provide a comprehensive overview of the main clinical manifestations of SVD that could help stroke physicians in their daily practice.

By |March 20th, 2020|clinical|0 Comments

Intra-Arterial Urokinase: Looking for the TICI 3

Elena Zapata-Arriaza, MD
@ElenaZaps

Kaesmacher J, Bellwald S, Dobrocky T, Meinel TR, Piechowiak EI, Goeldlin M, et al. Safety and Efficacy of Intra-arterial Urokinase After Failed, Unsuccessful, or Incomplete Mechanical Thrombectomy in Anterior Circulation Large-Vessel Occlusion Stroke. JAMA Neurol. 2020;77:318–326.

Given the association among successful reperfusion and good functional outcomes, it is rational to look for tools that allow us to achieve the best TICI in patients undergoing mechanical thrombectomy. Within the ways to improve recanalization, we find the employment of safe and reliable devices with the ability to navigate more and more distally or the use of intra-arterial medication at the occlusion site. To determine the safety and efficacy of intra-arterial urokinase after failed or incomplete reperfusion in stroke mechanical thrombectomy(MT), Kaesmacher et al. performed an observational cohort study, with data collected from a prospective registry in a tertiary care stroke center from 2010-2017.

Primary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH), and secondary endpoints included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of 2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale. Patients who were treated with intra-arterial urokinase (with or without intravenous tPA) only and patients presenting with posterior circulation large-vessel occlusion or distal anterior circulation vessel occlusions were excluded. Endovascular treatment was performed with second generation devices only, mostly stent retrievers. Urokinase was injected manually before or next to and distal to the thrombus, usually via the same microcatheter used to introduce the MT device. Final TICI grades were assessed by an independent researcher. When intra-arterial urokinase was administered after failed or incomplete MT, TICI grade was assessed before and after the intra-arterial urokinase administration. If no change occurred in TICI after urokinase administration, the rater had to assess whether any kind of angiographic improvement occurred compared with before administration of intra-arterial urokinase.

By |March 18th, 2020|clinical|0 Comments

Non-Contrast CT Signs for Acute Intracerebral Hematoma Expansion Prediction: Alternatives to Spot Sign

Piyush Ojha, MBBS, MD, DM

Law ZK, Ali A, Krishnan K, Bischoff A, Appleton JP, Scutt P, et al. Noncontrast Computed Tomography Signs as Predictors of Hematoma Expansion, Clinical Outcome, and Response to Tranexamic Acid in Acute Intracerebral Hemorrhage. Stroke. 2020;51:121–128.

Spontaneous intracerebral hemorrhage (ICH) remains a major cause of morbidity and mortality worldwide. Hematoma expansion affects 30-40% of patients with acute ICH within the first few hours of onset; hence, its prevention is an important treatment target in acute ICH care to prevent neurological worsening and poor long-term outcome, thus necessitating more close neurological monitoring. Although the presence of spot sign in Computed Tomography (CT) angiography predicts hematoma expansion, only a minority of ICH patients receives contrast injection during the initial imaging. Since non-contrast CT (NCCT) is widely available and used, NCCT markers represent an important alternative for prediction of hematoma expansion. 

NCCT signs can be divided into density markers (swirl sign, blend sign, black hole sign, hypodensity and fluid level) and shape markers (irregular shape, island sign and satellite sign).

Various observational studies, RCT populations and meta-analyses have suggested that NCCT signs markers might be reliable predictors of hematoma expansion and poor outcome in ICH, but with different effect size and strength of association.

Article Commentary: “Nonfocal Transient Neurological Attacks Are Associated With Cerebral Small Vessel Disease”

Richard Jackson, MD

Oudeman EA, Greving JP, Van den Berg-Vos RM, Biessels GJ, Bron EE, van Oustenbrugge R, et al. Nonfocal Transient Neurological Attacks Are Associated With Cerebral Small Vessel Disease. Stroke. 2019;50:3540–3544.

Oudeman et al. have published a paper on non-focal TIA’s which have been called transient neurological attacks (TNAs). As neurologists, we are always trained to localize first, but anyone who has taken stroke calls from the ER knows that not all the presentations and calls are localizable, such as those mentioned in this paper and described as “bilateral weakness, unsteadiness, or confusion.” In the introduction, the authors mention that these were historically thought to be secondary to hypoperfusion, but recent imaging have shown them to be associated with ischemia. Underlying risk factors are common to traditional TIA’s, such as smoking and hypertension, but not atherosclerotic disease or atrial fibrillation, which led to the current investigation for an association between small vessel disease and TNAs.

ISC 2020 Session: “Transradial Approaches for Stroke and Cerebrovascular Disease: The End of Femoral Artery Complications?”

International Stroke Conference
February 19–21, 2020

Kat Dakay, DO

Use of the transradial technique as an alternative to traditional femoral access in neuroendovascular procedures has increased substantially over the last few years after studies have demonstrated its advantages and lower risk of access site complications.[1]   

However, there is a learning curve that one must traverse when adopting the transradial approach. This year, the International Stroke Conference dedicated a symposium to a multifaceted discussion about the benefits, challenges, and potential complications unique to transradial access. 

The session was moderated by Dr. Tudor Jovin and Dr. Nathan Manning, and speakers included Dr. Michael Levitt, Dr. Eric Peterson, Dr. Marios Psychogios, and Dr. Brian Snelling. Some major topics discussed:

1. Why go radial?

There are several reasons to consider utilizing the transradial approach. Dr. Peterson discussed one major reason, patient preference — with a transradial approach, there is no need for patients to lay flat postoperatively, which can make even small tasks like using the restroom awkward and cumbersome. Increased awareness of the transradial method by the general public has led to increasing patient requests to use this approach. Anecdotally, as a fellow explaining and obtaining consent for diagnostic angiograms, many patients have said to me, “I really hope you can use my hand instead of the leg.” As the popularity of transradial access in both cardiology and neuroendovascular procedures grows, this is likely to become more common. Objectively, one study demonstrated that 24/25 patients who underwent prior transfemoral cerebral angiography and subsequently underwent transradial angiography preferred the radial method.[2] Another reason Dr. Peterson discussed is that in patients with obesity or significant arch tortuosity, transfemoral access can prove challenging and the radial approach may be easier in selected cases. Lastly, and probably the most compelling and important reason, which both Dr. Peterson and Dr. Levitt discussed, is that it is safer. Multiple cardiology trials have demonstrated that transradial procedures are safer than transfemoral procedures with an overall lower risk of major complications and mortality.[1, 3] 

Normal-Appearing White Matter – It’s Not What It Looks Like

Charlotte Zerna, MD, MSc
@CharlotteZerna

Sagnier S, Catheline G, Dilharreguy B, Linck P-A, Coupé P, Munsch F, et al. Normal-Appearing White Matter Integrity Is a Predictor of Outcome After Ischemic Stroke. Stroke. 2020;51:449–456.

The relationship between normal-appearing white matter (NAWM) integrity and specific brain functions has been reported during aging and in patients with cerebral small vessel disease, suggesting that it might be a relevant area of cerebral plasticity. In this study, the authors wanted to evaluate the predictive value of NAWM integrity on different domains of post-stroke recovery.

Through the Brain Before Stroke study undertaken by the Bordeaux University Hospital, eligible patients (>18 years, ischemic supratentorial stroke diagnoses within 24 to 72 hours after symptom onset, NIHSS between 1-25, in the absence of pre-stroke dementia and pre-stroke disability (mRS ≥1)) were prospectively and consecutively recruited between June 2012 and February 2015.

ISC 2020 Session: “Screening for Cognition and Factors Related to Brain Health”

International Stroke Conference
February 19–21, 2020

Session: “Screening for Cognition and Factors Related to Brain Health,” Thursday, February 20, 2020

Moderators: Dr. Ronald M. Lazar, Birmingham, AL; and Dr. Rebecca F. Gottesman, Baltimore, MD

Abstract: It is increasingly recognized that vascular risk factors promote cognitive decline, both independently and interactively with neurodegenerative disease. Because these risk factors are modifiable, evaluation in the setting of primary care represents a unique opportunity for early detection and treatment.

Shashank Shekhar, MD, MS
@ArtofStroke

The session had four presentations. Dr. Walter N. Kernan Jr. from New Haven, CT, led the first talk on “Evaluating cognition in elderly at primary care.” He explained why primary care is important in recognizing cognitive issues. He went on to explain the spectrum of cognitive impairment, which ranges from subjective, mild cognitive impairment (annual risk of progression?), dementia (annual risk of progression 7%). He then laid out a simple flow chart of evaluating cognition in the primary setting: identifying the 1) signal, 2) case finding, 3) Classification and management. The signal could be in the form of reporting by patient or family, the observation by a physician, or casual inquiry. Case finding refers to using assessment tools such as Memory Impairment screen, MMSE, MOCA, etc., to screen for cognition. The final step is to confirm the diagnosis, identify any treatable causes, identify functional impairment, classify etiology, and further neuropsychiatric assessment.

The speakers address audience questions during the session “Screening for Cognition and Factors Related to Brain Health” on February 20, 2020, during the International Stroke Conference. From left, Dr. Sudha Seshadri, Dr. Walter N. Kernan, Dr. Virginia J. Howard, Dr Philip B. Gorelick, Dr Ronald M. Lazar, and Dr. Rebecca F. Gottesman.
The speakers address audience questions during the session “Screening for Cognition and Factors Related to Brain Health” on February 20, 2020, during the International Stroke Conference. From left, Dr. Sudha Seshadri, Dr. Walter N. Kernan, Dr. Virginia J. Howard, Dr. Philip B. Gorelick, Dr. Ronald M. Lazar, and Dr. Rebecca F. Gottesman.

Dr. Virginia J. Howard from Birmingham, AL, gave the second presentation on “Considerations in cognitive assessment in disparate populations.” Her talk focused on disparities related to sex, age, disability, socioeconomic status, and geographic locations. She identified barriers to recruitment and retention at different levels, i.e., individual to research institutions. She suggested engaging community leaders in the research process and using community outreach programs, and that preparing a realistic budget would greatly help achieve the goal. Changes are also required in the study design, i.e., in-home evaluations, and identifying all levels of influences and barriers at the institution and community would help with more recruitment and higher retention.

ISC 2020 Session: “Contemporary Management of Unruptured Intracranial Aneurysms: What to Counsel Patients”

International Stroke Conference
February 19–21, 2020

Kat Dakay, DO

Deciding how to manage unruptured intracranial aneurysms is a common challenge in neuroendovascular surgery, as many of these aneurysms are incidentally found on imaging performed for other reasons. The classic dogma of the ISUIA study stratifies rupture risk based on size and location; however, this is an oversimplified picture. In this ISC session, the speakers discussed complex anatomical features, neuroimaging findings, and lifestyle counseling for patients with unruptured intracranial aneurysms.

Dr. Juhana Frösen discussed the influence of wall structure on rupture risk; the wall structure of aneurysms is very heterogenous. This may explain why some small aneurysms can rupture. Macrophages and inflammation can lead to aneurysm wall growth, which increases the stress on the aneurysm and can increase the risk of rupture. Future targets for drug research may include reducing inflammation and reducing wall growth.