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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.

Meet the Blogger: Richard Jackson, MD

Richard Jackson

Name: Richard Jackson, MD
Hometown: Radford , VA
Current Position: Glens Falls Hospital Stroke Director

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

A: My father was a general neurologist who believed that a generalist could treat anyone with the right resources and knowledge. He even starting the tPA program in my hometown. I, too, became a generalist, but I realized after three years that with the rapidly changing treatments and a large need in most communities, my current level of knowledge would not be enough in the near future. 

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

A: I started out as a generalist and created programs in Botox and confusion locally, but starting a primary stroke center showed me that to treat people on that size scale, specialized training would be required. The need, coupled with a previous interest in vascular neurology and neuroimaging, helped shape the decision to return to fellowship.

By |January 3rd, 2020|clinical|0 Comments

IV tPA or Mechanical Thrombectomy: Is One Better for Acute Posterior Cerebral Artery Occlusions?

Elizabeth M. Aradine, DO

Strambo D, Bartonlini B, Beaud V, Marto JP, Sirimarco G, Dunet V, et al. Thrombectomy and Thrombolysis of Isolated Posterior Cerebral Artery Occlusion: Cognitive, Visual, and Disability Outcomes. Stroke. 2019.

The benefit of mechanical thrombectomy (MT) compared to IV thrombolysis (tPA) for the treatment of an acute posterior cerebral artery (PCA) occlusion is uncertain. Patients with a PCA occlusion can have a low NIH stroke scale (NIHSS), a population that is underrepresented in mechanical thrombectomy trials. The PCA territory provides vascularization to the thalamus, the hub of cerebral connections not only for motor and sensory pathways, but also for cognition. Impaired cognition is not represented on the NIHSS, which further underestimates the deficits of a PCA occlusion. The authors of “Thrombectomy and Thrombolysis of Isolated Posterior Cerebral Artery Occlusion” sought to understand the impact of revascularization with MT, tPA, or conservative treatment and assessed the outcomes of visual field deficit, cognitive impairment, and disability.

This retrospective observational study included all acute stroke patients with radiographic evidence of a P1, P2, or fetal PCA occlusion. Analysis was separated into three treatment groups: conservative therapy (no tPA), tPA, and MT. The following outcomes were assessed: visual field normalization on confrontation, 90-day modified Rankin Scale (mRS), and cognitive function. Cognitive function was evaluated by a neuropsychologist in the subacute hospital, and a favorable outcome was defined as less than or equal to 2 impaired cognitive domains.

By |December 31st, 2019|clinical|0 Comments

Emergent CTA for Acute Ischemic Stroke Should Be Standard of Care

Charlotte Zerna, MD, MSc
@CharlotteZerna

Mayer SA, Viarasilpa T, Panyavachiraporn N, Brady M, Scozzari D, Van Harn M, et al. CTA-for-All: Impact of Emergency Computed Tomographic Angiography for All Patients With Stroke Presenting Within 24 Hours of Onset. Stroke. 2019.

Mechanical thrombectomy for acute ischemic stroke in the anterior circulation due to large-vessel occlusion (LVO) has been established as the new standard of care. The ESCAPE trial found no evidence of treatment heterogeneity between subjects in the early and late windows, and treatment effect favoring intervention was seen across all clinical outcomes in the extended time window.1 The DAWN and DEFUSE 3 trials were then further able to show benefit of mechanical thrombectomy > 6 hours from onset for patients selected by clinical-core mismatch or perfusion-core mismatch via advanced neuroimaging.2, 3 But even though benefit clearly exists beyond 6 hours, fast mechanical thrombectomy is critical since an LVO acute ischemic stroke typically leads to destruction of 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers per minute.4 Because LVO can only be diagnosed by time-efficient neurovascular imaging, the authors implemented a CTA-for-All stroke imaging policy in their regional health system for all patients presenting within 24 hours of last known well, regardless of baseline NIHSS scores and eliminating the requirement of obtaining baseline creatinine levels. The new policy applied to stroke codes in both the ED and on hospital floors, whereas before, an emergency CTA was reserved only for patients with acute ischemic stroke confirmed by non-contrast CT who presented within 6 hours of last known well and with an NIHSS score of at least 6 once serum creatinine levels were known.

By |December 30th, 2019|clinical|1 Comment

Meet the Blogger: Tamaya Van Criekinge, MSc, PT

Name: Tamaya Van Criekinge, MSc, PT
Hometown: Antwerp, Belgium
Current Position: PhD candidate at the Department of Rehabilitation Sciences and Physiotherapy, REVAKI/MOVANT, University of Antwerp, Antwerp, Belgium

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

A: During my bachelor studies at the KU Leuven, my grandfather had a stroke, which was very devastating for our entire family. I learned firsthand what the impact of a stroke could be on a person and their caregivers; for that reason, I wanted to pursue a career that enabled me to help as many stroke survivors as possible.

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

A: In 2014, I graduated as a physiotherapist with a specialized master’s degree in neurological rehabilitation. Afterwards, I started working in the rehabilitation hospital RevArte, where I treated patients with a variety of musculoskeletal and neurological pathologies, including stroke. In 2015, I took upon the challenge to expand my own knowledge concerning stroke rehabilitation and started working with stroke survivors in a more research-related setting, while also teaching the physiotherapists of tomorrow about stroke rehabilitation, gait analysis and trunk biomechanics. 

By |December 27th, 2019|clinical|0 Comments

Sleep Disturbances and Increased Risk of Atherosclerosis in the Young

Raffaele Ornello, MD

Zhao YY, Javaheri S, Wang R, Guo N, Koo BB, Stein JH, et al. Associations Between Sleep Apnea and Subclinical Carotid Atherosclerosis: The Multi-Ethnic Study of Atherosclerosis. Stroke. 2019;50:3340–3346.

Literature suggests that sleep disturbances, including sleep apnea (SA), are associated with an increased risk of stroke; however, the reasons for the association are unclear.

In their prospective observational study, the authors assessed the association between sleep disturbances and indirect markers of atherosclerosis, namely the carotid intima-media thickness (CIMT) and the presence of carotid plaque, in a multi-ethnic population of 1615 subjects aged 45-85 years. The authors found an association between SA and carotid plaque only in subjects younger than 68 years; on the other hand, decreased oxygen saturation during sleep was associated with an increase in CIMT, only in younger or black individuals.

The authors’ results suggest that the mechanisms linking sleep disturbances to carotid plaques and to increased CIMT are different and both more pronounced in younger individuals. However, the most relevant result of the study is perhaps a negative one: Habitual snoring was not associated with any increased risk of carotid atherosclerosis. The study findings are in line with the recently released 2019 AHA/ASA guidelines for the management of acute ischemic stroke, which recommend against systematic screening for SA in all patients with acute ischemic stroke.

Article Commentary: “Use of Statins After Ischemic Stroke in Young Adults and its Association With Long-Term Outcome”

Yan Hou, MD, PhD

van Dongen MME, Aarnio K, Martinez-Majander N, Pirinen J, Sinisalo J, Lehto M, et al. Use of Statins After Ischemic Stroke in Young Adults and Its Association With Long-Term Outcome. Stroke. 2019;50:3385–3392.

Young adults (aged 15 to 49) with ischemic stroke usually have a known low burden of atherosclerosis. The indication of statins to prevent recurrent stroke and other cardiovascular events is unclear in this population.  

By using the database of the Social Insurance Institution of Finland, the Finnish Care Register, and Statistics Finland, young adults with first-ever ischemic stroke from the Helsinki Young Stroke Registry were followed for a median of 8.3 years. The use of statin and its association with all-cause mortality, as well as recurrent stroke or other vascular events, were assessed. Use of statin was defined as at least two purchases over the entire follow up period. Low, intermediate and high usage correspond with yearly prescription purchases of 1, 2, and ≥3, respectively.

By |December 23rd, 2019|clinical|0 Comments

Meet the Blogger: Parneet Grewal, MD

Parneet Grewal

Name: Parneet Grewal, MD
Hometown: Chicago, IL
Current Position: Vascular Neurology Fellow at Rush University Medical Center, Chicago, IL

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

A: The experience of taking a stroke alert patient who was also 37 weeks pregnant personally to the angiography suite, and watching her beginning to speak and move her limbs after she returned from the procedure and then deliver a baby three weeks later, still makes me smile and feel contented whenever I think back. Starting with this case, my passion for stroke continued to gain ground through each year in residency as I continued to experience firsthand the immense role a vascular neurologist can play in the life of patients affected with this condition.

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

A: I completed all my training, including medical school, in India and then moved to the United States for my residency at the University of Kentucky Medical Center, followed by a fellowship in stroke at Rush University Medical Center.

By |December 20th, 2019|clinical|0 Comments

2019 AHA/ASA Updated Guidelines for the Early Management of Acute Ischemic Stroke: Changes

Parneet Grewal, MD
@parneetgrewal6

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418.

The evidence-based treatment of acute ischemic stroke (AIS) is constantly changing with new high-quality evidence, and the American Heart Association (AHA) has provided focused updates and guidelines on specific topics relating to the management of patients with AIS since 2013. The 2018 AIS Guidelines were published online on January 24, 2018 and are being followed throughout the United States for patient management.1 An independent evidence review committee appointed by the AHA Stroke Council’s Scientific Statements Oversight Committee performed a systemic review of literature, and a 2019 update to the 2018 guidelines was prepared with some new or revised recommendations. The guidelines focus on the prehospital care, emergency evaluation and treatment with intravenous alteplase (IV-tPA) and intra-arterial therapies and in hospital-management. In this blog post, I will discuss some of the recommendations that are new since the 2018 guidelines.

As per the updated guidelines, the benefit of bypassing the closest hospital capable of giving IV-tPA in favor of stroke centers providing a higher level of care including endovascular treatment (EVT) is uncertain at this point (COR: IIb, LOE: B-NR);2 however, the AHA does recommend that prehospital procedures to identify patients ineligible for IV-tPA and having a likelihood of large vessel occlusion (LVO) should be developed so that rapid transport of patients to centers capable of EVT could be facilitated (COR: IIb, LOE: C-EO).3,4 Transportation of patients with a stroke due to an LVO rapidly to improves the probability of effective reperfusion for those who qualify for this approach.5 However, the sensitivities and specificities of currently used LVO scales range from 47% to 73% and from 78% to 90%, respectively. A meta-analysis by the 2018 AHA systemic review committee concluded that, “No scale predicted LVO with both high sensitivity and high specificity,” which necessitates the development of new prehospital procedures.6

By |December 18th, 2019|clinical|0 Comments

Article Commentary: “Hypoperfusion Intensity Ratio Predicts Infarct Progression and Functional Outcome in the DEFUSE 2 Cohort”

Stephanie Lyden, MD, BS

Olivot JM, Mlynash M, Inoue M, Marks MP, Wheeler HM, Kemp S, et al. Hypoperfusion Intensity Ratio Predicts Infarct Progression and Functional Outcome in the DEFUSE 2 Cohort. Stroke. 2014;45:1018–1023.

In stroke care, it is important to understand the various factors that influence patients’ risk for infarct progression. In this regard, there has been increasing interest in understanding the collateral circulation. For example, in chronic vessel stenosis, ischemic preconditioning can cause collateral arborization that results in less than expected infarct size if an occlusion at that area of stenosis occurs. Additionally, in patients with large vessel occlusion who do not achieve recanalization, adequate collateral circulation may play a role in reducing infarct size. The use of perfusion imaging has contributed to a better understanding of the collateral circulation.

This study aimed to evaluate the association between the severity of perfusion-weighted imaging abnormalities, using a hypoperfusion intensity ratio (HIR), on infarct progression and functional outcome in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 2 (DEFUSE 2). HIR was defined as the proportion of TMax >6 s lesion volume with a Tmax >10 s delay and was dichotomized based on its median value (0.4) into low versus high subgroups and quartiles. Another way this definition was explained is that it is the Tmax 10/6 s ratio and assessed within 4.9 [+/- 2.6] hours after stroke onset. Initial infarct size was determined using diffusion weighted (DWI) imaging in patients who presented within 12 hours of stroke onset in whom endovascular treatment was anticipated. At day 5 from stroke onset of symptoms, final infarct volume was determined using the fluid attenuated inversion recovery (FLAIR) sequence on magnetic resonance imaging (MRI) of the brain. Total infarct growth was determined by the difference between final infarct volume and initial infarct volume. Baseline DWI lesion volume divided by the delay from symptom onset to baseline MRI of the brain calculated the initial infarct growth velocity. Conventional angiography was used to help determine good or poor collateral flow. A modified Rankin Scale ≤ 2 at 90 days was considered a good functional outcome.

By |December 17th, 2019|clinical|0 Comments