American Heart Association

Conference

ISC 2021 Session: Treatment of Acute Stroke in Childhood and Young Adults (Debate)

Sishir Mannava, MD
@sishmannMD

International Stroke Conference 2021
March 17–19, 2021
Session: Treatment of Acute Stroke in Childhood and Young Adults (Debate) (179, On Demand)

This session began with Dr. Lisa Sun from Johns Hopkins School of Medicine presenting on brain attacks in teenagers, and that “we can best care for adolescents with stroke by organizing existing adult stroke centers to be able to treat teenagers.” Dr. Sun discussed how adult stroke centers and dedicated stroke units have better outcomes with organized stroke teams and stroke protocols. This leads to faster stroke recognition and treatment times. Dr. Sun presented data from time to imaging/diagnosis in major pediatric stroke centers after stroke protocol initiation, and, at best, the times appear to be between 1.3-1.6 hours, which is slower than the DTN times median of about 1 hour in adult stroke programs. Although primary pediatric stroke center development has been proven by the TIPS trial, Dr. Sun argued that it may not be feasible or resourceful to develop the needed amount of pediatric stroke centers to provide adequate coverage to all pediatric stroke populations.

“Endovascular therapy can be more safely and effectively administered to adolescents at an adult stroke center.” Dr. Sun discussed how thrombectomy in adolescents is technically like adult thrombectomy, and that by 5 years of age, head and neck arteries approach adult size. The common femoral artery (FA) sheaths used in adults can even be used in smaller adolescents as long as the ratio of FA size to catheter size is maintained, to avoid vasospasm. Adult stroke centers also have greater procedural experience, larger stock of devices, and higher volume of thrombectomies than pediatric thrombectomy centers. Data from the TRACK registry showed a significant difference in mRS ≥ 2 and final mTICI ≥2c-3 amongst higher volume centers as opposed to lower volume centers.

ISC 2021 Session: Stroke in Pregnancy: What To Expect When They’re Expecting

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Stroke in Pregnancy: What To Expect When They’re Expecting (150, On Demand)

Eliza C. Miller, MD, MS: In this session, Dr. Miller pointed out three important topics: epidemiology, mechanism and prevention. The trend in maternal mortality in pregnancy in the United States increased from 1987 until 2016. And so is the rate of maternal stroke. The incidence is 30/100,00 deliveries. Half are hemorrhagic with a mortality of 10-16%, which is different than stroke in the general population, where 85% of strokes are ischemic. Hypertension is the leading cause, and there is some racial disparity among the prevalence. The risk is higher in the non-White population (African American, Asian and Hispanic). Migraine is another stroke risk factor, which increases the risk of hypertension and preeclampsia, which ultimately are risk factors for stroke.

The diagnostic criteria for Pre-eclampsia per ACOG and ISSHP is new onset hypertension at the gestational age greater than 20 with proteinuria or without proteinuria with a new onset headache unresponsive to the treatment or new onset focal neurological deficit. 

The take-home message from this talk was, headache and hypertension in pregnancy are red flags and should be taken seriously.

ISC 2021 Session: Tenecteplase Is Ready for Clinical Practice (Debate)

Saurav Das, MD
@sauravmed

International Stroke Conference 2021
March 17–19, 2021
Session: Tenecteplase Is Ready for Clinical Practice (Debate) (183)

Whether tenecteplase (TNK) is ready for clinical practice is certainly one of the crucial questions faced by the stroke community today, especially in the changing landscape with emerging evidence for non-inferiority of direct thrombectomy compared to bridging recanalization treatment, the success of mobile stroke units (MSU), and our ability for pre-hospital treatment of patients within the golden hour of last known well. TNK is not a new drug. It is successfully used in treatment of myocardial infarction, and we have evidence from five randomized controlled trials (alluded to several times in the following debate) for non-inferiority compared to alteplase (tPA) in treatment of stroke. The nay-sayers do point to inherent issues with these trials and argue that we need more data. But the question is, how much longer is this wait going to be?

This debate was in 5 segments. In the first segment, Dr. Jeffrey Saver from the University of California, Los Angeles (UCLA) argued in favor of the motion. In the second segment, Dr. Patrick Lyden from Keck School of Medicine, University of South California, argued against the motion. In the third segment, both the speakers had an opportunity for rebuttal. In the fourth segment, Dr. Shelagh Coutts from the University of Calgary provided her balancing view. And in the final segment, Dr. Steven Warach from Dell School of Medicine, UT Austin, shared his practical experience with use of TNK for the past 15 months. The session was moderated by Dr. E. Clarke Haley Jr. from the University of Virginia, Charlottesville.

ISC 2021 Session: Imposter Syndrome – Our Stories

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Imposter Syndrome – Our Stories

“Perfectionism is a sick mindset.”
— Darshan H Mehta

There is no formal definition of imposter syndrome, but it is defined vaguely as to doubt your abilities and capabilities. It is a feeling of discomfort, second-guessing, and mild anxiety in the workplace, especially for women.

The term gets its origin in 1978 when two psychologists, Pauline Rose Clance and Suzanne Imes, used the concept of “imposter phenomena” while studying high-achieving women. They found that despite stellar academic and professional achievements, women who experience the imposter phenomenon kept on believing that they are really not bright enough, and they question themselves if they are deserving of accolades.

This session put up a healthy discussion among women pointing out when they first recognized that they are suffering from imposter syndrome. It also discussed why imposter syndrome exists in the first place and what role workplace systems play in fostering and exacerbating it in women. Leaders must create a culture for women and people of color that addresses systemic bias and racism. By doing so, we can reduce the experiences that culminate in so-called imposter syndrome among employees from marginalized communities — or, at the very least, help those employees channel healthy self-doubt into positive motivation, which is best fostered within a supportive work culture.

ISC 2021 Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate)

Robert W. Regenhardt, MD, PhD
@rwregen

International Stroke Conference 2021
March 17–19, 2021
Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate) (33, On Demand)

The session “Challenging EVT Decision Making: When, Where, and Who to Treat” (Debate) highlights some of the most difficult management decisions regarding EVT.

Dr. Sandra Narayanan built the case “Low NIHSS proximal occlusions should undergo thrombectomy.” She started by reviewing the magnitude of the question. An LVO is present in 18% of patients with NIHSS 0-4 and 39% of those with NIHSS 5-8. Furthermore, 15% of LVO stroke patients have minor symptoms. Deterioration can happen in early or delayed fashion; about 40% deteriorate early. Current guidelines suggest that treating patients with low NIHSS is reasonable. Indeed, several studies show a benefit. The Grady experience (JNIS 2017; 9:917-921) described 32 patients with NIHSS<6. Analyses of this cohort, while small, suggested a benefit of EVT. 22 were treated with medical management, of which 9 declined requiring EVT. The median time from arrival to deterioration was 5.2 hours. Subsequently, a larger study of 6 CSCs (Stroke 2018;49: 2391-2397) described 300 patients with NIHSS<6; 11.3% of those treated with medical management later declined. At 90 days, mRS 0-2 was observed in 84% of those treated with EVT, 70% of those with medical management, and 55% of those who underwent rescue EVT. Those who are allowed to deteriorate tend to have worse outcomes. The risks versus benefits should be carefully weighed up front because waiting more than 3 hours appears to impact outcomes. There is growing data that patients at risk for decline can be selected by collaterals, orthostatic challenges, perfusion imaging, and NIHSS eloquence/disability. Three randomized controlled trials are forthcoming: ENDOLOW, IN EXTREMIS, and TEMPO 2.

ISC 2021 Session: Prognostication and Early Withdrawal of Care in Ischemic Stroke and ICH

Melanie R. F. Greenway, MD
@MRFGreenwayMD

International Stroke Conference 2021
March 17–19, 2021
Session: Prognostication and Early Withdrawal of Care in Ischemic Stroke and ICH (116)
Moderators: Aneesh Singhal, MD, and James Meschia, MD
Presenters: Gustavo Saposnik, MD, MPH, PhD, FRCPC; H B Van Der Worp, MD; Claire Creutzfeldt, MD; J Claude Hemphill III, MD, MAS; Wendy Ziai, MD, MPH

Moderated by Dr. Aneesh Singhal from Massachusetts General Hospital and Dr. James Meschia from Mayo Clinic, this session on prognostication in ischemic stroke and intracranial hemorrhage was informative, interactive, and diverse. Topics ranged from accurate prognostication to coaching physicians on important care discussions with patients and families. A must-watch session for those who were unable to watch it live, in my opinion.

Dr. Gustavo Saposnik of St. Michael’s Hospital and the University of Toronto started the session by (painfully) reminding us that poker players and meteorologists are much more accurate in predicting outcomes than physicians. With routine feedback, they are able to refine their practice with data less prone to outcome bias. From there, he took us on a tour of the many validated risk scores available, and their limitations, and encouraged the audience to use risk scores to supplement prognostication rather than “eyeballing” the assessment.

ISC 2021 Session: New Frontiers in Endovascular Therapy

Robert W. Regenhardt, MD, PhD
@rwregen

International Stroke Conference 2021
March 17–19, 2021
Session: New Frontiers in Endovascular Therapy (122, On Demand)

The session “New Frontiers in Endovascular Therapy” had a great line-up of panelists discussing hot topics in neuroendovascular therapies.  

Dr. Jenny Tsai spoke on a “Combined open vascular and endovascular approach for complex cerebrovascular cases.” She emphasized that open microsurgery has many advantages. In fact, open surgery and endovascular approaches can complement each other. A combined approach may be preferable in several scenarios: 1. Challenging anatomy and disease processes. 2. Limited access by individual approaches. 3. Complimentary treatment effects. Tsai emphasized that combined approaches can sometimes be simpler. In the past, combined approaches have been utilized especially for AVM and vascular tumor treatments, where embolization can be offered in stages before open surgery. However, joint approaches do not always require staging. More centers are developing hybrid combined open and endovascular rooms.

ISC 2021 Symposium: Enriched Environments and Recovery

Burton J. Tabaac, MD
@burtontabaac

International Stroke Conference 2021
March 17–19, 2021
Symposium: Enriched Environments and Recovery (121)

Preclinical work has shown the importance of enriched environments on post-stroke recovery. Enriched environments are designed to enhance sensory, motor, and cognitive stimulation by providing equipment, stimulation, open spaces, and a desire to want to engage in rehabilitative interventions. In rodent experiments, enriched environments include toys, ramps, tubes, mirrors, ropes, and the ability to interact with other animals. Rodents exposed to enriched environments early (but not late) post-stroke showed improved motor performance even on tasks for which they did not receive specific training. The proposed mechanisms of action are plethoric and may relate to multiple molecular pathways. Translating an enriched environment to human patients may take several forms, including access to iPads, books, puzzles, games, music, and interaction with other people. Additionally, one could imagine enrichment using virtual/augmented environments with video games and other technology that would not only increase dose and enjoyment.

ISC 2021 Session: Mismatch Misalignments for Extended-window IV-thrombolysis for Non-Large Vessel Occlusion Strokes (Debate)

Yasmin Aziz, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Mismatch Misalignments for Extended-window IV-thrombolysis for Non-Large Vessel Occlusion Strokes (Debate)
Moderator: Dr. Gotz Thomalla

Can thrombolytics be given safely and efficaciously beyond 4.5 hours? That was the debate topic for one of ISC’s first live debates to kick off Wednesday morning. 

Dr. Shlee Song: DWI-FLAIR Mismatch Rules!

The arguments began with Dr. Song, who focused on DWI-FLAIR mismatch. After a brief introduction with the MR WITNESS trial results, she then discussed how patients with DWI-FLAIR mismatch treated with alteplase had better outcomes at 90 days in the WAKE UP study. She also made the point that while efficient MRI scanning of acute stroke patients can be cumbersome, in addition to treating more patients, we can also avoid potential side effects of treating with conventional CT/CTA methods (i.e., contrast nephropathy and ICH in the event of unseen microhemorrhages only visible on MR).

ISC 2021: Novel Imaging Techniques in ICAD — Beyond the Stenosis

Song J. Kim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Advanced Imaging in Intracranial Atherosclerotic Disease: Misnomer or Game-Changer? (24, OnDemand)

A common stroke mechanism accounting for 20-30% of the ischemic strokes worldwide, intracranial atherosclerotic disease (ICAD) is a diagnosis that primarily relies on visualization of luminal narrowing on CTA/MRA. This session expanded upon cutting-edge advances in imaging of ICAD, specifically in revealing plaque morphology, collateral status, and cerebrovascular reserve distal to the stenosis of the culprit lesion.

Before the panel delved into discussion of the advanced imaging, Dr. Achala Vagal provided a comprehensive overview highlighting the limitations of the current conventional lumen-based imaging: failure to detect on-stenosing plaque, compensatory remodeling, and the status of distal flow and collateralization.