American Heart Association


How Long Should We Give Dual Antiplatelet Therapy After Minor Acute Ischemic Stroke?

World Stroke Congress
October 17-20, 2018

Danielle de Sa Boasquevisque, MD

Following a Transient Ischemic Attack (TIA) or minor ischemic stroke, the risk of having another ischemic stroke or vascular events within the next three months is 10-20%. The Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial was a randomized, double-blind study designed to evaluate the benefit of dual antiplatelet therapy (DAPT) compared to aspirin alone during the first 90 days after a minor ischemic stroke or transient ischemic attack. The primary efficacy outcome was major ischemic events, and the primary safety outcome was major hemorrhage.

The POINT Trial was halted after 84% of the anticipated number of participants had been enrolled. They found that patients enrolled in 3 months of DAPT had fewer major ischemic events than patients given aspirin alone (5% versus 6.5%, respectively; hazard ratio, 0.75; 95% confidence interval [CI], 0.59 to 0.95; p=0.02). However, the DAPT also seemed to increase chances of major hemorrhage compared to the aspirin controls (0.9% versus 0.4%, respectively; hazard ratio 2.32; 95% CI, 1.10-4.87; p=0.02).

A secondary analysis of POINT Trial data was presented by Jordan J. Elm at the World Stroke Congress in October in Montreal. It aimed to identify the time course of risks versus benefits of clopidogrel and aspirin in acute minor ischemic stroke and high-risk TIA patients and determine if there is an optimal time when patients would benefit most from using both aspirin and clopidogrel.

World Stroke Congress Session: Advances in Stroke Imaging

World Stroke Congress
October 17-20, 2018

Ravinder-Jeet Singh, MBBS, DM

The session on advances in stroke imaging was very interesting and informative. Three speakers — Dr. Ken Butcher from Edmonton and Drs. Gregory Albers and Chitra Venkatasubramanian from Stanford — discussed some of the recent changes in the field of stroke imaging and how it is influencing the practice of stroke care.

Dr. Butcher spoke about multimodal CT based imaging paradigms in acute ischemic stroke, especially use of CTA and CTP in patient selection. It is of note that two of the “early window” EVT trials (SWIFT PRIME and EXTEND IA) and both the late window trials (DAWN and DEFUSE 3) used perfusion imaging for patient selection. He discussed various software platforms available for processing and interpreting CTP data. Options include inbuilt software provided by CT vendors and other commercially available software including RAPID (iSchemaView Inc.), MIstar (Apollo Medical Imaging Technology), and OleaSphere (Olea Medical). The key message was that clinicians should be careful in interpreting CTP images and also the outputs (core, penumbra volumes, and mismatch ratios) provided by these softwares. It is essential to look at arterial input function and venous output function curves to assess the quality of CTP data. These curves should display rapid upslopes and downslopes. Presence of any truncation of these curves should also be noted, which could lead to misestimation of core and penumbra size. In addition, the presence of motion artifacts can severely degrade image quality and, therefore, its interpretation. He also pointed out another important area in which CTP could be helpful — the stroke mimics — where a normal CTP would be reassuring in the appropriate clinical context.

European Stroke Organisation Conference 2018: Insights from the Large Clinical Trials Session

European Stroke Organisation Conference
May 16–18, 2018

Aristeidis H. Katsanos, MD, PhD

Dr. Robert Hart presented the first results of the NAVIGATE ESUS trial, a randomized clinical trial (RCT) on the safety and efficacy of Rivaroxaban 15mg once daily compared to acetylsalicylic acid (ASA) 100mg in patients with embolic strokes of undetermined source (ESUS). The trial was stopped prematurely at the second interim analysis, and after randomization of a total of 7213 patients, due to the absence of significant differences between the two groups regarding the primary efficacy outcome of all recurrent stroke or systemic embolism. Moreover, a significant increase in the risk of both hemorrhagic stroke and all major bleeding events was found in the Rivaroxaban group compared to the ASA group. Although no significant differences were found in other pre-specified subgroup analyses, a subgroup analysis of patients with patent foramen ovale randomized within the NAVIGATE ESUS trial presented by Dr. Scott Kasner suggests that Rivaroxaban treatment may reduce the risk of recurrent cerebral ischemic events in this specific patient population compared to ASA.

Tranexamic Acid for Acute Intracerebral Hemorrhage

European Stroke Organisation Conference
May 16–18, 2018

Andrea Morotti, MD

The results of the Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2) randomized controlled trial were presented at the 4th congress of the European Stroke Organisation in Gothenuburg, Sweden. Subjects with primary, spontaneous intracerebral hemorrhage (ICH) presenting within 8 h from symptom onset/last time seen well were randomized to treatment with intravenous tranexamic acid (1 g bolus followed by 1 g over an 8 h infusion) versus placebo. 1 The main outcomes of interest were hematoma expansion (defined as absolute hemorrhage growth>6mL or relative hemorrhage growth>33% from baseline volume) and the proportion of patients with death or severe disability at 3 months from the index event.

Author Interview: Mike Sharma, MD, MSc, FRCPC

Mike Sharma

Mike Sharma

A conversation with Mike Sharma, MD, MSc, FRCPC, Michael G. DeGroote Chair in Stroke Prevention and Associate Professor of Medicine (Neurology) at McMaster University/Population Health Research Institute and one of the co-authors of the COMPASS clinical trial, which studied the utility of combined low dose rivaroxaban and aspirin for cardiovascular disease prevention in patients with peripheral artery disease. Dr. Sharma presented a platform presentation on the findings of stroke prevention at the International Stroke Conference in February 2018 in Los Angeles, California.

Interviewed by Alexis N. Simpkins, Assistant Professor of Neurology, University of Florida School of Medicine.

They will be discussing the paper “Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease,” published in October 2017 in The New England Journal of Medicine (Eikelboom JW, et al. N Engl J Med 2017; 377:1319-30).

Saving Stroke Lives with EMS Prehospital Notification: Interview with Dr. Ethan Brandler

Dr. Ethan Brandler

Dr. Ethan Brandler

A conversation with Dr. Ethan Brandler, MD, MPH, FACEP, assistant professor of clinical emergency medicine at the State University of New York at Stony Brook, during the International Stroke Conference 2018 poster session.

Interviewed by Dr. Rohan Arora, MD, director of stroke fellowship at Hofstra Northwell School of Medicine.

How often does EMS call you before bringing a stroke patient to your center? How do you use that information to expedite stroke treatment? Wondering how EMS pre-notification can make a difference in your center’s outcomes?

Read this author interview for an update on how EMS triage can tremendously benefit patients with LVO (large vessel occlusions).

Author Interview: Dr. Greg Albers, on DEFUSE 3 and its Implications for Systems of Stroke Care in the U.S.

Dr. Greg Albers

Dr. Greg Albers

A conversation with Dr. Greg Albers, professor of neurology at Stanford and the principal investigator for DEFUSE 3.

Interviewed by Dr. Kaustubh Limaye, assistant professor of neurology in the division of cerebrovascular diseases at the University of Iowa, at the International Stroke Conference 2018 following the presentation of the final results of DEFUSE 3 and a simultaneous publication in the New England Journal of Medicine.

Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. New England Journal of Medicine. 2018

Dr. Limaye: Dr. Albers, first accept my hearty congratulations on the phenomenal success of the DEFUSE 3 trial.

Dr. Albers: Thank you so much.

Dr. Limaye: Just like everybody else, I was patiently waiting to hear what the results were going to be. All of us are delighted looking at the strong treatment effect that DEFUSE 3 showed in this extended time window. Thanks again for taking time out from your busy schedule. I’m sure this conference was extremely busy for you.

Dr. Albers: It’s been a very exciting week. We’ve been anticipating this for some time, and it’s wonderful to see this come to fruition.

Highlights from the International Stroke Conference 2018

International Stroke Conference
January 24–26

Philip Chang, MD

This year’s International Stroke Conference revealed big advances and changes to the acute ischemic stroke guidelines. I had a great time at the Los Angeles Convention Center and learned a lot, as new exciting trials revolutionized the acute ischemic stroke treatment landscape, most notably tripling the reperfusion time windows. As with every conference, there were tons of different lectures and abstracts to go to, but I’ll highlight what I found the most interesting, and key take-home points from the conference.

By |February 9th, 2018|Conference|0 Comments

ISC Session: The Efficacy and Safety of Cilostazol in Subarachnoid Hemorrhage

International Stroke Conference
January 24–26

Pouya Tahsili-Fahadan, MD

Vasospasm and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH) are a major cause of morbidity and mortality. The only proven medication to improve outcomes after SAH is nimodipine.

Cilostazol is a phosphodiesterase III inhibitor that has been shown to decrease vasospasm and DCI in animal studies, as well as in small clinical series. The proposed mechanisms include increase in endothelial release of nitric oxide (NO) and inhibition of platelet derived growth factor (PDGF), vascular smooth muscle proliferation, and expression of adhesion molecules on endothelium.

Dr. Muhammad F. Ishfaq presented the results of a meta-analysis of previous studies on the effects of cilostazol on vasospasm and DCI. A total of 6 studies were included in the meta-analysis after reviewing 33 studies (three studies were randomized clinical trials). The primary end-point was incidence of DCI secondary to vasospasm. Secondary end-points included: angiographic vasospasm, new stroke, mortality, and major disability (defined as modified Rankin scale 4-6 at discharge and follow-up exams).

By |February 2nd, 2018|Conference|1 Comment

ISC Session: Tough Decisions in ICH

International Stroke Conference
January 24–26

Danny R. Rose, Jr., MD

New advances in our understanding of intracerebral hemorrhage in recent years have led to new questions, as well as revisiting previously held notions about treatment and prevention.  The talks in this session covered coagulopathy reversal, anticoagulant usage in patients with a history of ICH, the relationship between statins and ICH and anti-edema therapy.

Dr. Thorsten Steiner, MD, PhD, began the session by discussing drug-induced coagulopathy reversal in ICH. The primary purpose of such therapies is to prevent hematoma expansion, which occurs in 30% of cases in the first 4 hours after ICH and is associated with increased morbidity and mortality. Anticoagulants increase this rate to upwards of 54% for vitamin K antagonists (VKAs) and 38% with direct-acting oral anticoagulants (DOACs). Timing is an important thing to consider in this scenario, given the half-life of VKAs are around 2 days, while DOACs are all around 14 hours, with peak effect somewhere between 3–4 hours. Specifically, many patients on DOACs may present in a time window when reversal would have little to no effect given the lack of active drug at the time. It is important to consider things that may cause variations in half-life for DOACs, including body size, inhibiting/inducing medications, and renal function (most important for dabigatran).

By |February 1st, 2018|Conference|0 Comments