American Heart Association

Conference

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] 

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.

ISC 2020 Session: “Widening the Lens of Telestroke: From the ED Across the Stroke Continuum”

International Stroke Conference
February 19–21, 2020

Session: “Widening the Lens of Telestroke: From the ED Across the Stroke Continuum,” Thursday, February 20, 2020

Speakers:
Jennifer Majersik, MD: Physician at the University of Utah – Expansion of Telestroke Networks
Matthew Koenig, MD: Physician at Queens Medical Center – Tele-ICU
Steven Cramer, MD: UCLA, University of California Irvine – Tele-rehabilitation
Christine Holmstedt, DO: Medical University of South Carolina – Outpatient Telestroke Follow-up

Stephanie Lyden, MD, BS

This talk provided multiple examples of varied practice settings that use telemedicine to provide patient care. The talk started with Dr. Jennifer Majersik discussing the Expansion of Telestroke Networks. She initially explained the process of consulting a neurologist via telestroke. This is often being utilized by community hospitals that do not have a local neurologist to consult. She explained that there are different levels of acuity (hyper-acute with telestroke vs acute with emergent teleneurology vs non-urgent with scheduled teleneurology) within teleneurology consults. She noted that with a telestroke consult, the main questions addressed include whether the patient is eligible for tPA or thrombectomy, both of which are time sensitive, and the goal of these consults is for them to be completed within 10-30 minutes.

ISC 2020: “Paola de Rango Memorial Session. Sex Differences in Stroke (a Go Red for Women Session)”

International Stroke Conference
February 19–21, 2020

Charlotte Zerna, MD, MSc
@CharlotteZerna

Go Red For Women was created in 2004 and is a comprehensive platform designed to increase women’s health awareness and focus on research into women’s cardiovascular health, and it is meant to empower female patients to take charge of their own heart and brain health to improve outcomes. This year’s International Stroke Conference featured multiple sessions under the Go Red For Women track. The inaugural Paolo de Rango Memorial Session about sex differences in stroke was moderated by Nada El Husseini (Durham, NC) and Amytis Towfighi (Los Angeles, CA).

Salvador Cruz-Flores (El Paso, TX) emphasized that differences have to be avoidable, unjust, and unfair to constitute a disparity and can occur in any one group when compared to the most advantaged group. These differences systematically place socially disadvantaged groups at further disadvantage in regards to their health. Such disparities or social determinants of health are, for example, the adoption of health-promoting behavior and exposure to unhealthy/stressful living and working conditions, as well as access to health care and other public services. Measuring health disparity necessitates an indicator variable for one’s health, an indicator variable for one’s social position, and the ability to compare the health indicators across social position strata. A recent study by Rinaldo and colleagues was able to show the racial and ethnic disparities in the utilization of acute treatment for ischemic stroke in the United States.1 Intravenous alteplase was offered to 4.3% more white patients compared to black/Hispanic patients. About 10% more were also admitted to an endovascular-capable center, and 2.8% more received endovascular treatment.

ISC 2020 Session: “The New Frontiers in Thrombolysis of Patients with Acute Ischemic Stroke (25th Anniversary of NINDS Trial)”

International Stroke Conference
February 19–21, 2020

Mausaminben Hathidara, MD
@mausameen

This session was divided in topics as below, each discussing different aspects associated with making decisions for tPA for extended window, proper patient selection for mild strokes and the dilemma for patients with relative contraindication, as well as thrombolysis in women with ischemic stroke.

The story from bench to bedside by Patrick Lyden

In 1995, the NINIDS trial proved the efficacy of tPA and reasonable safety. Per pilot study analysis, the dose 0.9 mg/Kg demonstrated the best efficacy, therefore, was chosen for the NINDS trial up to 3 hours from symptoms onset, which showed that patients in the treatment arm were 30% more likely to have minimal or no disability at 3 months with reasonable safety (symptomatic ICH 6.4%) for intra-cerebral. Before the NINDS trial, there were several studies that looked into tPA for acute ischemic strokes, including ECASS I and ECASS II, which did not show successful results due to different time window and dosing selection.

ISC 2020 Session: “Is Less More? Controversies in Imaging Endovascular Treatment Candidates”

International Stroke Conference
February 19–21, 2020

Parneet Grewal, MD                           

Moderators: Dr. Ashutosh Jadhav and Dr. Robin Novakovic

This session at the International Stroke Conference 2020 in Los Angeles included extensive discussion about various imaging modalities that are being used to select patients as candidates for endovascular treatment (EVT) in the real world, along with their pitfalls. The discussion was led by Dr. Albert J. Yoo, Dr. Achala Vagal, and Dr. Bernard Yan. There were also case scenarios presented by Dr. Richard Aviv of challenging CT angiography (CTA) cases.

Early time, late time, large core, small core: Non-con CT is all you need (Dr. Albert J. Yoo)

In his presentation, Dr. Yoo discussed the importance of non-contrast CT head in selecting patients for EVT and urged the clinicians to consider CT head and CTA as the only imaging modalities that are needed prior to making decisions for EVT. The EVT candidate patients are broadly divided into early window (0-6 hours) and late window (> 6-24 hours) based on their time of presentation, as well as into small core and large core based on the size of ischemic infarct. All the major landmark trials in the early window, such as MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME and REVASCAT, utilized CT head/CTA for patient selection with EXTEND IA and SWIFT PRIME also using CT perfusion (CTP) imaging. All the trials demonstrated improved perfusion and functional outcome for patients with large vessel occlusion who underwent EVT but had different criteria for patient selection. A study by Tawil et al. on comparing eligibility for different trial protocols to estimate the number of patients eligible for treatment showed that 53% of the patient population met criteria for MR CLEAN, which decreased to only 17% for EXTEND IA. Secondary analysis of the MR CLEAN trial has also shown that the patients who were ineligible per EXTEND IA criterion also benefitted from the EVT, which means that excluding patients in the early window using CTP might lead us to miss a subset of the population which can still benefit from thrombectomy.

ISC 2020 Session: “Widening the Lens of Telestroke: From the ED Across the Stroke Continuum”

International Stroke Conference
February 19–21, 2020

Burton J. Tabaac, MD

With a room filled with astute and engaged listeners, this talk was aimed at featuring some of the most preeminent minds in the field of vascular neurology to comment on particular intricacies as pertains to telestroke.  The session was subdivided into four sections, with each delving into a specific approach and perspective on the spectrum of telemedicine.

The first talk, titled “Expansion of Telestroke Networks” was illustriously given at the lectern by Dr. Jennifer Majersik. This presentation highlighted post-hyperacute care options for community hospitals without neurologists, underscored the value of inpatient stroke follow up via telestroke, and outlined suggested requirements to conduct post-acute stoke follow up. The acute telestroke consult relies on three main questions: 1. Is the patient likely having an acute ischemic stroke? 2. Is a large vessel occlusion (LVO) present / Is the patient a candidate for mechanical thrombectomy? 3. Would the patient benefit from transfer to a higher level of care? Majersik details, “The goal of the telestroke consult is to provide accurate and fast revascularization for patients with acute ischemic stroke, and stroke care does not end after this goal is met.” The neurologist should aim to assist with avoidance of complications, consider the underlying stroke etiology, and discuss initiation of targeted secondary preventative therapies. Majersik succinctly concluded the talk by suggesting the following telestroke follow up requirements: the local availability of stroke diagnostic tools (MRI, ECHO, vessel imaging, and potentially non-stroke diagnostics such as EEG), the local availability of rehabilitation services, personnel training (nursing, other physicians, teleprompter), as well as administrative assistance (EMR, scheduling, financial agreement(s) between hospitals, and adequate neurologist staffing).

ISC 2020 Session: “Expanding Indications for Thrombectomy”

International Stroke Conference
February 19–21, 2020

Robert Regenhardt, MD, PhD
@rwregen

The session “Expanding Indications for Thrombectomy” at the International Stroke Conference 2020 included several debates about which patients should be treated with thrombectomy (EVT). Moderated by Thabele Leslie-Mazwi and Marc Ribo, topics included whether to treat patients with mild symptoms, tandem occlusions, and large cores.

Pooja Khatri argued to treat patients with mild symptoms. She first defined mild as NIHSS 0-5, as these patients were largely not included in the landmark RCTs. 20-40% of patients with mild symptoms will decline. Dr. Khatri made the point that NIHSS doesn’t modify the treatment effect of EVT; it may be reasonable to expect benefit even with lower NIHSS. While non-randomized data are mixed, a recent meta-analysis showed a non-significant benefit with treatment.

ISC 2020: LINQing Real-World Data to Evidence-Based Medicine: A Glimpse of Preliminary Results of Long-Term Atrial Fibrillation Monitoring from the Reveal LINQ Real-World Registry Analysis

International Stroke Conference
February 19–21, 2020

Abbas Kharal, MD, MPH

Some interesting preliminary data about stroke etiologies was revealed at the Stroke Etiology Oral Abstracts sessions at the first day of the International Stroke Conference 2020 held at the Los Angeles Convention Center on February 19, 2020. 

Preliminary results from the Reveal LINQ Real World Registry data were disclosed on the incidence rate of atrial fibrillation (AF) in cryptogenic stroke and TIA patients enrolled to date in the registry. Presence of AF was defined as an episode of AF ≥2 min over 1 year of monitoring. 192 patients (61±14 years, 61% male, mean CHA2DS2-VASc score 3.8±1.4) from 29 centers in 8 countries were included. During an average follow-up of 19±6 months, AF was detected in 19% patients, similar to that previously reported in CRYSTAL AF1 data when monitored for 2 years. As a result of longer-term monitoring and higher sensitivity of AF detection, therapeutic anticoagulation was initiated in 29 (15%) patients during follow-up, while 14 of 45 initially on anticoagulation discontinued the treatment due to lack of AF detected.