American Heart Association

Conference

ESOC 2019 Session: Intracerebral Haemorrhage I

European Stroke Organisation Conference
May 22–24, 2019

Andrea Morotti, MD

This interesting session dedicated to intracerebral hemorrhage (ICH) started with a pragmatic talk on rare causes of intracranial bleeding, discussing the diagnostic accuracy of neuroimaging in the acute phase, by Floris Schreuder.

Christian Weimar presented the main strengths and limitations of currently available tools to stratify ICH prognosis.

The pathophysiology and management of perihematomal edema was illustrated by Kevin Sheth, with a focus on edema measurement with advanced neuroimaging.

ESOC 2019 Session: Endovascular Treatment – Clinical Practice

European Stroke Organisation Conference
May 22–24, 2019

Elena Zapata-Arriaza, MD
@ElenaZaps

The annual European Stroke Organisation Conference was held May 22 to 24 in Milan. There were countless sessions with a high scientific quality. In particular, the scientific communications session “Endovascular Treatment – Clinical Practice,” held on May 22, revealed interesting findings. Among all the refreshing results, I would like to highlight the following:

Dr. Georgios Tsivgoulis, from the National & Kapodistrian University of Athens, showed interesting data about a systematic review and meta-analysis of bridging therapy (BT) versus direct mechanical thrombectomy(MT) in stroke patients with large vessel occlusion (LVO). The mentioned systematic review included 38 studies with a sample of 11.798 patients. The main conclusions of the study exposed that pretreatment with IVT does not increase complication nor results in measurably delayed reperfusion in LVO patients treated with MT. In addition, their results, also showed a potential benefit on functional outcome and mortality in patients receiving BT compared to direct MT.

ESOC 2019: Insights from the Large Clinical Trials Sessions, May 23 and 24

European Stroke Organisation Conference
May 22–24, 2019

Aristeidis H. Katsanos, MD, PhD

Thursday, May 23

In the first presentation of the second day of the Large Clinical Trials section, Dr. Hatem Wafa presented a study on the burden of stroke in Europe: 30-year projections of incidence, prevalence, deaths and disability-adjusted life years (DALYs). Dr. Wafa presented data on the epidemiological trends and demographic changes in stroke epidemiology across Europe, using data from the global burden of disease (GBD) between 1990 and 2017. Future trajectories up to 2047 were based on population projections and GDP prospects. Investigators found that the absolute burden of stroke increased between the years 1990 and 2017 and will continue to increase through 2047 in most EU countries. Lithuania was found to be the country with the largest increase in both stroke incidence (+0.48%) and prevalence (+0.7%), while Portugal was found to have the greatest reductions in both metrics (-1.57% and -1.3%, respectively). Stroke survivors are expected to increase by 27%, posing the need for more rehabilitation services and care homes.

In the presentation of a post-hoc analysis from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) trial on the interaction of blood pressure (BP) lowering and alteplase dose in thrombolysis-eligible acute ischemic stroke (AIS) patients, it was reported that in thrombolysis-treated AIS patients, low (0.6 mg/kg) vs. standard-dose alteplase (0.9 mg/kg) does not clearly modify the treatment effects of intensive (systolic BP<130-140mmHg) vs. guideline BP lowering (SBP<180mmHg) on the primary outcome of functional outcome, intracranial hemorrhage (ICH), death or serious adverse events. Investigators concluded that intensive BP lowering does not improve functional recovery or ICH risk with either low or standard-dose alteplase.

ESOC 2019 Session: Cerebral Small Vessel Disease

European Stroke Organisation Conference
May 22–24, 2019

Raffaele Ornello, MD

At the 5th European Stroke Organisation Conference, there was an interesting session on Thursday, May 23, about small vessel disease (SVD), a frequent cause of ischemic and hemorrhagic stroke.

Professor Leif Østergaard from Aarhus University presented the role of the alterations of capillary hemodynamics in the pathogenesis of SVD, while Professor Nikolaus Plesnila from the University of Munich discussed the role of pericytes in brain ischemia and neurodegeneration.

ESOC 2019 Session: Future Directions on Thrombolysis

European Stroke Organisation Conference
May 22–24, 2019

Lina Palaiodimou, MD

In general, this year’s European Stroke Organisation Conference was characterized by the presentation of numerous clinical dilemmas and highlighted the need for new research targeted to their resolution, which is most likely to be found on the ground of personalized medicine. The session “Future Directions on Thrombolysis” provided some insight about subjects regarding management of acute ischemic stroke that have perpetually troubled clinicians during everyday practice.

The first talk, by William Whiteley, confirmed safety and efficacy of intravenous thrombolysis using data from the analysis of pooled stroke thrombolysis trials. Specifically, it was confirmed that the proportional benefits of alteplase increase with earlier treatment, and this association is independent of age and stroke severity. There is, of course, an increased risk of death from intracerebral hemorrhage (ICH) in the alteplase treated patients, but there is no significant effect on other causes of early or later death. Among those patients treated earlier, there is a suggestion that the early hazard due to death from ICH may be compensated by a later benefit regarding death from any cause within 90 days. Whiteley finally concluded, presenting a well-intelligible graph, that the absolute balance of benefit versus risk depends chiefly on treatment delay and stroke severity.   

ESOC 2019 Session: Official Welcome & Large Clinical Trials

European Stroke Organisation Conference
May 22–24, 2019

Alan C. Cameron, MB ChB, BSc (Hons), MRCP

The 5th European Stroke Organisation Conference (ESOC 2019) has opened with a fantastic session in Milan on Wednesday! The conference was opened by ESO President Bart van der Worp, Conference Chair Jesse Dawson, and Chair of the Local Organising Committee Danilo Toni, who welcomed over 5,500 participants from 94 countries to the conference, which has doubled in size since inception over the last four years.

Ten landmark studies were presented at the official welcome. Key highlights include results from RESTART, which answers whether to start or avoid antiplatelet therapy after ICH in patients taking antiplatelets for the prevention of occlusive vascular disease. Remarkably, restarting antiplatelet therapy does not increase major haemorrhagic events. In contrast, restarting antiplatelet therapy may reduce recurrent ICH and protect against recurrent major vascular events. This provides reassuring evidence on restarting antiplatelet medication for secondary prevention of occlusive vascular disease in patients with ICH.

RESILIENT demonstrates the overwhelming efficacy of mechanical thrombectomy persists when implemented in the challenges of a developing country healthcare system such as Brazil. In this setting, thrombectomy decreases disability with a number needed to treat of only 6.6, has low complication rates and no increase in symptomatic ICH compared to medical therapy. We must now ensure the tremendous benefits of thrombectomy are available to more patients globally, including developing countries. 

ISC 2019: Acute Endovascular Treatment Oral Abstracts III

International Stroke Conference
February 6–8, 2019

Deepak Gulati, MD

There is uncertainty about factors affecting collaterals, natural course of collaterals and the type of anesthesia during thrombectomy. The session started with the detailed analysis of the GOLIATH trial to identify predictors of collateral circulation grade, infarct growth at 24hrs and the effect of collaterals on clinical outcome. The GOLIATH trial was a single center RCT comparing GA vs CS in acute patients with ELVO within 6 hours. Successful reperfusion was better in GA vs CS (76.9% vs 60.3, p=0.04). This study categorized Grade 2 ASTIN Collateral grading into 2- and 2+ based on <50% or >50% defect in ischemic territory, respectively. The anesthesia protocol included MAP>70 but could not be achieved in 26% of the entire population (35.4% in GA vs 15.9% in CS). Patient were also found to be hypocarbic with median ET CO2 of 33mmHg. There is no effect of collaterals noticed on clinical outcomes. Infarct growth is found to be associated with the use of pressor use (phenylephrine). This study concluded that sedation induced intraprocedural BP drop has a deleterious effect on collateral circulation and may not be reversed by IV pressor administration.

ISC 2019: Opening a Window and Throwing Out the Clock

International Stroke Conference
February 6–8, 2019

Session: “Extending the Thrombolytic Time Window to 9 Hours for Acute Ischemic Stroke using Perfusion Imaging Selection – The Final Result”

Kara Jo Swafford, MD

Henry Ma, PhD, from Monash University in Melbourne, Australia, presented the final results of the EXtending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND) trial at the 2019 International Stroke Conference in Honolulu, HI, on Friday, February 8. The EXTEND trial was a randomized, multicenter, double-blinded, placebo-controlled phase III trial of intravenous alteplase versus placebo designed to test the hypothesis that the time window for treatment could be as long as 9 hours from stroke onset (including wake-up stroke patients with unknown last known well). Recruitment for the EXTEND trial halted in June 2018 after the WAKE-UP trial demonstrated benefit from imaging-guided intravenous thrombolysis in acute stroke patients with unknown last known well. The WAKE-UP trial used MRI rather than CT perfusion for patient selection.

ISC Session: “Medical Therapy for Symptomatic Carotid Stenosis: Time for Modern Data”

International Stroke Conference
February 6–8, 2019

Deepak Gulati, MD

There has been significant improvement in medical management in the last decade leading to various options in 2019 as compared to the era when earlier clinical trials on carotid stenosis were performed.

Dr. Seemant Chaturvedi from the University of Maryland presented on multi-modal treatment of carotid stenosis. Statins plays an important role by reducing LDL being the primary focus of treatment. In the SPARCL study, 32% risk reduction was seen with statins. The cardioprotective mechanisms of physical activity includes psychological, anti-arrhythmic, anti-thrombotic, anti-atherosclerotic and improved hemodynamics. Various studies/guidelines support the encouragement of regular exercise as a stroke prevention strategy and should be emphasized to patients. Physical activity is often found to be a ‘neglected prescription.’ Exercise volumes of 150 min/week of moderate-intensity or 75 min/week of vigorous-intensity aerobic exercise further reduce CVD mortality. Several diets have been proposed for CV risk reduction, including the DASH diet and Mediterranean diet. Being DM as one of the major vascular risk factor, stroke physicians should be aware of recent advances in anti-hyperglycemic drugs. Some newer antihyperglycemic agents have an FDA indication for reduction of either CV death or CV events. The use of dual antiplatelet therapy has been increasing based on the CHANCE and POINT trial. Some of the newer strategies include PCSK9 inhibitors, ezetimibe and TG reduction. Our current management of symptomatic carotid stenosis is based on the NASCET trial published in 1991. Given the recent advances in multimodal medical treatment, there appears to be a strong need of new clinical trials in patients with carotid stenosis.

ISC Session: “What’s Old Is New Again: Neuroprotection for Stroke in 2019”

International Stroke Conference
February 6–8, 2019

Robert W. Regenhardt, MD, PhD
@rwregen

Moderators: Jean Claude Baron, Andrew Demchuk

The first talk, by Nerses Sanossian, was titled “Neuro-protection in the Pre-hospital Setting.” Sanossian began by introducing the ischemic cascade in which there are rapid changes over minutes to hours (O2 depletion, energy failure, terminal depolarization, ion homeostasis failure), secondary changes over minutes to days (excitotoxicity, SD-like depolarizations, disturbance of ion homeostasis), and delayed changes over days to weeks (inflammation, apoptosis). While no neuro-protective agent has proven successful in phase 3 clinical trials, he asserts that these agents still hold promise. Reconsideration of mechanistic targets is important as there has been a shift in treatment paradigm with thrombectomy now the priority for LVO strokes. As these patients are collected from locations of symptom onset, transported to thrombectomy capable hospitals, and admitted for acute care, when is the best time to offer a neuro-protective agent? Future trials must balance the timing against the cost. An agent could be administered pre-hospital, post-arrival/pre-imaging, post-tPA, pre/during transfer if needed, pre-thrombectomy, or post-thrombectomy. There are unique considerations for each timepoint. In the pre-hospital setting, consent can be difficult, there is no imaging available, agents should be safe in ICH, have no interaction with tPA, easily stored in ambulances, administration should be easy (avoid pumps and compounding), agents should be effective despite fewer patients recanalizing, and have robust experimental data at early time points. In-hospital initiation allows standard consent, imaging is available (could tailor agent to stroke subtype), pharmacies can store and dispense agents, agents can be combined with recanalization (improved delivery to target tissue and opportunity for targeting reperfusion injury and hemorrhagic transformation), and patients can be more carefully selected after imaging for those most likely to benefit.