American Heart Association

Conference

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.

ISC 2020: Pre-Conference Symposium III: HEADS-UP: Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving (AM Session)

International Stroke Conference
Pre-Conference Symposia: February 18, 2020
Sessions: February 19–21, 2020

Rachel Forman, MD
@bustinclots247

I had the privilege to attend this important symposium shedding light on different aspects of stroke disparities. As someone who is passionate about stroke community education and addressing healthcare disparities, it was really incredible to be able to listen in person to people I have admired throughout my training.  The symposium was moderated by Drs. Bruce Ovbiagele and Amytis Towfighi. 

The first talk was by Dr. Mitchell Elkind (Columbia University), who began by describing disparities: “… a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.” He also mentioned that approximately 1/3 of people in the United States, or more than 100 million people, identify as belonging to a racial or ethnic minority population. Another interesting point from the discussion is that Hispanic and Asian men and women are less likely to use EMS versus white men and women, and that black women are less likely than white women to use EMS (Journal of the American Heart Association, Smith 2015). We were then introduced to his work with the Northern Manhattan Study (NOMAS): a study of the population in Washington Heights (beginning in 1990) that has enrolled over 4,400 people from the surrounding community with neurological conditions. This work is ongoing and exciting (and, importantly, includes a diverse patient population).

ANS 2019 Sessions: “Injury to the Nervous System” and “Pathway to Success: Paving the Way for Translational Stroke Research”

The Annual Scientific Meeting of the Australasian Neuroscience Society
December 2–5, 2019

Lin Kooi Ong, PhD
@DrLinOng

Rebecca Hood, PhD*
@Biohazard_Hood

The Annual Scientific Meeting of the Australasian Neuroscience Society was held December 2 to 5 in Adelaide. There were many high-quality and exciting sessions. We would like to highlight two key sessions that focused on stroke and brain injury.

The first session, “Injury to the Nervous System,” provided the audience a sample of the insights gleaned from various studies on injury to the nervous system. Dr. Shenpeng Zhang (La Trobe University) kicked off the session with a retrospective analysis of 5 years’ experimental stroke data from 716 mice to identify interrelationships between measures such as infarct volume, brain edema, functional outcomes and leukocytes.

Interview: Dr. Noortje Maaijwee, MD, PhD, on Highlights from ESOC 2019

Dr. Noortje Maaijwee
Dr. Noortje Maaijwee

An interview with Dr. Noortje Maaijwee, MD, PhD, a neurologist specializing in neurorehabilitation. She is a full-time faculty member in the Department of Neurology and Neurorehabilitation at the Lucerne Cantonal Hospital in Switzerland. She completed her medical school and residency at Radboud University Nijmegen Medical Centre in the Netherlands. Her primary area of research interest includes stroke in young adults, long-term consequences of stoke, and quality of life issues after suffering a stroke. During her PhD, Dr. Maaijwee defended a thesis on “Long-term neuropsychological and social consequences after stroke in young adults.”

Interviewed by Dr. Rohan Arora, MD, Assistant Professor of Neurology, director of stroke fellowship at the Hofstra Northwell School of Medicine and medical director of the stroke program at LIJ Forest Hills, a part of Northwell Health, New York.

In this interview, Dr. Maaijwee discusses highlights from the European Stroke Organization Conference, held May 22–24 in Milan, Italy.

Dr. Arora: At ESOC 2019, what were some major breakthroughs? 

Dr. Maaijwee: The indications and contra-indications for acute treatment of ischemic stroke by IV thrombolysis and endovascular therapy are ever-changing. For example, the time-window when treatment is successful. In the Large Clinical Trials session on the first day of ESOC, a meta-analysis was presented that showed that intravenous thrombolysis increases the percentage of good clinical outcome (modified Rankin Score (mRS) 0-1) at 3 months, if treatment is started between 4.5–9 hours after onset of symptoms in select patients with CT or MRI perfusion mismatch.1

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.