Conference

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.

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.

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).

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

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.