Conference

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.

International Stroke Conference
February 6–8, 2019

Victor J. Del Brutto, MD

I had the pleasure to attend the session “Cost Effective Stroke Interventions in Low and Middle Income Countries” moderated by Dr. Salvador Cruz-Flores during the International Stroke Conference held in Honolulu, HI, last week.

Dr. Sheila Martins, founder of the Brazilian Stroke Network, initiated the session, sharing her experience on the implementation of dozens of stroke centers across Brazil as part of a National Stroke Project, as well as the accomplishment of stroke telemedicine, rehabilitation programs and initiatives to increase stroke awareness among the population. Martins emphasized the mortality reduction achieved by such government policies, as well as the future expectations of creating systems able to deliver acute endovascular therapies and establishing a national stroke registry.

International Stroke Conference
February 6–8, 2019

Robert W. Regenhardt, MD, PhD
@rwregen

Moderators: Carmelo Graffagnino, Edward Jauch

The first talk, “Challenges in Patient Access,” by Carmelo Graffagnino discussed the system problems we face in the thrombectomy era. There are many system models that can be used to organize a region for the care of acute stroke patients. The models that worked well in the past allowed rapid access to tPA, but as thrombectomy expertise is a scarcer resource, there are new challenges. Graffagnino described two cases: one that showed how the system can work perfectly and another that highlighted limitations as a patient experienced severe delay in transferring to the thrombectomy capable center. Some of these limitations are difficult to predict and even more difficult to fix from the perspective of physicians, such as lack of helicopter and ambulance availability.

International Stroke Conference
February 6–8, 2019

Richard Jackson, MD

I’m writing to you from ISC reporting on another difficult topic: chronic kidney disease (CKD) and stroke.  From past experience, both with traditional vascular CKD and Fabry’s disease, I know that there is a higher incidence of ICH in CKD; however, I’ve never been able to find a source that goes deep into the subject matter. Enter “Neuro-Nephrology,” a new word I had never heard before introduced to me at this mini-series. I had no idea this was a word, let alone an emerging field. I have always thought that stroke needs a subspecialty field for each subset of disease for proper study.  So, welcome to the fray, Neuro-Nephrology.

First Lecture: Epidemiology of CKD and Stroke by Angela Webster, MBBS, MM(Clin Epid), PhD, FRCP, FRACP

Mortality in ESRD is 10%/year all cause and a higher incidence of ICH. Interestingly, she presented the data that most ESRD with strokes don’t go to Stroke Units despite the proven benefits of the units and the proven benefit of the units in ESRD.

She then move on to cognition and showed data that Attention and Memory worsen early in CKD and are dose dependent with decreases in GFR peaking in HD with worsening further still in the non-dialyzed. Interestingly, but not surprisingly, there is improvement after transplant.

International Stroke Conference
February 6–8, 2019

Burton J. Tabaac, MD
@burtontabaac

Presenter: Mark Parsons, MD, PhD, FRACP — “tNK Is Ready for Prime Time”

This speaker argued that tenecteplase is the future of IV lysis. Tenecteplase is a genetically modified version of alteplase with an increased half life. Notably, tNK has been successfully used for myocardial infarction for decades, essentially replacing tPA. A phase II randomized trial comparing tNK and tPA (NEJM 2012) identified patients with LVO (large vessel occlusion) who benefited from reperfusion with tNK as compared to a relative lack of reperfusion with tPA. A phase 3 study currently being completed, TASTE, is comparing tNK and tPA. There is evidence to show that tNK has been more useful in drip and ship cases because tenecteplase does not require an hour long infusion following a bolus dose (as is required with tPA). Notably, using tNK instead of tPA will significantly reduce cost and decrease the risk of hemorrhage, and is more effective prior to thrombectomy.