Conference

Sishir Mannava, MD
@sishmannMD

International Stroke Conference 2021
March 17–19, 2021
Session: Treatment of Acute Stroke in Childhood and Young Adults (Debate) (179, On Demand)

This session began with Dr. Lisa Sun from Johns Hopkins School of Medicine presenting on brain attacks in teenagers, and that “we can best care for adolescents with stroke by organizing existing adult stroke centers to be able to treat teenagers.” Dr. Sun discussed how adult stroke centers and dedicated stroke units have better outcomes with organized stroke teams and stroke protocols. This leads to faster stroke recognition and treatment times. Dr. Sun presented data from time to imaging/diagnosis in major pediatric stroke centers after stroke protocol initiation, and, at best, the times appear to be between 1.3-1.6 hours, which is slower than the DTN times median of about 1 hour in adult stroke programs. Although primary pediatric stroke center development has been proven by the TIPS trial, Dr. Sun argued that it may not be feasible or resourceful to develop the needed amount of pediatric stroke centers to provide adequate coverage to all pediatric stroke populations.

“Endovascular therapy can be more safely and effectively administered to adolescents at an adult stroke center.” Dr. Sun discussed how thrombectomy in adolescents is technically like adult thrombectomy, and that by 5 years of age, head and neck arteries approach adult size. The common femoral artery (FA) sheaths used in adults can even be used in smaller adolescents as long as the ratio of FA size to catheter size is maintained, to avoid vasospasm. Adult stroke centers also have greater procedural experience, larger stock of devices, and higher volume of thrombectomies than pediatric thrombectomy centers. Data from the TRACK registry showed a significant difference in mRS ≥ 2 and final mTICI ≥2c-3 amongst higher volume centers as opposed to lower volume centers.

Saurav Das, MD
@sauravmed

International Stroke Conference 2021
March 17–19, 2021
Session: Tenecteplase Is Ready for Clinical Practice (Debate) (183)

Whether tenecteplase (TNK) is ready for clinical practice is certainly one of the crucial questions faced by the stroke community today, especially in the changing landscape with emerging evidence for non-inferiority of direct thrombectomy compared to bridging recanalization treatment, the success of mobile stroke units (MSU), and our ability for pre-hospital treatment of patients within the golden hour of last known well. TNK is not a new drug. It is successfully used in treatment of myocardial infarction, and we have evidence from five randomized controlled trials (alluded to several times in the following debate) for non-inferiority compared to alteplase (tPA) in treatment of stroke. The nay-sayers do point to inherent issues with these trials and argue that we need more data. But the question is, how much longer is this wait going to be?

This debate was in 5 segments. In the first segment, Dr. Jeffrey Saver from the University of California, Los Angeles (UCLA) argued in favor of the motion. In the second segment, Dr. Patrick Lyden from Keck School of Medicine, University of South California, argued against the motion. In the third segment, both the speakers had an opportunity for rebuttal. In the fourth segment, Dr. Shelagh Coutts from the University of Calgary provided her balancing view. And in the final segment, Dr. Steven Warach from Dell School of Medicine, UT Austin, shared his practical experience with use of TNK for the past 15 months. The session was moderated by Dr. E. Clarke Haley Jr. from the University of Virginia, Charlottesville.

Robert W. Regenhardt, MD, PhD
@rwregen

International Stroke Conference 2021
March 17–19, 2021
Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate) (33, On Demand)

The session “Challenging EVT Decision Making: When, Where, and Who to Treat” (Debate) highlights some of the most difficult management decisions regarding EVT.

Dr. Sandra Narayanan built the case “Low NIHSS proximal occlusions should undergo thrombectomy.” She started by reviewing the magnitude of the question. An LVO is present in 18% of patients with NIHSS 0-4 and 39% of those with NIHSS 5-8. Furthermore, 15% of LVO stroke patients have minor symptoms. Deterioration can happen in early or delayed fashion; about 40% deteriorate early. Current guidelines suggest that treating patients with low NIHSS is reasonable. Indeed, several studies show a benefit. The Grady experience (JNIS 2017; 9:917-921) described 32 patients with NIHSS<6. Analyses of this cohort, while small, suggested a benefit of EVT. 22 were treated with medical management, of which 9 declined requiring EVT. The median time from arrival to deterioration was 5.2 hours. Subsequently, a larger study of 6 CSCs (Stroke 2018;49: 2391-2397) described 300 patients with NIHSS<6; 11.3% of those treated with medical management later declined. At 90 days, mRS 0-2 was observed in 84% of those treated with EVT, 70% of those with medical management, and 55% of those who underwent rescue EVT. Those who are allowed to deteriorate tend to have worse outcomes. The risks versus benefits should be carefully weighed up front because waiting more than 3 hours appears to impact outcomes. There is growing data that patients at risk for decline can be selected by collaterals, orthostatic challenges, perfusion imaging, and NIHSS eloquence/disability. Three randomized controlled trials are forthcoming: ENDOLOW, IN EXTREMIS, and TEMPO 2.

Yasmin Aziz, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Mismatch Misalignments for Extended-window IV-thrombolysis for Non-Large Vessel Occlusion Strokes (Debate)
Moderator: Dr. Gotz Thomalla

Can thrombolytics be given safely and efficaciously beyond 4.5 hours? That was the debate topic for one of ISC’s first live debates to kick off Wednesday morning. 

Dr. Shlee Song: DWI-FLAIR Mismatch Rules!

The arguments began with Dr. Song, who focused on DWI-FLAIR mismatch. After a brief introduction with the MR WITNESS trial results, she then discussed how patients with DWI-FLAIR mismatch treated with alteplase had better outcomes at 90 days in the WAKE UP study. She also made the point that while efficient MRI scanning of acute stroke patients can be cumbersome, in addition to treating more patients, we can also avoid potential side effects of treating with conventional CT/CTA methods (i.e., contrast nephropathy and ICH in the event of unseen microhemorrhages only visible on MR).