American Heart Association

Conference

ISC Session: “Vulnerable Carotid Plaque Imaging and Management: A New Dawn?”

International Stroke Conference
February 6–8, 2019

Richard Jackson, MD

I’m writing to you from ISC reporting on an extremely well-planned lecture series on symptomatic carotid artery identification by imaging. I’ve always thought this topic extremely vague as the imaging technology progressed, the medical treatment progressed, but the evaluation and treatment remained surgical with guidelines from the 1990s and most of the research spread across multiple sub-specialties. This same sentiment was echoed today in each mini-series lecture. There’s no easy way to summarize each mini lecture except to keep it in its original format and hit the relevant highlights, which are numerous to say the least.

First Lecture: “Ultrasound Imaging of Carotid Wall and Plaque” by J David Spence
His focus is clearly the identification of vulnerable plaques by ultrasound, and he was a proponent of upcoming volumetric plaque morphology assessment. He quotes the prevalence of asymptomatic carotid stenosis in the >60 year old population at 10% and identifies vulnerable plaques using TCD with emboli detection and plaque characteristics as echo-lucency, hemorrhage, and plaque ulcerations. Of interest was a paper he showed in which TMAO and lecithins produced by intestinal flora worsened carotid stenosis. As GFR decreased, including with age, the metabolites increased, possibly explaining the age relationship to carotid stenosis. Also of interest were the timelines in which carotid stenosis responded to medication. He presented his own carotid plaque and showed a transition from hypoechoic to hyperechoic in 3 months with atorvastatin, and then presented a paper in which ezetimibe doubled the effectiveness of statin therapy.

“What Do I Do with this Aneurysm?” — ISC Symposium Highlights the Challenges and Complexity of Treatment Decisions

International Stroke Conference
February 6–8, 2019

Kat Dakay, DO

One of the talks I was most looking forward to at ISC 2019 was the invited symposium titled “What Do I Do with this Aneurysm?” As advanced imaging allows for the detection of smaller and smaller aneurysms, many of them incidental, this is becoming a more challenging and pertinent topic.

This symposium, moderated by Dr. Sepideh Amin-Hanjani, MD, co-director of neurovascular surgery at the University of Illinois, was a lively discussion incorporating both neuroendovascular and open neurosurgical approaches to aneurysm treatment.

First, Dr. Mervyn Vergouwen, MD, PhD, from UMC Utrecht, began the symposium with a lecture titled “What Aneurysms Should I Treat?” He discussed patient-specific factors such as patient preference and life expectancy/comorbidities, as well as the challenging task of weighing the risk of aneurysmal rupture versus the risk of aneurysm treatment complications. One scoring system mentioned during the lecture was the PHASES score (published in Lancet Neurology in 2014 by Greving et al.), a score developed to approximate the five-year risk of rupture in an unruptured aneurysm; this score takes into account both patient-specific characteristics such as age and hypertension, as well as aneurysm-specific characteristics such as size and location. He discussed also considering the risk of the treatment approach — e.g., stent-assisted coiling versus coiling alone — when deciding whether to treat or observe an asymptomatic aneurysm.

ISC Session: “I Know the Best Way to Select Patients and Perform Stroke Thrombectomy” (Debate)

International Stroke Conference
February 6–8, 2019

Burton J. Tabaac, MD
@burtontabaac

First Presenter: Xin Cheng, MD, PhD
This insightful discussion focused on the identification of intracranial atherosclerotic disease (ICAD) and its relationship to large vessel occlusion (LVO). The speaker pointedly detailed the differences in truncal type vs. branching type anatomies. This difference in dynamic may be correlated with baseline NIHSS and size of penumbra, with larger penumbra suggesting better collateral circulation. This portion of the talk was aided by neuroimaging to demonstrate the presence of a “susceptibility vessel sign” (SVS) on GRE/SWI MRI sequencing. If present, SVS suggests an embolic etiology, whereas the absence of SVS suggests ICAD.

The current treatment of ICAD-LVO lacks consensus amongst the scientific community. Notably, patients with ICAD were observed to experience much longer procedure times compared to patients with LVO of embolic origin. The presenter posed the question, “Is endovascular treatment, or even thrombosis, necessary in this subset of patients?” ICAD-LVO is highly common in Asian populations, and there are no definitive clinical and/or imaging profiles for ICAD-LVO patients. It remains to be clear how treatment and patient selection criteria will change, the take-away being that intervention is safe, but it is unclear if it is beneficial.

How Long Should We Give Dual Antiplatelet Therapy After Minor Acute Ischemic Stroke?

World Stroke Congress
October 17-20, 2018

Danielle de Sa Boasquevisque, MD

Following a Transient Ischemic Attack (TIA) or minor ischemic stroke, the risk of having another ischemic stroke or vascular events within the next three months is 10-20%. The Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial was a randomized, double-blind study designed to evaluate the benefit of dual antiplatelet therapy (DAPT) compared to aspirin alone during the first 90 days after a minor ischemic stroke or transient ischemic attack. The primary efficacy outcome was major ischemic events, and the primary safety outcome was major hemorrhage.

The POINT Trial was halted after 84% of the anticipated number of participants had been enrolled. They found that patients enrolled in 3 months of DAPT had fewer major ischemic events than patients given aspirin alone (5% versus 6.5%, respectively; hazard ratio, 0.75; 95% confidence interval [CI], 0.59 to 0.95; p=0.02). However, the DAPT also seemed to increase chances of major hemorrhage compared to the aspirin controls (0.9% versus 0.4%, respectively; hazard ratio 2.32; 95% CI, 1.10-4.87; p=0.02).

A secondary analysis of POINT Trial data was presented by Jordan J. Elm at the World Stroke Congress in October in Montreal. It aimed to identify the time course of risks versus benefits of clopidogrel and aspirin in acute minor ischemic stroke and high-risk TIA patients and determine if there is an optimal time when patients would benefit most from using both aspirin and clopidogrel.

World Stroke Congress Session: Advances in Stroke Imaging

World Stroke Congress
October 17-20, 2018

Ravinder-Jeet Singh, MBBS, DM

The session on advances in stroke imaging was very interesting and informative. Three speakers — Dr. Ken Butcher from Edmonton and Drs. Gregory Albers and Chitra Venkatasubramanian from Stanford — discussed some of the recent changes in the field of stroke imaging and how it is influencing the practice of stroke care.

Dr. Butcher spoke about multimodal CT based imaging paradigms in acute ischemic stroke, especially use of CTA and CTP in patient selection. It is of note that two of the “early window” EVT trials (SWIFT PRIME and EXTEND IA) and both the late window trials (DAWN and DEFUSE 3) used perfusion imaging for patient selection. He discussed various software platforms available for processing and interpreting CTP data. Options include inbuilt software provided by CT vendors and other commercially available software including RAPID (iSchemaView Inc.), MIstar (Apollo Medical Imaging Technology), and OleaSphere (Olea Medical). The key message was that clinicians should be careful in interpreting CTP images and also the outputs (core, penumbra volumes, and mismatch ratios) provided by these softwares. It is essential to look at arterial input function and venous output function curves to assess the quality of CTP data. These curves should display rapid upslopes and downslopes. Presence of any truncation of these curves should also be noted, which could lead to misestimation of core and penumbra size. In addition, the presence of motion artifacts can severely degrade image quality and, therefore, its interpretation. He also pointed out another important area in which CTP could be helpful — the stroke mimics — where a normal CTP would be reassuring in the appropriate clinical context.

European Stroke Organisation Conference 2018: Insights from the Large Clinical Trials Session

European Stroke Organisation Conference
May 16–18, 2018

Aristeidis H. Katsanos, MD, PhD

Dr. Robert Hart presented the first results of the NAVIGATE ESUS trial, a randomized clinical trial (RCT) on the safety and efficacy of Rivaroxaban 15mg once daily compared to acetylsalicylic acid (ASA) 100mg in patients with embolic strokes of undetermined source (ESUS). The trial was stopped prematurely at the second interim analysis, and after randomization of a total of 7213 patients, due to the absence of significant differences between the two groups regarding the primary efficacy outcome of all recurrent stroke or systemic embolism. Moreover, a significant increase in the risk of both hemorrhagic stroke and all major bleeding events was found in the Rivaroxaban group compared to the ASA group. Although no significant differences were found in other pre-specified subgroup analyses, a subgroup analysis of patients with patent foramen ovale randomized within the NAVIGATE ESUS trial presented by Dr. Scott Kasner suggests that Rivaroxaban treatment may reduce the risk of recurrent cerebral ischemic events in this specific patient population compared to ASA.

Tranexamic Acid for Acute Intracerebral Hemorrhage

European Stroke Organisation Conference
May 16–18, 2018

Andrea Morotti, MD

The results of the Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2) randomized controlled trial were presented at the 4th congress of the European Stroke Organisation in Gothenuburg, Sweden. Subjects with primary, spontaneous intracerebral hemorrhage (ICH) presenting within 8 h from symptom onset/last time seen well were randomized to treatment with intravenous tranexamic acid (1 g bolus followed by 1 g over an 8 h infusion) versus placebo. 1 The main outcomes of interest were hematoma expansion (defined as absolute hemorrhage growth>6mL or relative hemorrhage growth>33% from baseline volume) and the proportion of patients with death or severe disability at 3 months from the index event.

Author Interview: Mike Sharma, MD, MSc, FRCPC

Mike Sharma

Mike Sharma

A conversation with Mike Sharma, MD, MSc, FRCPC, Michael G. DeGroote Chair in Stroke Prevention and Associate Professor of Medicine (Neurology) at McMaster University/Population Health Research Institute and one of the co-authors of the COMPASS clinical trial, which studied the utility of combined low dose rivaroxaban and aspirin for cardiovascular disease prevention in patients with peripheral artery disease. Dr. Sharma presented a platform presentation on the findings of stroke prevention at the International Stroke Conference in February 2018 in Los Angeles, California.

Interviewed by Alexis N. Simpkins, Assistant Professor of Neurology, University of Florida School of Medicine.

They will be discussing the paper “Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease,” published in October 2017 in The New England Journal of Medicine (Eikelboom JW, et al. N Engl J Med 2017; 377:1319-30).

Saving Stroke Lives with EMS Prehospital Notification: Interview with Dr. Ethan Brandler

Dr. Ethan Brandler

Dr. Ethan Brandler

A conversation with Dr. Ethan Brandler, MD, MPH, FACEP, assistant professor of clinical emergency medicine at the State University of New York at Stony Brook, during the International Stroke Conference 2018 poster session.

Interviewed by Dr. Rohan Arora, MD, director of stroke fellowship at Hofstra Northwell School of Medicine.

How often does EMS call you before bringing a stroke patient to your center? How do you use that information to expedite stroke treatment? Wondering how EMS pre-notification can make a difference in your center’s outcomes?

Read this author interview for an update on how EMS triage can tremendously benefit patients with LVO (large vessel occlusions).

Author Interview: Dr. Greg Albers, on DEFUSE 3 and its Implications for Systems of Stroke Care in the U.S.

Dr. Greg Albers

Dr. Greg Albers

A conversation with Dr. Greg Albers, professor of neurology at Stanford and the principal investigator for DEFUSE 3.

Interviewed by Dr. Kaustubh Limaye, assistant professor of neurology in the division of cerebrovascular diseases at the University of Iowa, at the International Stroke Conference 2018 following the presentation of the final results of DEFUSE 3 and a simultaneous publication in the New England Journal of Medicine.

Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. New England Journal of Medicine. 2018

Dr. Limaye: Dr. Albers, first accept my hearty congratulations on the phenomenal success of the DEFUSE 3 trial.

Dr. Albers: Thank you so much.

Dr. Limaye: Just like everybody else, I was patiently waiting to hear what the results were going to be. All of us are delighted looking at the strong treatment effect that DEFUSE 3 showed in this extended time window. Thanks again for taking time out from your busy schedule. I’m sure this conference was extremely busy for you.

Dr. Albers: It’s been a very exciting week. We’ve been anticipating this for some time, and it’s wonderful to see this come to fruition.