American Heart Association

Conference

ESOC 2021 Session: “Closing Ceremony and Large Clinical Trials 2”

Vignan Yogendrakumar, MD, MSc
@VYogendrakumar

European Stroke Organisation Conference
September 1–3, 2021

Wrapping up our coverage of this year’s ESOC, the second round of results from major clinical trials!

APACHE-AF: Apixaban after Anticoagulation-Associated Intracerebral Hemorrhage In Patients with Atrial Fibrillation: A Randomized, Open-Label, Phase 2 Trial

APACHE-AF was a prospective, randomized, open-label clinical trial, recruiting adults with a history of atrial fibrillation and anticoagulation associated ICH. Following their ICH event (days 7-90 days post ICH event), participants were randomized to apixaban 5mg twice daily or to avoiding anticoagulation. Primary outcome was vascular death or non-fatal stroke and was evaluated using a Cox proportional hazards regression model. Between January 16, 2015 and July 6, 2020, 101 participants (46% female, median age 77 years) were recruited at a median of 46 (IQR 21-74) days after ICH in an intention to treat analysis. Participants were followed for a median of 1.9 (IQR 1.0-3.1) years. There were 10 patients who crossed over. For the primary outcome, comparing Apixaban to Avoiding Anticoagulation: Adjusted HR: 1.05 (0.48-2.31), indicating no major difference between the two groups. There were no major differences in subsequent ICH between the two groups.

By |September 7th, 2021|clinical, Conference|Comments Off on ESOC 2021 Session: “Closing Ceremony and Large Clinical Trials 2”

ESOC 2021 Session: “Presidential Symposium Awards and Large Clinical Studies”

Thomas Meinel, MD
@TotoMynell

European Stroke Organisation Conference
September 1–3, 2021

The first part of the symposium was the awards ceremony for the presidential awards for 2021 and 2020 for exceptional late-stage researchers. The awardees were Professor Michael Brainin, past ESO and WSO president and founder of the ESO European Stroke Master programme, followed by Professor Bo Norrving, editor-in-chief of the European Stroke Journal, ESO founding member, past WSO president, and past ESO vice-president. Both were honored for their outstanding contributions to both stroke research and development of the ESO.

Next up were the awardees of the Scientific Excellence Award of 2021 and 2020. The first awardee was Professor Georgios Tsivgoulis, the vice-president of ESO. He not only contributed significantly to the recent guidelines on intravenous thrombolysis and blood pressure management, but he also has an impressive scientific track record with a special focus on evidence synthesis. The second awardee was Professor Urs Fischer, the former ESO secretary general. He is the principal investigator of several multicenter international trials answering burning questions of present stroke care with important results presented at this conference. Both awardees pointed out that clinical research is a team effort and dedicated their award to the study teams, collaborators, and PhD students.

By |September 7th, 2021|clinical, Conference|Comments Off on ESOC 2021 Session: “Presidential Symposium Awards and Large Clinical Studies”

ESOC 2021 Session: “Scientific Communication 06 – Acute Treatment and Thrombolysis”

Vignan Yogendrakumar, MD, MSc
@VYogendrakumar

European Stroke Organisation Conference
September 1–3, 2021

This session opened with a presentation by Dr. Mikhail Kalinin and the CEREHETIS Investigators on the potential neuroprotective effect of Cerebrolysin as an add-on therapy during acute reperfusion. In a pilot RCT designed to assess safety, patients were randomized to cerebrolysin + IV tPA versus IV tPA alone. The primary outcome of the study was post-treatment symptomatic hemorrhagic transformation. 117 patients were randomized to the intervention arm, while 201 were randomized to the control arm.  Symptomatic hemorrhagic transformation occurred at lower rates in those who received cerebrolysin + thrombolysis, compared to thrombolysis alone. However, functional outcomes (mRS ≤ 2) did not differ between the two groups.

This was followed by a presentation by Dr. Wayneho Kan and the American Heart Association Get With The Guidelines-Stroke group. Using the registry of 160,000+ patients, Dr. Kan presented on the outcomes of tPA use in patients who were on a NOAC versus those not on anticoagulation using propensity score overlap weighting and regression modelling. Adjusting for baseline clinical factors, the risks of symptomatic intracranial hemorrhage did not differ between the two groups (sICH: aOR, 0.88 [95%CI, 0.70-1.10]; in-hospital mortality: aOR, 0.84 [95%CI, 0.69-1.01]). Of note, the exact time of last NOAC dose was not measured in this registry, and levels of factor Xa were also not available. Based on an analysis of a smaller registry used within this study which reported time of NOAC dose, a large majority of NOAC patients treated with lysis had taken their last dose more than 24 hours prior to the stroke event.

By |September 2nd, 2021|clinical, Conference, treatment|Comments Off on ESOC 2021 Session: “Scientific Communication 06 – Acute Treatment and Thrombolysis”

Fluoxetine in Stroke Fails to Deliver

Muhammad Rizwan Husain, MD
@RIZWANHUSAINMD  

Lundström E, Isaksson E, Greilert Norin N, Näsman P, Wester P, Mårtensson B, Norrving B, Wallén H, Borg J, Hankey GJ, et al. Effects of Fluoxetine on Outcomes at 12 Months After Acute Stroke: Results From EFFECTS, a Randomized Controlled Trial. Stroke. 2021.

The Efficacy oF Fluoxetine—a randomisEd Controlled Trial in Stroke (EFFECTS) was a randomized clinical trial whose primary outcome was to assess if oral fluoxetine initiated within 2-15 days of an acute stroke (ischemic or hemorrhagic) and taken up to 6 months improved functional outcomes. The initial trial results, which were published in August 2020, demonstrated no improvement in functional outcomes (modified Rankin Score-mRS-adjusted odds ratio: 0.94 [95% CI 0.78–1.13]) at 6 months with fluoxetine use and noted an increased rate of fractures and hyponatremia, though occurrence of depression was reduced (by 4%).

The authors now report 12-month follow-up results on outcomes that include the mRS, health status, quality of life, fatigue, mood and depression to see if any effects of fluoxetine persisted or were delayed.

By |September 1st, 2021|clinical, Conference, treatment|Comments Off on Fluoxetine in Stroke Fails to Deliver

Article Commentary: “Switching to Tenecteplase for Stroke Thrombolysis: Real-World Experience and Outcomes in a Regional Stroke Network”

Ericka Samantha Teleg, MD

Mahawish K, Gommans J, Kleinig T, Lallu B, Tyson A, Ranta A. Switching to Tenecteplase for Stroke Thrombolysis: Real-World Experience and Outcomes in a Regional Stroke Network. Stroke. 2021.

Accessibility to stroke services, timely treatment and management differ in regions and locations throughout the world. Each geographic location is different in terms of barriers to stroke treatment. Evidence translated to real-world findings is an important key element in this article by Mahawish et al. The New Zealand Central Region Hyper-Acute Stroke Network switched to tenecteplase driven by data supporting probable improvement of large vessel occlusion (LVO) recanalization in areas wherein, first, endovascular accessibility is a challenge due to geographical limitations, and second, the ease of tenecteplase administration. This model can contribute to other regions that have similar landscape in terms of medical resources and accessibility to tertiary or regional centers with endovascular administration infrastructure.

By |September 1st, 2021|clinical, Conference, treatment|Comments Off on Article Commentary: “Switching to Tenecteplase for Stroke Thrombolysis: Real-World Experience and Outcomes in a Regional Stroke Network”

ISC 2021 Session: Treatment of Acute Stroke in Childhood and Young Adults (Debate)

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.

By |March 26th, 2021|clinical, Conference, treatment|Comments Off on ISC 2021 Session: Treatment of Acute Stroke in Childhood and Young Adults (Debate)

ISC 2021 Session: Stroke in Pregnancy: What To Expect When They’re Expecting

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Stroke in Pregnancy: What To Expect When They’re Expecting (150, On Demand)

Eliza C. Miller, MD, MS: In this session, Dr. Miller pointed out three important topics: epidemiology, mechanism and prevention. The trend in maternal mortality in pregnancy in the United States increased from 1987 until 2016. And so is the rate of maternal stroke. The incidence is 30/100,00 deliveries. Half are hemorrhagic with a mortality of 10-16%, which is different than stroke in the general population, where 85% of strokes are ischemic. Hypertension is the leading cause, and there is some racial disparity among the prevalence. The risk is higher in the non-White population (African American, Asian and Hispanic). Migraine is another stroke risk factor, which increases the risk of hypertension and preeclampsia, which ultimately are risk factors for stroke.

The diagnostic criteria for Pre-eclampsia per ACOG and ISSHP is new onset hypertension at the gestational age greater than 20 with proteinuria or without proteinuria with a new onset headache unresponsive to the treatment or new onset focal neurological deficit. 

The take-home message from this talk was, headache and hypertension in pregnancy are red flags and should be taken seriously.

By |March 24th, 2021|clinical, Conference|Comments Off on ISC 2021 Session: Stroke in Pregnancy: What To Expect When They’re Expecting

ISC 2021 Session: Tenecteplase Is Ready for Clinical Practice (Debate)

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.

By |March 22nd, 2021|clinical, Conference, treatment|Comments Off on ISC 2021 Session: Tenecteplase Is Ready for Clinical Practice (Debate)

ISC 2021 Session: Imposter Syndrome – Our Stories

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Imposter Syndrome – Our Stories

“Perfectionism is a sick mindset.”
— Darshan H Mehta

There is no formal definition of imposter syndrome, but it is defined vaguely as to doubt your abilities and capabilities. It is a feeling of discomfort, second-guessing, and mild anxiety in the workplace, especially for women.

The term gets its origin in 1978 when two psychologists, Pauline Rose Clance and Suzanne Imes, used the concept of “imposter phenomena” while studying high-achieving women. They found that despite stellar academic and professional achievements, women who experience the imposter phenomenon kept on believing that they are really not bright enough, and they question themselves if they are deserving of accolades.

This session put up a healthy discussion among women pointing out when they first recognized that they are suffering from imposter syndrome. It also discussed why imposter syndrome exists in the first place and what role workplace systems play in fostering and exacerbating it in women. Leaders must create a culture for women and people of color that addresses systemic bias and racism. By doing so, we can reduce the experiences that culminate in so-called imposter syndrome among employees from marginalized communities — or, at the very least, help those employees channel healthy self-doubt into positive motivation, which is best fostered within a supportive work culture.

By |March 22nd, 2021|clinical, Conference|Comments Off on ISC 2021 Session: Imposter Syndrome – Our Stories

ISC 2021 Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate)

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.

By |March 22nd, 2021|clinical, Conference, treatment|Comments Off on ISC 2021 Session: Challenging EVT Decision Making: When, Where, and Who to Treat (Debate)