American Heart Association

Conference

ISC Session: Sickle Cell Disease and Stroke in Populations of African Ancestry

International Stroke Conference
January 24–26

Deepak Gulati, MD

Stroke is a leading cause of morbidity and mortality among children with sickle cell disease. It was an interesting discussion by national and international speakers during one of the dedicated sessions at ISC 2018 on epidemiology of stroke, genetics, use of transcranial Doppler and hydroxyurea trial in sickle cell disease. Sickle cell disease is an inherited monogenetic disorder with a polygenic phenotype. Stroke affects 10–30% of children with sickle cell disease.

Dr. Rufus Akinyemi, MBBS, from the University of Ibadan in Nigeria, provided an update on the epidemiology of stroke in Africa. Non-communicable diseases contribute as much as 80% to medical admissions in some African hospitals. There are numerous studies providing varying number for stroke prevalence in Africa, ranging from 58 to 1,331/100,000. In one of the studies (Interstroke study), the one-month case fatality rate for stroke was 22% in Africa. Hemorrhagic strokes are reported to be more common in Africa. There has also been observed a relationship between HIV infection and stroke, but the pathogenesis is not entirely clear. One of the major concerns is the gaps in the stroke knowledge in health care workers and treatment choice influenced by cultural and religious beliefs. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. ARISES (African Rigorous Innovative Stroke Surveillance) aims to conduct a 3-year surveillance of stroke cases in selected urban and rural sites in Nigeria, which have an existing demographic surveillance system. There is a great need for rigorous and reliable data to inform implementation efforts for prevention and control of stroke in Africa.

By |January 29th, 2018|Conference|0 Comments

Addressing the Controversy: Report from the ISC Guidelines Q&A

International Stroke Conference
January 24–26

Kevin S. Attenhofer, MD

Following a mixed reception at the reveal of the new 2018 AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke, selected members of the guidelines panel spent time Thursday with conference-goers to field questions. The session was in such demand that the fire marshal had to start turning people away at the door, leading to the creation of a second session in the afternoon. All told, the panel spent about 3 hours answering questions from stroke practitioners in the trenches.

In this post, I highlight 6 of the most contentious topics brought up by clinicians. I have attempted to summarize the lengthy and passionate discussion between the panel and the crowd. The panel frequently reminded the crowd that these guidelines are here to help guide clinical practice when the clinician has a question, not dictate it. These are much more streamlined guidelines than previous versions, as the authors feel they have “trimmed the fat” to make them more usable and accessible.

By |January 26th, 2018|Conference|0 Comments

ISC Session: Acute Ischemic Stroke Guidelines

International Stroke Conference
January 24–26

Alexis N. Simpkins, MD, PhD

Session: Acute Ischemic Stroke Guidelines
Date: Wednesday, January 24, 2018

Speakers: William Powers, MD, FAHA, University of North Carolina; Opeolu Adeoya, MD, University of Cincinnati; Alejandro Rabinstein, MD, Mayo Clinic; Thabele Leslie-Mazwi, MD, Massachusetts General Hospital

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018

The new American Heart Association acute ischemic stroke guidelines were presented at the 2018 International Stroke Conference in Los Angeles. There were several new notable recommendations and updates, which are now published. Some of the updates emphasized during the presentation addressed mild stroke symptoms in the 3-4.5 hour time window for intravenous alteplase, indications for tenecteplase, risk of intracerebral hemorrhage with intravenous thrombolysis in patients with cerebral microbleeds, anti-thrombotic use within 24 hours of intravenous thrombolysis, triage of patients in the field by EMS to tPA capable versus tPA/mechanical thrombectomy capable hospitals, and tPA eligibility in adult patients with sickle cell disease.

By |January 25th, 2018|Conference|9 Comments

ISC Session: Unruptured Aneurysms: Novel Insights and Treatment Concepts

International Stroke Conference
January 24–26

Kaustubh Limaye, MD

Management of unruptured aneurysms continues to be a clinical conundrum. This session at ISC 2018 was geared toward identifying better strategies for identifying patients at higher risk of rupture and selecting appropriate management modalities.

The session started with a talk by Dr. Mervyn Vergouwen, who discussed risk factors for aneurysm growth and rupture. He discussed the prevalence of aneurysm to be 3% of the world population. “Growth predicts rupture,” he said. What to do: treat or wait and scan? Weigh risk of rupture and risk of treatment. He discussed the PHACES and ELAPSS studies, highlighting the important features and also the important predictors of aneurysm rupture that were excluded from these studies, like data on smoking, familial history and aneurysm morphology. “Risk predicting scores are the beginning and not the end,” he said. Multiple factors, rather than just diameter or location, should be included in deciding treatment.

By |January 25th, 2018|Conference|0 Comments

“Telestroke 3.0. Beyond Acute Ischemic Stroke”: Leveraging Technology for Stroke Management

International Stroke Conference
January 24–26

Deepak Gulati, MD

During “Telestroke 3.0. Beyond Acute Ischemic Stroke,” one of the last symposium sessions on day one of ISC 2018 in Los Angeles, many national and international speakers discussed the innovative use of telestroke beyond acute ischemic stroke care in different settings.

The first presentation was on “Telestroke Networks Providing Community Education: Stroke ECHO” by Dr. Chung from the University of Utah. He discussed the project ECHO — Extension for Community Healthcare Outcomes — which is a rural, resource-limited focus initiative by the University of Utah. It is an extensive network with spokes in other states and countries, including Canada and West Africa. There is a growing demand of vascular neurologists nationally and internationally. Project ECHO is based on a case review model, and the initial focus is on acute stroke care while addressing multiple changing practice updates, along with CME and outreach beyond spoke ED’s. The future opportunities with the telestroke include pre-hospital and post-hospital long term care, expanding educational and clinical needs, and inter-disciplinary partnerships.

By |January 25th, 2018|Conference|0 Comments

The Fellows in Training (FIT) Initiative

International Stroke Conference
January 24–26

Gurmeen Kaur, MBBS

This year at ISC 2018 in Los Angeles, the American Heart Association/American Stroke Association put together a new program called the Fellows in Training program (FIT). In addition to introducing attendees to the International Stroke Conference and the AHA/ASA, the workshop was meant to provide stroke fellows with tools and training that will benefit them in their professional career, as well as opportunities to interact with thought leaders and potential mentors in the national and international stroke community.

Around 50 fellows from vascular neurology programs around the country were a part of the workshop, which began with an introduction and several talks on how to identify your mission statement, good ways to present your data, and introducing changes in healthcare by understanding business, quality improvement and leadership models and roles. Day 1 also included a talk on how to build a practice and various practice models and their limitations. This was an excellent way of introducing fellows and early career attendees to academic, hospital-owned and physician-owned practice models to help this young group select their first jobs. The final session of the day was a networking event for all the participating fellows and faculty.

By |January 25th, 2018|Conference|0 Comments

Sweet Tooth for Stroke: Looking at Diabetes from Bench to Bedside

International Stroke Conference
January 24–26

Kevin S. Attenhofer, MD

Diabetes is not just a matter of the sugar! Like stroke, diabetes is a vascular disease. This morning, Drs. Wuwei Feng, Karen C. Johnston, Kunjan Dave, and Adviye Ergul presented an intriguing series of lectures looking into some of the subtleties of pathophysiology and management of diabetes in the acute stroke patient. This is a particularly important topic here in the United States, where 1 in 4 patients carry this diagnosis — an independent risk factor for stroke that is modifiable!

By |January 24th, 2018|Conference|0 Comments

ISC Session: Role of Neuroimaging in Stroke Prevention, Treatment and Recovery

International Stroke Conference
January 24–26

Deepak Gulati, MD

During one of the first symposium sessions on day one at ISC 2018 in Los Angeles, speakers discussed a few interesting topics, including the role of MR imaging and high resolution MR (vessel wall) imaging in acute stroke.

The first presentation was on “MRI Guided Treatment of Patients With Resolved or Minimal Symptoms” by Dr. Richard Leigh from NINDS. There are always few cases in daily practice when there is a diagnostic dilemma, whether it is a stroke mimic or making treatment decisions for patients with high risk of bleeding or an unclear time window. When performed as first modality in the setting of acute stroke, MRI can provide additional information in patients with resolving or resolved NIHSS or where the risk/benefit of thrombolysis is in debate. MRI could also identify blood flow abnormalities that are concerning for clinical decline and prevent treatment of patients with a high burden or worrisome pattern of microbleeds. However, there are practical difficulties in performing DWI-MRI in a timely manner, including scheduling issues, the patient’s condition, pacemaker, patient movements, etc., even though it has been reported that 11% of hospitals with MRI on site had performed MRI on any stroke patient within 6 hours of onset.  MRI rapid stroke protocol usually takes approximately 8 minutes.

By |January 24th, 2018|Conference|0 Comments

Some Interesting Late-breaking Abstracts

European Stroke Organisation Conference (ESOC)
May 16–18, 2017

May 18, 2017
Should you restart anticoagulation after a cerebral haemorrhage? And other questions.

There are few things as devastating as a large ischaemic stroke in a patient who you had previously advised not to take anticoagulation.

As a stroke physician, I’ve been asked questions about whether I should give anticoagulation to a patient who has had an intracerebral haemorrhage (ICH). Many people who have had an ICH are at high risk of having an ischeamic stroke. At the late-breaking trials session of ESOC, there was some useful evidence that will help me sleep after these consults.

What Causes Lacunar Stroke, and How Should You Treat It?

European Stroke Organisation Conference (ESOC)
May 16–18, 2017

May 17, 2017
What if I told you that nearly 1/4 of ischaemic strokes weren’t caused by emboli at all? With the focus on retrieving clots with clever devices, and preventing them from forming with anticoagulants, it’s easy to forget that some ischeamic strokes have quite a different cause.  Lacunar strokes are caused by small vessel disease: an intrinsic disease of the small deep perforating arteries. Small vessel disease also causes vascular dementia, and is likely to  play a role in gait disturbance and falls.

At ESOC, there was an excellent session on SVD, which gave plenty of practical advice and food for thought.