Six Highlights from the International Stroke Conference 2022
The American Heart and American Stroke Association hosted the annual International Stroke Conference in New Orleans in February. Over 5000 participants attended the event, both in-person and virtually. There was a palpable excitement in the air as many of us were attending an in-person conference for the first time in over two years, reuniting with old colleagues and networking with new connections. The science presented truly matched the excitement. Without further ado, we highlight six key takeaways!
- Cerebral Venous Thrombosis – An update and the ACTION – CVT
- Artificial Intelligence and Technology
- RESCUE – JAPAN
- Mobile Stroke Units
- Robotic TCDs for shunt detection
- CHOICE – EVT w/ AI TPA
CVST update and trial presentation ACTION – CVST
Dr. Lily Zhou from Stanford presented an excellent overview of the evolving epidemiology and pathophysiology of cerebral venous thrombosis, showing the increasing incidence of CVTs over time. Also highlighting that many patients are diagnosed in the context of co-morbid trauma, infection, inflammatory disease, cancer, and also in the setting of COVID infection and vaccination.
Dr. Thalia Field discussed medical management in CVST, noting that over half of patients will have some degree of recanalization after only one week of anticoagulation and over 10% of patients will experience a seizure.
Lastly, Dr. Violiza Inoa described imaging modalities including MRI being 80% sensitive and 95% specific for diagnosis. In addition, she described the limited but important role of endovascular therapy in some patients with CVST.
Artificial Intelligence in stroke
Physicians and companies from across the country highlighted the important and growing role of artificial intelligence in stroke care access, evaluation, and delivery. From telestroke software to radiology tools to aiding in imaging evaluation,companies including RAPID-AI, Viz.AI and doc.AI displayed their innovative software platforms that deliver imaging results to stroke care teams instantly, leading to more rapid decision-making.
Dr. Ameer Hassan, current president of the Society of Vascular and Interventional Neurology presented a historical summary of artificial intelligence and technology in stroke care. Dr. Hassan described that the tenets of artificial intelligence can be seen throughout modern history. In terms of stroke, centers across the country are utilizing deep neural networks to improve recognition of large vessel occlusion. Dr. Hassan described how this technology has greatly improved his own center’s ability to rapidly triage patient transfers from their large catchment area.
In addition, the platforms act as a one point touch down place for communication for possible clinical trial enrollment and communication on a patient’s clinical status. This is highlighted with early detection, rapid triage and synchronized care coordination. “Green is go, Red is dead,” in reference to the perfusion mapping that can even be sent to your smartwatch. Using this tool they showed the time and economic savings by implementing stroke software.
RESCUE – JAPAN
Previous thrombectomy trials guided the delivery of mechanical thrombectomy past the 6 hours of symptoms onset to patients with minimal “core” or minimal completed stroke at time of intervention. Current guidelines support thrombectomy as a safe and highly effective therapy in select patient populations. New emerging data supports possibly expanding eligibility and including patients who present with a large ischemic core.
A group out of Japan led by Dr. Shinichi Yoshimura concluded that “Patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone.” The study presented was met with a standing ovation by the crowd in New Orleans!
The primary outcome was mRS of 0 to 3 at ninety days. Notably, it also showed a trend to less craniectomies. For the safety outcomes, the intervention arm did not show a significant difference in symptomatic intracranial hemorrhage. This study gives more support for expanding the scope of patients who may benefit from established interventions.
Mobile Stroke Units
Mobile stroke units have been highlighted in the literature multiple times in recent years, including the paper in NEJM, led by Dr. James Grotta https://www.nejm.org/doi/full/10.1056/NEJMoa2103879 showing improved mRS at 90 days when patients were treated by a mobile stroke unit compared to standard EMS.
At ISC22, a team from UTHealth led by Dr. Rajan analyzed the economic and clinical impact of mobile stroke units. Using primary end point measures of quality-of-life, the team presented their prospective multicenter study, demonstrating improved quality-adjusted life years in all patients. The study showed early neurologic recovery and functional independence was more frequently achieved in the MSU group compared to EMS. This study adds to the growing body of literature with data supporting both clinical and economic advantages of mobile stroke units.
Transcranial Doppler (TCD) for shunt detection, BUBL study
The role of imaging and technology in stroke evaluation continues to grow. There were multiple abstracts regarding the utility of TCD in patients with neurovascular disease, highlighting the importance of this low-cost, safe technology. At the late breaking science session, Dr. Mark Rubin presented the results of the BUBL study showing improvement in right-to-left shunt detection using robotic assisted transcranial doppler compared to transthoracic echo. The study evaluated 129 patients for right-to-left shunt. A shunt was detected by the robotic assisted TCD in 62% of patients, compared to only 19.4% using echocardiogram (P<0.001). This study emphasizes that TCD technology, with the assistance of the robotic device, is safe and effective in detecting right-to-left shunt, even without a skilled technician.
CHOICE – EVT w/ AI TPA
The CHOICE-EVT group led by Dr. Chamorro evaluated the use of intra-arterial alteplase after successful thrombectomy. The group discussed in their JAMA neurology publication that the planning of their trial was based on “postulated that thrombi persist within the microcirculation in patients with normal or nearly normal cerebral angiograms at the end of thrombectomy, and it was hypothesized that these smaller thrombi would be more suitable to dissolve than more proximal thrombi because the efficacy of thrombolysis is related to the extent of clot burden.”
The study aimed at improving the reperfusion in the microvascular bed. The design was double-blind, placebo controlled, and results of the intervention arm of IA alteplase showed improved outcomes in mRS at 90 days and no increased risk of intracranial hemorrhage.
- RESCUE Japan
Yoshimura S, Sakai N, Yamagami H, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med. Published online February 9, 2022.
- Mobile Stroke Units
Grotta JC, Yamal JM, Parker SA, et al. Prospective, multicenter, controlled trial of mobile stroke units. N Engl J Med. 2021;385(11):971-981.
Yaghi S, Shu L, Bakradze E, et al. Direct oral anticoagulants versus warfarin in the treatment of cerebral venous thrombosis (Action-cvt): a multicenter international study. Stroke. 2022;53(3):728-738.
Renú A, Millán M, San Román L, et al. Effect of intra-arterial alteplase vs placebo following successful thrombectomy on functional outcomes in patients with large vessel occlusion acute ischemic stroke: the choice randomized clinical trial. JAMA. 2022;327(9):826-835.