Jan. 14, 2014

ISC symposium delves into recent advances in small vessel disease

Advances and insights into the management of small vessel disease from contemporary clinical trials is the focus of the “Treatment of Small Vessel Disease: Lessons from the Clinical Trials” session February 13.

Lees

Kennedy Lees, MD, FRCP, FESO, FRSE (UK)

The session will begin with important news from Jeffrey Saver, MD, FAHA, FAAN, said Co-moderator Kennedy Lees, MD, FRCP, FESO, FRSE (UK), professor of cerebrovascular medicine and director of the Acute Stroke Project at the University of Glasgow, United Kingdom. Saver, who is a professor of neurology and the director of the stroke and vascular neurology program at the University of California, Los Angeles, will discuss results from “Ultra-early Magnesium Treatment in Suspected Lacunar Stroke,” a randomized, placebo-controlled clinical trial that evaluated the neuroprotective benefits of field-administered magnesium given very early after the onset of subcortical ischemic stroke. A decade ago, a subgroup analysis of a different trial suggested possible benefits from magnesium in lacunar and hypertensive stroke patients, probably through lowering blood pressure, and FAST-MAG may further those findings, Lees said.

Philip Bath, MB, BS, MD, FRCPath, FRCP, FESC, professor of stroke medicine at the University of Nottingham, United Kingdom, will discuss the Efficacy of Nitric Oxide in Stroke (ENOS) Trial in his presentation “Is It Time to Stop Testing Blood Pressure Treatment and Start Lowering It Instead?” This study looked at the efficacy and safety of lowering blood pressure with nitric oxide and continuing prior antihypertensive medications in stroke patients. Bath is likely to have an “inkling” of the much-awaited results, Lees said.

Blood pressure reduction in patients with intracranial hemorrhage was also the focus of the recently completed INTERACT-2 (Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial). During this session, Craig Anderson, MD, professor of stroke medicine and clinical neuroscience at the University of Sydney, will present subgroup results in “Does the Location or Etiology of ICH Influence Response to Acute Blood Pressure Lowering.” The main trial “reported an overall neutral effect of blood pressure lowering in all ICH patients but a strong beneficial trend,” Lees said. “It will be intriguing to learn from Dr. Anderson if subcortical strokes — likely associated with small vessel disease — respond differently than larger lobar bleeds in terms of blood pressure lowering,” Lees added.

Finally, Oscar Benavente, MD, FRCPC, professor of neurology and research and director of stroke and cerebrovascular health program at the University of British Columbia, Vancouver, Canada, will present “MRI Correlates and Cognitive Outcomes in SPS3.” The Subcortical Strokes Trial (SPS3) was a randomized comparison of aspirin alone versus aspirin plus clopidogrel for the secondary prevention of stroke in patients with MRI-identified symptomatic lacunar infarcts. In the main trial, there was no significant difference in efficacy or safety between treatment strategies. This subgroup analysis will “be able to tell us more about which MRI appearances are associated with certain outcomes or treatment needs,” Lees said.

Clinicians with an interest in the management of patients with small vessel disease should plan on attending this session, said Lees, whose co-moderator will be Charlotte Cordonnier, MD, staff neurologist in the stroke unit at Lille University Hospital, France.

This session will present some of the latest clinical trial results in the treatment of small vessel disease and the discussion among the experts should be illuminating.

New Pre-Conference Symposium tackles preclinical modeling of stroke

A new ISC 2014 pre-conference symposium will introduce important training concepts to those who are early in their careers by providing insights on the next generation of preclinical modeling of stroke.

Carmichael

S. Thomas Carmichael, MD, PhD, FAHA

The Feb. 11 program, “ISC Pre-Conference Symposium II (Student, Trainee and Early Career): Animal Models 2.0: Co-morbid Conditions, Optogenetics and Other New Directions,” will be moderated by S. Thomas Carmichael, MD, PhD, FAHA, professor of neurology at the University of California, Los Angeles, School of Medicine.

“Neuroscience in general is a field really driven by technology, and so part of any symposium for trainees in the field of neuroscience in stroke should cover the latest technologies and methods,” he said. “In preclinical modeling, we’ve achieved kind of a next phase overall. Many of the initial uses of preclinical models were in the 1990s and early 2000s, and they were structured around understanding cell death and trying to promote neuroprotection — in other words, a reduced amount of stroke damage.

“These models evolved in kind of a standard platform or protocol, and what we’ve done now is move a level above that in terms of sophistication and in terms of what we measure, how we measure it and some of the biology that we can understand during stroke.”

Carmichael, who also is vice chair of research and programs for the department of neurology at UCLA, said planners had two goals for the symposium.

One is to help participants understand the functional effects of stroke — from initial damage to subsequent repair — in preclinical models, so they can gain the means for better interrogation of true brain function.

“A second goal is for participants to understand how stroke is modeled in more clinically relevant ways that involve males and females, age and other co-morbid conditions that are relevant to the human situation,” Carmichael said. “That has been neglected in preclinical modeling on a routine basis.”

The symposium will offer four speakers. “They are great speakers. All four not only are experts, but they can provoke discussion, challenge concepts and enliven things, so they are going to be a lot of fun to have in the same room,” Carmichael said.

The talks will focus on:

  • “Female Sex and Age in Animal Models of Stroke” with Louise D. McCullough, MD, PhD, professor of neurology and neuroscience and director of stroke research at the University of Connecticut, Farmington
  • “New and More Sophisticated Pre-clinical Stroke Outcome Measures” with Theresa A. Jones, PhD, professor of psychology at the University of Texas, Austin
  • In Vivo Imaging of Stroke Damage and Recovery” with Craig E. Brown, MD, assistant professor in the Division of Medical Sciences at the University of Victoria, British Columbia, Canada
  • “Primate Models of Stroke Neuroprotection and Neural Repair” with D.J. Cook, MD, assistant professor of neurosurgery at Queen’s University, Kingston, Ontario, Canada

In particular, Brown’s talk will also focus on optogenetics, which Carmichael described as the use of molecules that can indicate cell shape, neural connections, blood flow and the overall physiological state of brain tissue over time in living animals.

“This is done with genetic coding of ‘reporter’ molecules that are florescent and can be seen through a microscope in the living animal. That’s the optical part, and the genetic part, of course, is that you make it so that these things turn on or turn off in cells over time in the living animal,” Carmichael said. “The power with optogenetics is that you can determine in real time what’s happening in stroke and in stroke brain repair. It’s also more sophisticated, so we can view in more detail structure and function in the brain and visualize damage, repair and recovery.”

Carmichael said he was hopeful that participants would return home with the same kind of knowledge that he gained when he attended such courses as a trainee.

“I remember fondly my days just starting out,” he said. “I felt it was key to take something in that would help build my career — both in terms of the direct scientific development and an understanding of how a field is evolving.”

Pre-Conference Symposium focuses on stroke treatment in the ED

“ISC Pre-Conference Symposium I: Stroke in the Real World: Emergency Stroke Care 2014” on Feb. 11 is designed to provide up-to-date information highlighting scientific advances in cerebrovascular disease while emphasizing their application in the real world.

Wein

Theodore Wein, MD, FRCPC, FAHA

“Our goal was to put together a comprehensive course for emergency department doctors so that they can maximally treat their acute stroke patients with the latest therapies, and interventions and improve outcomes. This not only includes medical management of patients but also exploring triaging of stroke patients and knowing when patients should be sent to comprehensive or primary stroke centers,” said Co-moderator Theodore Wein, MD, FRCPC, FAHA, assistant professor of neurology and neurosurgery at McGill University Health Centre in Montreal.

While this year’s symposium will focus on issues pertinent to the acute management of stroke in the emergency department, ED physicians as well as hospitalists, neurologists, nurses, nurse practitioners, physician assistants, stroke fellows and pharmacists will greatly benefit from the symposium.

“The program is geared for anyone who would treat acute stroke patients. There is a role for EMS to be there, and this is a great opportunity for hospital administrators and coordinators to see what needs to be done in their institutions,” Wein said. “It also will be beneficial for hospitalists, internists and family doctors who work in communities and deal with emergency settings, so they know how to triage their patients and make sure they get appropriate therapy at the appropriate center.”

The main focus will be on identifying unusual presentations of stroke; reviewing data on the use of intravenous and intra-arterial therapy; field triage of stroke patients and the utilization of primary stroke centers; treating intracerebral hemorrhage, subarachnoid hemorrhage and ischemic stroke during the golden hour in the ED; and managing complications of novel anticoagulants as well as a series of concurrent sessions. Participants will also have the opportunity to have an informal lunch with the faculty where questions or challenging stroke cases may be discussed.

“We’ve put together a great day. It covers all aspects of stroke care and is designed to be straight and to the point with clear take-home messages for each of the talks,” said Wein, whose co-moderator is Joshua Goldstein, MD, PhD, FAHA, associate professor of surgery at Harvard Medical School in Boston.

He pointed to a presentation on putting the ED in an ambulance. The speaker will present data on the effectiveness of using CT in an ambulance, which he has done in Germany.

“We want to give people an up to date look at what’s going on in the world, what we’re doing, what we can do better and perhaps what we should be doing. We’re using an international faculty to bring their experiences from around the world,” Wein said.

Two presentations — on intravenous thrombolysis in 2014 and decision analysis in thrombolytic therapy — will focus on the latest therapies.

“The reality is that the only treatment we have for acute stroke care that’s FDA approved is the use of intravenous TPA within the first four and a half hours after stroke,” Wein said. “The purpose of this program is to give the audience a clear-cut picture of where we stand in 2014, how people should proceed to administer these advanced therapies, and when to realize perhaps when patients should be considered for these therapies,” Wein said.

Beyond hearing 16 expert presentations, attendees can choose to participate in two of four concurrent sessions that will be offered on:

  • “The 5-Minute Neurological Exam”
  • “Dissecting Dizziness”
  • “Are You Up to Snuff? Current Standard of Care for Treating TIA and Stroke”
  • “Imaging and Thrombolysis Workshop”

“The concurrent sessions are designed to help people by going back to the basics. For example, I’ll speak on the 5-minute neurological exam. Many are worried about the neurological exam, and I think that a fairly compressive exam can be done in five minutes,” Wein said.

“All of these concurrent sessions are meant to be interactive workshops for people to make sure they’re performing as they should and are up to date on the latest guidelines.”

Ultimately, the day is devoted to improving systems, physicians and organizations in the care and management of stroke in the ED.

“We want to make people aware that there are therapies available for stroke outside of TPA and help them understand when to ask for these other therapies,” Wein said. “We want to ensure that they leave with a comprehensive knowledge of not only acute stroke care in the emergency room, but a systems approach on how to organize interactions with their EMS services and their tertiary or secondary stroke centers, and to help identify who they can treat in their centers, how they can order emergency services in their communities, and, most importantly, how they can decide who needs to go on to a different institution.”

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