Pre-Conference Symposium I addresses challenges across continuum of stroke care

Theodore Wein, MD, FRCPC, FAHA“ISC Pre-Conference Symposium I: Stroke in the Real World — Working Man Blues: Challenges in Inpatient Stroke Care,” Tuesday, Feb. 10, will take attendees through the often under-addressed area of what happens to a stroke patient across the continuum of care — from the emergency department, to the inpatient units to a rehab facility — and how physicians can optimize patient outcomes.

“The majority of care happens after these patients they leave the emergency room. How do you care for patients on the floor, what are their complications, what investigation should be done and at what pace should they be done?” said Symposium Co-moderator and Symposium Program Chair Theodore Wein, MD, FRCPC, FAHA, assistant professor of neurology and neurosurgery at McGill University Health Centre in Montreal.

Wein and his co-moderator, David Likosky, MD, neurologist, director of the stroke program and president of the medical staff at EvergreenHealth Medical Center, Kirkland, Wash., sought to provide hospitalists, neurohospitalists, internists and others who care for these patients a review of what’s at the forefront of post-emergency room care and the evidence behind those treatments.

Taking a cue from the host city of Nashville, Wein looked to the top 100 country songs for inspiration in creating the symposium presentation titles. Kyra Becker, MD, professor of neurology and neurological surgery, co-director of the University of Washington Medicine Stroke Center at Harborview and the ISC Program Committee Chair, will kick off the day with “Lord, I Hope This Day Is Good.”

Then two faculty will debate “Dueling Banjos: Justifying Investigations in the Stroke Workup” from the maximum and minimum perspectives. Taking the maximum position will be Lee H. Schwamm, MD, vice chairman of neurology, director of acute stroke services and director of the Partners TeleStroke Center at Massachusetts General Hospital, and professor of neurology at Harvard Medical School, Boston. William J. Powers, MD, H. Houston Merritt Distinguished Professor and Chairman of Adult Neurology at the University of North Carolina School of Medicine, Chapel Hill, will take the minimum position.

“This debate will be quite dynamic between two strong personalities in the stroke field,” Wein said.

The debate will then lead into “What Kind of Fool Do You Think I Am? Interpreting Findings in the Stroke Workup” with James F. Meschia, MD, professor and chair of neurology at the Mayo Clinic, Jacksonville, Fla.

“Frequently, we’re faced with findings that are not related to a stroke and are abnormal. What do these findings mean once we find them, and how do we have to act on them? With neuro-hospitalists and stroke neurologists taking care of stroke patients now, we need a strong understanding of the medical aspects of stroke care so we can try to determine how to proceed with these findings,” Wein said.

Thomas G Brott, MD, professor of neurology, director for research, the Eugene and Marcia Applebaum Professor of Neurosciences, and the James C. and Sarah K. Kennedy Dean for Research at the Mayo Clinic, Jacksonville, will look at two carotid endarterectomy procedures during “If the Devil Danced: Timing of CEA.”

Philip M. Bath, MD, stroke association professor of stroke medicine and head of the Division of Clinical Neuroscience at the University of Nottingham, United Kingdom, will take on a controversial topic in “Don’t Rock the Jukebox: Blood Pressure Management in Ischemic and Hemorrhagic Stroke.”

“Blood pressure has been controversial since I was in medical school,” Wein said. “We have some data from two trials looking at the safety of lowering blood pressure in hemorrhagic stroke. We don’t have a lot of data on ischemic stroke. Questions surrounding what to do with blood pressure and when it’s best to lower it still remain incredibly controversial and are important to address.”

After lunch with faculty, Sharon Poisson, MD, assistant professor of neurology at the University of Colorado, Aurora, will present “I Walk the Line: Inpatient Stroke Care — Practical Issues.”

“She will address all the medical issues that arise on a daily basis in stroke care — what we need to do when there are PEG tubes, NG tubes, Foley catheters and all the basic stuff. It’s what we take for granted, but maybe we should take a step back and make sure we’re doing them for the right reasons. We should understand the risks and benefits for these procedures, the common complications and how they can be avoided,” Wein said.

From 1:40 to 2:20 p.m. and 2:25 to 3:10 p.m., attendees will participate in concurrent sessions:

  • Concurrent IA: “Blood Red and Goin’ Down: When to Anti-coagulate — Common Scenarios”
  • Concurrent IB: “Stand by Your Man: Managing and Treating the Neurologically Deteriorating Patient” with Thorsten G Steiner, MD, PhD, professor of neurology and neurointensive care, and vice director of neurology at the University of Heidelberg, Germany
  • Concurrent IC: “Take This Job and Shove It: Challenging Consultations in Stroke Care” with David Likosky, MD, neurologist, director of the stroke program and president of the medical staff at EvergreenHealth Medical Center, Kirkland, Wash.
  • Concurrent ID: “Always on My Mind: Common Clinical Dilemmas Regarding Antithrombotic Agents”

After the concurrent sessions, Pamela W Duncan, PhD, professor of neurology at Wake Forest School of Medicine, Winston-Salem, N.C., will discuss “He’ll Have to Go: Maximizing Early Rehabilitation in the Acute Setting and Key Steps in Transition of Care.”

Duncan will look at how physicians can prepare patients to transition to rehab facilities, how they can optimize treatments to get patients to rehab within 72 hours for better patient outcomes, and how they can ensure that their patients will receive the maximum treatment.

Claire Creutzfeldt, MD, assistant professor of neurology at the University of Washington School of Medicine, Seattle, will then discuss “If Bubba Can Dance, I Can, Too: Prognosis After Stroke.”

“Clair will address what are probably the most important questions that every family asks when you walk in. Is my dad or mom going to be able to go home? Is she going to walk and talk?” he said, adding that people want to know if they will lose their jobs, need to restructure their family and become providers for their parents.

“Claire will give a realistic view of where patients are going to end up, and what we can tell our patients with confidence in terms of our ability to prognosticate outcomes,” Wein said. “We’re always guarded on this, but these are the first things laymen want to know. Stroke impacts the entire family.”

During “Don’t Happen Twice: Maximizing Stroke Prevention,” Ralph L. Sacco, MD, MS, Miller Professor and Chair of Neurology, Olemberg Family Chair in Neurological Diseases executive director of the Evelyn F. McKnight Brain Institute at the University of Miami Miller School of Medicine, and past president of the AHA/ASA, will then talk about what physicians can do to maximize stroke prevention by reviewing Get With The Guidelines.

Bruce Ovbigele, MD, MSc, professor and chair of neurology, at the Medical University of South Carolina, Charleston, will sum up the day with “What a Difference You’re Made in My Life” by describing the impact stroke care has had for patients and their physicians.

For Wein, who graduated from medical school in 1993, the field has advanced by leaps in bounds.

“The changes in stroke care have been tremendous since I was in medical school. There was no organized stroke care (or stroke teams per se except in research) or a neuro-rehab team. We gave patients aspirin and a drug called Ticlid, which we really don’t use any more,” Wein said. “We now have Plavix and Aggrenox to add to aspirin as three secondary prevention modalities. We know the importance of blood pressure. We’ve had warfarin around for years, and we now have three new anticoagulants to choose from and a fourth possibly coming on the market. We know the benefit of high-dose statins. We have carotid endarterectomy and carotid angioplasty. We have some evidence that interventional retrieval devices are beneficial for helping acute stroke patients. We know an interdisciplinary stroke team is ideal for improving patient outcome. We’ve learned that starting rehab early is better. There are so many advances not only in the acute setting, but also in the patient management setting and in the transition to rehab. It’s just amazing.”