ISC 2010: Top Research Slideshow

The American Stroke Association's International Stroke Conference (ISC) 2010 was convened February 24-26 in San Antonio, Texas, by ISC Stroke Council Program Committee Chair, Patricia Hurn, PhD, FAHA, from Oregon Health Sciences University in Portland.

Among the ISC highlights:

• CREST results show equal safety and efficacy with endarterectomy or stenting for carotid stenosis;
• Executive dysfunction is common in transient ischemic attack and minor stroke, but most cognitive tests do not detect it;
• Stroke incidence is increasing among younger adults;
• A high-fat diet increases risk for ischemic stroke; and
• RE-LY trial results show that bleeding rates are lower with dabigatran than with warfarin after stroke or transient ischemic attack.

Final results of the long-awaited Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) show similar net outcomes with carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the treatment of carotid stenosis, announced principal investigator Wayne Clark, MD, from the Oregon Health Sciences University in Portland.

"I think both procedures are excellent, with low perioperative rates and apparently excellent clinical durability, so I'm excited to say that I think we have two good options to treat patients with carotid stenoses," Dr. Clark told meeting attendees. See CREST Shows Similar Net Safety and Efficacy With Stenting vs Endarterectomy for Carotid Stenosis for more information.

"There was a higher risk for events for older patients in CREST who underwent stenting," said investigator Thomas G. Brott, MD, professor of neurology and director of research at the Mayo Clinic in Jacksonville, Florida.

"When we went into this, I think we thought the less-invasive procedure would be best suited for the older patient," Dr. Brott said. "Now that we have data from studies in the United States and Europe, we have to question that."

A subanalysis from the Randomized Evaluation of Long-Term Anticoagulant Therapy, Warfarin, Compared With Dabigatran (RE-LY) trial showed that in patients with a prior stroke or TIA, dabigatran was not inferior to warfarin and was associated with a lower incidence of major hemorrhages, particularly intracerebral hemorrhages (ICHs).

"Cerebral hemorrhage on warfarin was higher than in patients without prior TIA or stroke, and this was not the case with dabigatran," Hans-Christoph Diener, MD, PhD, from the Department of Neurology at University Hospital Essen in Germany, told delegates here. See RE-LY Subanalysis Suggests Similar Benefit, Less Bleeding With Dabigatran in AF Patients With Prior Stroke or TIA for more information.

Looking at rates of ICH in this population with prior TIA or stroke, low- and high-dose dabigatran were associated with relative risk reductions of 80% and 59%, respectively, both of which were statistically significant reductions compared with warfarin, Dr. Diener reported.

The phosphodiesterase inhibitor cilostazol is more effective in secondary stroke prevention with a significantly lower incidence of serious cerebral hemorrhage compared with aspirin in patients with non-cardioembolic cerebral infarction, according to new research presented by lead investigator Yukito Shinohara, MD, of the Federation of National Public Service at Tachikawa Hospital in Tokyo, Japan. See Cilostazol Trumps Aspirin in Secondary Stroke Prevention for more information.

Combining endovascular hypothermia with thrombolytic therapy appears to be feasible and safe in treating patients with moderate to severe acute ischemic stroke, results from a randomized, multicenter clinical trial suggest. However, a higher than average rate of pneumonia needs further investigation.

"Of all of the neuroprotective agents available, there's no doubt that hypothermia is the most potent at preventing neuronal death. It is so potent that when you conduct animal studies you must always control for temperature. If you allow the animal to cool even a few degrees, the cooling will outpace any potential protective effect of the intervention being tested," principal investigator Thomas Hemmen, MD, PhD, director of the University of California–San Diego Stroke Center, told Medscape Neurology. See Combination of Endovascular Hypothermia, Thrombolytic Therapy Feasible, Safe, in Acute Stroke for more information.

Using ultrasonography to augment thrombolytic therapy appears to be safe and effective in evacuating blood clots in patients with spontaneous intraventricular hemorrhage and ICH.

"There's really no good proven treatment to evacuate hemorrhage [in this patient population]," principal investigator David W. Newell, MD, executive director, Swedish Neuroscience Institute, Seattle, Washington, said during a press conference. See Sonothrombolysis Effective in Clot Evacuation in Intracerebral Hemorrhage for more information.

High-intensity, repetitive rehabilitation exercise can result in improved function and quality of life in severely disabled chronic stroke patients, even years after they have experienced their initial event.

Principal investigator Albert Lo, MD, PhD, from the Providence Veterans Affairs Medical Center and Brown University, Rhode Island, said his findings contradict a widely held belief that little can be done to improve function in stroke patients longer than 1 year after the index event. See High-Intensity, Repetitive Rehabilitation Improves Function, Quality of Life in Chronic Stroke Patients for more information.

Stroke patients who received thrombolytic therapy using the "time last seen normal" to calculate whether they fall within the treatment window, rather than by witnessed onset of symptoms, actually had lower rates of hemorrhagic transformation with treatment.

"Far from any degree of reluctance, patients with unwitnessed symptom onset are better candidates" for treatment, said Demetrios Sahlas, MD, the Michael G. DeGroote professor in stroke management at McMaster University in Hamilton, Ontario, Canada.

More than half of patients who experience a transient ischemic attack (TIA) or minor ischemic stroke experience executive dysfunction, new research from Michael Harnadek, PhD, and colleagues from the London Health Sciences Centre in Ontario, Canada, suggest. However, the Mini-Mental State Examination, the most commonly used test to assess cognitive dysfunction, does not accurately detect mental impairment in this patient population. See Executive Dysfunction Common in TIA, Minor Stroke Patients but Common Cognitive Test Does Not Detect Impairment for more information.

"By definition, the symptoms [of TIA or minor ischemic stroke] are transient and mild, but if we can tell patients 'Right now you have cognitive impairment, likely as a result of this event,' then it may have a huge upside in getting patients to adhere to their treatment," said Bruce Ovbiagele, MD, from the University of California–Los Angeles School of Medicine, who was not involved in the study.

Fewer older people are having strokes, but stroke incidence among younger people appears to be increasing, according to a new study.

The average age of a stroke patient decreased by nearly 3 years between 1993-1994 and 2005 in a study conducted in Ohio and Kentucky, by Brett M. Kissela, MD, associate professor, codirector of the Neurology Residency Program, and vice-chair of education and clinical services at the University of Cincinnati Neuroscience Institute, Ohio, and colleagues. During the same period, the percentage of stroke patients aged 20 to 45 years increased from 4.5% to 7.3%. See Stroke Incidence Rising Among Younger Adults for more information.

Older women who consume the most total fat, including both "good" fats such as monounsaturated and polyunsaturated fats and "bad" fats such as trans and saturated fats, had a 40% higher incidence of ischemic stroke compared with those who ate the least amount of total fat.

Looking at trans fats alone, Sirin Yaemsiri, MSPH, a doctoral student in the Department of Epidemiology at the Gillings School of Global Public Health, University of North Carolina in Chapel Hill, reported that the incidence of ischemic stroke was 30% higher in the quartile of women consuming the highest amount compared with those who consumed the least amount of fat. See Diet High in Fat, Particularly Trans Fat, Raises Risk for Ischemic Stroke for more information.

Data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, involving 30,239 US residents aged 45 years or older between January 2003 and October 2007, shows that:

• Blacks and those living in the so-called Stroke Belt are most likely to have a stroke;
• Blacks are more likely than whites to be unaware they have atrial fibrillation (AF);
• Blacks with AF are less likely to be taking warfarin than whites with AF; and
• Patterns of stroke incidence are similar to those of stroke mortality drawn from US death certificate data.

Lead author Virginia J. Howard, PhD, associate professor of epidemiology, School of Public Health, University of Alabama at Birmingham, told Medscape Neurology that the racial difference was most apparent in younger people. In the group aged 45 to 54 years, blacks had almost a 2.5 times higher stroke incidence compared with whites (192 per 100,000 vs. 74 per 100,000).

"We have seen significant declines in stroke mortality overall, which has been one of the great public health achievements of the 20th century, but while we have reduced stroke deaths, we still have these disparities," said Dr. Howard. See Racial and Geographic Disparities Seen in Stroke Incidence and Racial Differences in AF Treatment for more information.

Rishi Gupta, MD, assistant professor, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, reported that in a study of more than 1000 severe stroke patients treated with one or more therapies within eight hours of symptom onset, blood flow was restored in 76% of patients who received intracranial stents compared with 72% of those receiving intra-arterial tissue plasminogen activator.

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• Other Slideshows

For more information, see the following resources:

• Medscape Medical News from the International Stroke Conference (ISC) 2010
• Medscape Neurology
• eMedicine Neurology
• American Stroke Association

Contributor Information

Authors
Susan Jeffrey
Neurology News Editor
Medscape Medical News
Medscape
New York, New York

Disclosure: Susan Jeffrey has disclosed no relevant financial relationships.

Caroline Cassels
Psychiatry News Editor
Medscape Medical News
Medscape
New York, New York

Disclosure: Caroline Cassels has disclosed no relevant financial relationships.

Martha Kerr
Conference News Editor
Medscape Medical News
Medscape
New York, New York

Disclosure: Martha Kerr has disclosed no relevant financial relationships.