Mark J. Alberts, MD


May 12, 2017

Hello. This is a Medscape Stroke Update from the 2017 American Academy of Neurology (AAN) meeting in Boston. My name is Dr Mark Alberts, head of neurology at Hartford Hospital and physician-in-chief of the Ayer Neuroscience Institute for Hartford Healthcare System. Thank you for joining me.

Today, I would like to update you on two recent stroke studies reported at the AAN Meeting. The first study was done by Dr Hoyte.[1] Dr Hoyte and her colleagues looked at using an automated ASPECTS [Alberta Stroke Program Early CT score] to figure out which patients would or would not qualify for endovascular therapy in the setting of an acute ischemic stroke. As many of you know, interpreting a head CT scan and calculating an ASPECTS can be very challenging, because of nuances and subjectivity in how the CT scan is performed and read and how the ASPECTS is calculated.

The researchers developed a computer algorithm that would automatically read the head CT scan and automatically generate an ASPECTS. What Dr Hoyt and colleagues found is that in general, this automated ASPECTS—an e-ASPECTS—was effective, with a high degree of reliability in terms of calculating the score. They found that it was particularly useful at places that were not comprehensive stroke centers, where perhaps they did not have a high level of expertise in terms of reading and interpreting head CT scans and calculating an ASPECTS. In other words, this type of technology may be translatable and transportable to smaller outside facilities; it could help to screen which patients with an ASPECTS may be amenable to endovascular therapy and which patients may be too sick, with too severe a stroke, to qualify for endovascular therapy.

This was a preliminary study, so we will have to see whether subsequent studies confirm these preliminary findings or not. Overall, this was a very encouraging result in terms of looking at CTs and being able to come up with a consistent, reliable ASPECTS.

Another study I would like to talk about very briefly was done by Dr Ess and her colleagues. This was a study that looked at treatment of children with ischemic stroke to see what their outcomes were if they got intravenous (IV) tissue plasminogen activator (tPA).[2] Overall, out of their cohort of several hundred patients with stroke, only 2% of them ended up getting IV tPA. What they found, somewhat surprisingly, was that overall, the kids who got IV tPA had a worse outcome than children with strokes who, for various reasons, did not get IV tPA.

I think this [finding] is largely due to the heterogeneity of etiologies of stroke in the pediatric population. In most adults, stroke is due to atherothrombotic disease. In kids with strokes, it is due to a number of different etiologies, including sickle cell disease, moyamoya disease, genetic disorders, structural disorders of the brain and blood vessels, and the like.

Other recent studies have also shown that pediatric patients with ischemic strokes may not benefit from IV tPA therapy. At this point, the recommendation is to avoid IV tPA therapy, and in some cases clot removal, in a pediatric population with ischemic stroke. In these patients, many of whom are too young to consent for themselves, there needs to be a full and engaged discussion between the healthcare provider, the patients' parents, and the patients themselves so that we fully understand the risks and the benefits of tPA and/or endovascular therapy in this group.

At this point, my recommendation is to avoid lytic therapy and thrombectomy in the vast majority of these pediatric patients because of [the risk for] a bad outcome.

That is the end of my report from the 2017 AAN meeting as it relates to stroke. Thank you for joining me for this Medscape Stroke Update.


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