Posts Tagged 'stroke'

Hugh Markus – 2011 Merrill P. Spencer Lecturer

 

Hugh Markus, B.M., B.Ch., D.M., FRCP
Featured Presenter: 6th Annual Merrill P. Spencer, M.D. Endowed Lecture

 

Each spring, The Merrill P. Spencer, M.D. Endowed Lecture is presented in conjunction with the annual Swedish Neuroscience Institute Cerebrovascular Symposium. This year, we are pleased to welcome Dr. Hugh Markus, Professor of Neurology at St. George’s University of London.

Hugh Markus was educated in Medicine at Cambridge and Oxford Universities and then carried out medical jobs in Oxford, London and Nottingham before training in neurology in London. He was senior lecturer and subsequently, reader in neurology at Kings College London before moving to the chair of neurology at St George’s in 2000.

His clinical interests are in stroke, and he is clinical lead for stroke at St George’s Hospital. He is involved in both acute stroke care and outpatient stroke clinics, and runs specialist services for patients with sub cortical vascular disease and genetic forms of stroke.

His research interests are in applying molecular genetic and imaging techniques to investigate the pathogenesis of stroke. Genetic studies are primarily trying to identify genetic causes of sporadic stroke and he is the principal investigator for the Wellcome Trust Case Control Consortium 2 Ischemic Stroke Study, which is performing a large genome-wide association study in ischemic stroke. The imaging techniques he uses are Transcranial Doppler emboli detection and MRI.

His postdoctoral thesis was on emboli detection, which involved experimental studies validating the technique and early clinical studies applying it to patients with a variety of potential embolic sources. He has carried out a number of studies showing that embolic signals predict stroke in carotid artery stenosis, and pioneered the use of the technique to evaluate anti-platelet therapies. He was also principal investigator for the CARESS study. Recently, he finished the Asymptomatic Carotid Emboli Study (ACES) which demonstrated that embolic signals predict risk in asymptomatic carotid stenosis.

The first international conference which Dr. Markus attended was a Transcranial Doppler ultrasound workshop organized by Merrill Spencer, M.D. in the early 1990s.

To register for the 5th Annual Cerebrovascular Symposium: New Therapeutics for Today’s Patient on May 12-13, visit www.swedish.org/cvdregister. Registration for the conference includes the Merrill P. Spencer, M.D. Endowed Lecture.

To attend only the reception and Merrill P. Spencer, M.D. Endowed Lecture on May 12: www.swedish.org/cvdspencer. This is a free CME program. However, pre-registration is required as space is limited.

 

 

 

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Advances in thrombolysis

Bill Likosky, MD, FAAN, FAHA, Director for Stroke and Telestroke, Swedish Neuroscience Institute

 

 

Washington State has one of the high­est stroke mortality rates in the nation. To improve this situation, acute intervention­al therapies for stroke are being employed to restore circulation to ischemic brain tissue that surrounds areas of completed infraction, while avoiding risk of hemor­rhage due to reperfusion of large areas of infracted brain tissue.

Urgent thrombolysis with intrave­nous alteplase is the only therapy known to improve clinical outcomes following acute stroke. Unfortunately, alteplase has had limited usage because many patients arrive in an emergency department after the three-hour treatment window. The FDA has also approved two clot removal devices based on the ability to restore circulation. These devices are used up to eight hours after symptom onset. Several approaches to improved acute stroke care are now under way, including extension of the thrombolysis window to 4.5 hours, identification of safer thrombolytic agents and research identifying brain at risk of in­farction following a stroke.

A recent European study demonstrat­ed the efficacy of alteplase up to 4.5 hours after ischemic stroke in patients younger than age 80 years who have neither dia­betes mellitus or prior stroke. The safety profile during this longer window for these patients appears similar to that at three hours.

Another promising advance employs a new thrombolytic agent called des­moteplase. Derived from the saliva of the vampire bat, this agent has a longer half life than alteplase and does not break down basement membranes, leading to a lower risk of hemorrhagic complica­tions. The Swedish Stroke Program is part of an international effort to test this drug in a nine-hour window.

Todd Czartoski, M.D., and Bart Keogh, M.D., Ph.D., are collaborat­ing with the stroke team at Stanford University to identify patients with vi­able ischemic tissue regardless of time from onset of symptoms. Perfusion MRI identifies impaired blood flow in brain (the “penumbra”) surrounding an infarct. In cases where there is a large area at risk, the use of alteplase or clot retrieval may prove beneficial long after the three-hour window has elapsed.

Telestroke is another important development in acute stroke care. This program enables the timely alteplase treatment of patients in emergency rooms around the Pacific Northwest that lack onsite neurological expertise.

For more information about the Swedish Stroke Program, contact Sherene Schlegel, R.N., FAHA, at 206-320-3484. For information about telestroke, contact Tammy Cress, R.N., MSN, at 206-320-3112.

Emerging concepts in vascular neurology: TIA clinics help prevent strokes and unnecessary hospital admissions

Michael Fruin, ARNP, Swedish Neuroscience Institute

Tom Jaspee placed an anxious call to Dr. Lewis’s office at 9 a.m. sharp. He didn’t give many details, other than to say his wife was worried about problems he was having with his speech the previous night. Later that morning in Dr. Lewis’s office, Tom said he had trouble getting his thoughts out for a few minutes. He said he felt fine im­mediately afterwards and didn’t want to raise a ruckus. Tom’s wife added that his right face drooped and the episode took al­most 30 minutes to clear up. She was wor­ried that Tom had suffered a stroke.

Dr. Lewis was well aware of Tom’s high risk of stroke following his transient isch­emic attack (TIA). Realizing that he could not manage this urgent issue in his office, Dr. Lewis sent the patient to the emergency room and after a six-hour stay, Tom was admitted as an inpatient for a 24-hour ob­servation and evaluation.

This mock case study highlights the role a TIA clinic might have played in avoiding an emergency room visit and hos­pitalization, while still providing the TIA patient the necessary urgent care.

While hospital admission is appropri­ate for the subset of patients at high risk for having a stroke after TIA, significant num­bers of emergency room visits and admis­sions could be avoided by a recent advance in evaluating patients in a TIA clinic. TIA clinics are being pioneered in the United Kingdom, where patients with TIA can be seen by a stroke specialist in an urgent-care clinic setting in which a standardized pro­tocol of neurologic evaluation and diagnos­tic testing is administered.

The effectiveness of the TIA clinic is supported by findings from the EXPRESS Trial (Luengo-Fernandez R, et al.). In this trial, there was an 80 percent reduction of 90-day stroke risk when TIA and minor stroke patients received urgent evaluation and treatment in a standardized urgent-care clinic setting. Patients at high risk of stroke, such as those with high-grade ste­nosis of the internal carotid artery or with atrial fibrillation, are admitted to the neurology service as indicted. Patients at low risk of stroke receive patient education and a stroke prevention plan is implemented.

Reference

Luengo-Fernandez R, Gray AM, Rothwell PM. “Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison.” Lancet Neurology 8:235-243. 2009.

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SNI Grand Rounds Series 2010 – Extending the Window for Stroke Therapy: The Role of Imaging

Thursday December 16, 2010
7:30am – 8:30am
Swedish Education and Conference Center, Room B

 Gregory W. Albers, M.D., Professor of Neurology, Stanford University

 

 

 

 

Objectives:

At the conclusion of this session, attendees will have an increased ability to:

  • Discuss options for expanding the treatment window for acute ischemic stroke
  • Review the role of neuroimaging for identification of salvable tissue in stroke patients 
  • Discuss the results of the DEFUSE trial and the study design of the ongoing DEFUSE 2

SNI Grand Round Series is every 1st and 3rd Thursday of each month.

Staying Fit to Prevent Stroke

William H Likosky, MD, Neurology
Medical Director for Stroke and Telestroke

 

A brisk walk for as little as 30 minutes a day can improve your health in many ways and may reduce your risk for stroke. Join our Stroke Program’s medical director, William Likosky, M.D., and one of our exercise physiologists to learn how to stay fit and reduce your risk for stroke. Free blood pressure screening will also be available.

Cherry Hill – Pinard Foyer

Tuesday, Oct. 12, 11 a.m.-1 p.m

For more information, please contact Sherene Schlegel:

sherene.schlegel@swedish.org

Office: 206-320-3484

Desmoteplase may hold the key for stroke patients

Dan Rizzuto, PhD, Research Manager, Swedish Neuroscience Institute

Acute stroke is the third leading cause of mortality and the major cause of long-term disability in the developed world. Ischemic strokes account for about 85 percent of all acute strokes and are caused by clots that block blood vessels in the brain, stopping the flow of blood to crucial brain areas.

The main approach to treating acute ischemic stroke is thrombolysis, which degrades the clot causing the stroke and provides significant clinical improvements. The only thrombolytic intervention for acute ischemic stroke that is currently approved by the U.S. Food and Drug Administration (FDA) is alteplase. However, alteplase must be administered within three hours after symptom onset to avoid the risk of inducing a hemorrhage in the brain. (More recent evidence supports delivering alteplase up to 4.5 hours.) Because of this time limitation, it is estimated that alteplase is currently administered to less than five percent of acute stroke patients. While this time limitation is a large factor, a high proportion of patients arriving within the appropriate time window still do not receive alteplase due to contraindications (e.g. age, severity, hypertension etc.) or due to the unfavorable risk-benefit ratio.

Recently a new thrombolytic agent, desmoteplase, has been developed that is based upon a protein found in the saliva of the Desmodus rotundus, better known as the common vampire bat. Studies conducted so far suggest desmoteplase breaks down clots efficiently and elicits few side effects, indicating the potential for better clinical outcomes. Importantly, it is possible to administer desmoteplase up to nine hours after symptom onset. Swedish Medical Center is participating in DIAS-4, a new study to assess the safety and effectiveness of desmoteplase.

“This new agent holds great promise,” said William Likosky, M.D., principle investigator for the clinical trial and medical director of the Swedish Acute Telestroke Program. “Currently, we are fortunate to have a network of emergency departments in which alteplase can be administered within an early window. If stroke patients have an initial treatment window up to nine hours, however, we can consider transferring them to medical centers that can provide thrombolysis beyond that available for alteplase.”

This clinical research study to test desmoteplase is being carried out under strict oversight by the FDA. By participating in this study, Swedish continues its tradition of offering the most advanced therapies available to patients who have few other options. In addition, the Swedish Acute Telestroke Program is able to offer this trial to patients outside the Seattle area who are brought emergently to Swedish for treatment.