What's Hot at International Stroke Conference 2013?

Susan Jeffrey

Feb 01, 2013

 Honolulu is the backdrop this year for the International Stroke Conference 2013, and sessions will kick off with a Hawaiian ceremonial welcome at the opening plenary session on Wednesday.

Chairman of the Program Committee this year is Steven M. Greenberg, MD, PhD, professor of neurology at Harvard Medical School, John J. Conway Endowed Chair in Neurology and Director, Hemorrhagic Stroke Research at Massachusetts General Hospital Stroke Research Center in Boston, Massachusetts.

"The number of abstract submissions set the record for the International Stroke Conference, and I certainly give first level of credit to the setting in Honolulu," Dr. Greenberg laughs, "but I think it's also a tribute to what we still see, which is a growth in both the quality and quantity of stroke-related research."

Dr. Greenberg discussed some of the highlights of this year's program with Medscape Medical News.

Latest Research

Of primary interest, as always, is the top research, presented in hundreds of oral sessions and posters, symposia, and lectures. In particular, there are 2 major sessions of late-breaking science: 1 a concurrent session held Thursday afternoon and 1 a plenary session held Friday morning.

Another trial presented here for the first time is a second arm of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial, which looks at aggressive blood pressure–lowering to prevent recurrence in patients with recent lacunar stroke. The first arm of the trial, presented last year at this meeting and reported by Medscape Medical News at that time, compared aspirin alone with aspirin plus clopidogrel in these patients and was stopped early because of increased bleeding with dual therapy.Among the most eagerly anticipated trials presented for the first time at this year's meeting is the Mechanical Embolectomy versus Standard Care for Acute Ischemic Stroke (MR RESCUE), he said. "This will be the first report of a large randomized trial that used neuroimaging, magnetic resonance imaging criteria, to select patients to be randomized either to mechanical embolectomy or regular medical care," he said. "In a field where there have been exciting technologic advances in how to remove a clot in an acute stroke but relatively few carefully controlled trials, these are results that people are very anxious to hear."

Another first presentation, the Randomized Evaluation of Carotid Occlusion and Neurocognition (RECON), looks at cognitive outcomes from extracranial-intracranial (EC-IC) bypass surgery among patients with symptomatic internal carotid occlusion in the Carotid Occlusion Surgery Study (COSS). Main COSS results, already reported, showed no benefit of the surgery for stroke prevention, but this analysis will look at whether the surgery may improve cognitive functioning.

Session IX: Concurrent G; Thursday, February 7, 12:30 pm; Kalakaua Ballroom B

• LB1: Mistie Trial: 365-day Results
• LB2: Intra-operative CT-Guided Endoscopic Surgery for ICH (ICES)
• LB3: Qualifying and Outcome Strokes in the RESPECT PFO Trial: Additional Evidence of Treatment Effect
• LB4: Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke-Enhanced Regimen (CLEAR-ER) Stroke Trial
• LB5: Prolonged Ambulatory Cardiac Monitoring Improves the Detection and Treatment of Atrial Fibrillation in Patients with Cryptogenic Stroke: Primary Results from the EMBRACE Multicenter Randomized Trial
• LB6: Results of the Membrane-Activated Chelator Stroke Intervention (MAC SI) Randomized Trial of DP-b99 in Acute Ischemic Stroke
• LB7: Final Results of the Solitaire FR Thrombectomy for Acute Revascularization (STAR) – Prospective, Multicenter, Controlled Clinical Trial in EU, Australia and Canada

Session XIII: Plenary Session III; Friday, February 8, 11:30 am; Hall III

• LB8: The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial: Results of the Blood Pressure Intervention
• LB9: Time to Angiographic Reperfusion Is Highly Associated With Good Clinical Outcome in the Interventional Management of Stroke Phase III (IMS III) Trial
• LB10: Randomized Evaluation of Carotid Occlusion and Neurocognition (RECON): Main Results
• LB11: Clopidogrel and Aspirin Versus Aspirin Alone for the Treatment of High-risk Patients With Acute Non-disabling Cerebrovascular Event (CHANCE): A Randomized, Double-blind, Placebo-controlled, Multicenter Trial
• LB12: Primary Results of a Randomized Trial of Neuroimaging Selection for Mechanical Embolectomy versus Standard Care for Acute Ischemic Stroke (MR RESCUE)

Session X: Concurrent Symposia C; Thursday, February 7, 2:30 pm; Kalakaua Ballroom B

Main results of the long-anticipated MS-III trial will be presented by principal investigator Joseph P. Broderick, MD, from the University of Cincinnati, Ohio, at a session dedicated just to this trial. "The bottom line for this trial is it was stopped early because it was clear that it would be unable to generate a positive result, but the most important information will be in the details," Dr. Greenberg notes.

IMS III was a phase 3, randomized, open-label trial that assessed whether a combined intravenous and intraarterial approach to stroke treatment was superior to intravenous tissue plasminogen activator alone. As reported previously by Medscape Medical News, the trial was halted in April 2012 when a preplanned interim analysis showed "a low likelihood of demonstrating the pre-specified clinically significant difference in benefit between treatment arms of the study," according to a statement from the National Institute of Neurological Disorders and Stroke at that time.

The Data and Safety Monitoring Board's decision was based on the primary outcome of the trial, the Modified Rankin score at 3 months, "meeting the threshold for futility," the statement adds. "While enrollment was stopped because of futility, no serious safety concerns were identified."

Investigators from the 50 sites involved would be disappointed with the decision, one of the investigators, Pooja Khatri, MD, associate professor of neurology at the University of Cincinnati, toldMedscape Medical News at that time. "We all expected this trial to show a significant advantage of this therapy in severe strokes."

At the meeting, Dr. Broderick will present the overall results and subgroup comparisons, and other speakers will look more closely at the data and at the current and future use of endovascular treatment in stroke care.

The "Next Big Thing" for Stroke

New this year is a forward-looking session examining the "next big thing" in stroke, but "at lightning speed," Dr. Greenberg said. "The idea will be to have 11 leaders in stroke ranging from high-level population epidemiology of stroke, both in the US and world-wide, down to the level of individual clinical trials in specific areas of stroke such as vascular cognitive impairment and neuroimaging, and focusing all the way down to t he molecular level on new approaches for stroke prevention and stroke recovery," he said.

The format is for speakers to present for exactly 5 minutes, no more, with a "hard cutoff, even if it's midsentence," he added. The result is "sort of speed-dating for stroke," he says wryly. The idea is "a realistic but forward-looking idea of where the stroke field might be going, and to do it in a fun and stimulating atmosphere, and also provide time for rapid-fire questions from the audience to what will be a very strong speaker panel."

"It will be either a glorious success or a noble failure," he added. "We'll see how people respond, but I'm really looking forward to it."

Wednesday, February 6, 2013; Session V: Concurrent Symposia B; The Next Big Thing in Stroke (at Lightning Speed); Kalakaua Ballroom B

Moderators: Steven M Greenberg, MD, PhD, Boston, Massachusetts, and Kyra Becker, MD, Seattle, Washington

• 2:30 Session Overview: Steven M. Greenberg, MD, PhD, Boston, Massachusetts
• 2:32 Race, Ethnic and Socioeconomic Disparities throughout the Globe: Lewis B Morgenstern, MD, Ann Arbor, Michigan
• 2:38 Biological Case Definition — The Science of Stroke Clinical Trials Comes of Age: Steven Warach, MD, PhD, Austin, Texas
• 2:44 Brain Ischemia Orchestrates Remote Organ Responses That Impact Outcome: Michael Moskowitz, MD, Charlestown, Massachusetts
• 2:50 Carotid Artery Disease Worldwide: Present and Future Trials: Thomas G Brott, MD, Jacksonville, Florida
• 2:56 The Emergence of Restorative Therapies: Drugs and Devices: Randolph J. Nudo, PhD, Kansas City, Kansas
• 3:02 Vascular Cognitive Impairment Exists: Now What?: Lenore Launer, PhD, Bethesda, Maryland
• 3:08 Worldwide Stroke Prevention: Setting the Priorities Right: Valery Feigin, MD, PhD, Auckland, New Zealand
• 3:14 Stroke Genetics: Moving to Personalized Stroke Prevention: Ralph L Sacco, MS, MD, Miami, Florida
• 3:20 Robotics in Stroke Recovery: Joel Stein, MD, New York, New York
• 3:26 Neuroprotection Within a Decade: Good News and Bad: Michael Tymianski, MD, PhD, Toronto, Ontario, Canada
• 3:32 Stroke Prevention and Treatment: The Need for a Life Course Perspective: Joanna Wardlaw, MD, Edinburgh, United Kingdom

In Memoriam: C. Miller Fisher

Of note as well this year at the meeting will be sessions remembering Charles Miller Fisher, MD, professor emeritus at Harvard Medical School, by all accounts a giant in the stroke field, who died April 14, 2012, at the age of 98.

"Many of us feel that Dr. Fisher towers over just about all of us, and there will be both an In Memoriam presentation at one of the plenary sessions and a symposium focusing on how Dr. Fisher's work continues to influence the stroke field," notes Dr. Greenberg, who will give the In Memoriam address.

Dr. Fisher's approach to understanding stroke, he said, "continues to be front and center in terms of how we think about the causes and treatments of stroke."

According to his obituary in the Harvard Crimson, Dr. Fisher was born in 1913 in Waterloo, Ontario, Canada, and graduated from the University of Toronto Medical School before serving as a surgical lieutenant in the British Royal and Canadian navies. "His ship, the HMS Voltaire, was sunk off the coast of Cape Verde in 1941, and Fisher was held in a Nazi prison camp for the next 3 and a half years," the obit notes. "After the war, Fisher returned to Canada and then to Boston and MGH [Massachusetts General Hospital], where he ultimately spent more than 50 years serving as both teacher and clinician."

"In a quiet and modest way, he was just a true visionary and the kind that doesn't come along every day," Dr. Greenberg says. "He was just a tremendously influential guy in the field."

Wednesday, February 6, 2013; Session III: Plenary Session I; Hall III

• In Memoriam: C Miller Fisher: Steven M. Greenberg, MD, PhD, Boston, Massachusetts

Thursday, February 7, 2013; Session VII: Concurrent Symposia A; Kalakaua Ballroom C

• C. Miller Fisher's Approach to Stroke: Past, Present and Future
• 7:40 Introduction: J. Philip Kistler, MD, Boston, Massachusetts
• 7:48 "No Man's Land": Large Vessel Brain Disease: J.P. Mohr, MS, MD, New York, New York
• 8:05 "Outnumbering All Other Lesions Combined": Lacunar Infarction: Geoffrey Donnan, MD, MBBS, Parkville Victoria, Australia
• 8:22 "Avalanche": Intracerebral Hemorrhage: Steven M. Greenberg, MD, PhD, Boston, Massachusetts
• 8:39 "Quite Different from a Gaping Patulous Hole": Subarachnoid Hemorrhage and Vasospasm: Robert Loch Macdonald, MD, Toronto, Ontario, Canada

Major Awards

Major awards this year again honor some great names in stroke research, Dr. Greenberg said.

The Thomas Willis Lecture, for achievement in basic science, is won this year by Eng H. Lo, PhD, a colleague of Dr. Greenberg's at Massachusetts General Hospital. "Eng has just been a tremendous inspiration to the field in his ability to open up new molecular and cellular pathways in both normal vessel function and abnormal function following stroke," he said.

The William M. Feinberg Award for Excellence in Clinical Stroke goes this year to Marc I. Chimowitz, MD, from the Medical University of South Carolina in Charleston, for major contributions in clinical research. "Dr. Chimowitz has led 2 of the most influential trials in our understanding of how to prevent stroke, he said, including the WASID trial, looking at the role of anticoagulation in patients with intracranial stenosis, and more recently, and the SAMMPRIS trial, which argued against use of stenting over best medical therapy to address intracranial lesions.

Finally, the David G. Sherman award is a lifetime achievement honor in basic or clinical research, won this year by Robert Adams, MD, by coincidence also from the Medical University of South Carolina. "Dr. Adams is really a pioneer and a leader in an otherwise poorly studied aspect of stroke, which is strokes related to sickle cell anemia. It's a devastating aspect of the disease, and he has really been the beacon setting the direction for how strokes related to sickle cell are studied and treated."

• 
  Medscape Medical News will be onsite, providing in-depth news coverage and feature interviews, beginning Tuesday, February 5. Follow us on Twitter (@MedscapeNeuro) and Facebook (http://www.facebook.com/#!/medscapeneurology). Follow ISC on Twitter @HeartNews, #ISC13.Thomas Willis Lecture: Friday, February 8, 11:05 am, Hall III: Causation and Collaboration for Stroke Research, Eng H. Lo, PhD
• William M. Feinberg Award for Excellence in Clinical Stroke: Wednesday, February 6, 10:35 am, Hall III: Treatment of Intracranial Atherosclerosis: Learning From the Past and Planning for the Future, Marc I. Chimowitz, MD
• David G. Sherman Lecture: Thursday, February 7, 10:40 am, Hall III: Towards a Stroke-Free Childhood in Sickle Cell Anemia, Robert Adams, MD

Next year's ISC is planned for February 2014 in San Diego, California.

Dr. Greenberg reports receiving research grants from the National Institutes of Health and participating as a Consultant/Advisory Board member for Hoffman-Laroche, MRI review committee.

International Stroke Conference (ISC) 2013: February 6-8, 2012. Hawaii Convention Center, Honolulu