Recent Studies in Cerebrovascular Diseases in IndiaAnnual Stroke Masterclass 2017: the Summary of Meeting Proceedings: Annual Stroke Masterclass 2017: The Summary of Meeting Proceedings

Abstract

The “Annual Stroke Masterclass 2017 (ASM, 2017)”
focused on providing a comprehensive knowledge on
medical and interventional management of ischemic
stroke with specific emphasis on “How to?” handle
dilemmas, workshop on vascular neuroimaging, live
endovascular session, live transcranial Doppler workshop demonstration of findings in specific pathological
conditions, and “hands on” Botox in spasticity. The masterclass was held at Taj Dwarka, New Delhi on the 23rd
and 24th of September 2017. It was organized by the
“Stroke and Neurovascular Interventions Foundation”
and “Artemis Agrim institute of Neuroscience” under
the aegis of Indian Stroke Association, Indian Academy
of Neurology and the Society of Therapeutic Neurointervention. The conference chairmen were Dr. Sumit Singh
and Dr. Vipul Gupta and the meeting was organized by
Dr. Rajsrinivas Parthasarathy.
Preconference e-learning commenced in June 2017 and
was conducted for a period of three months through
electronic media that included more than 500 doctors
with neuroscience background from across India. The
meeting was highly subscribed and attended by over 300
neurologist and neurointerventionist from India and the
neighbouring countries. The ASM, 2017 was granted
14.5 credit hours by the Delhi Medical Council. The
meeting started at 8.30 AM on the 23rd September 2017
with “Imaging in Stroke,” the topics discussed were:
NCCT and CTA is the gold standard—lessons learnt.
“The pitfall—I felt further imaging would have helped
in selected cases” (Dr. David Liebeskind), perfusion
imaging in acute ischemic stroke—lessons learnt;
“When not to rely on it?”(Dr. Kenneth Butcher) and
Vessel wall imaging—How to differentiate Intracranial
atherosclerosis/vasculitis/moyamoya? Case scenarios!
(Dr. A. R. Chatterjee). The dilemma theme was “Acute
stroke: To intervene or not based on Imaging” (Dr.
Jayanta Roy). The second session was on “Heart and
Brain”; the theme was “In pursuit of atrial fibrillation.”
Is “30-day’ cardiac monitoring justified?” the “pros” and
“cons” (Dr. Manjinder Sandhu). The dilemma addressed
was “Short (very brief) duration AF and stroke” (Dr.
Rajsrinivas Parthasarathy). The next session was on
non-vitamin K oral antagonists and the subject matter
for discussion was “Individualizing NOAC therapy
‘How to choose your drug?’(Dr Kenneth Butcher),
‘Stopping the ooze’ while on NOAC; How to monitor
anticoagulation on NOAC therapy” (Dr. Kenneth
Butcher), “Left atrial appendage exclusion—a nonpharmacological alternative?” (Dr. Manjinder Sandhu) and
“Early initiation of NOAC” (Dr. Kenneth Butcher). The
brain teaser themes were “Dual antiplatelet and anticoagulant—when and why? & is it safe?” (Dr. Rajsrinivas
Parthasarathy) and “When NOACS don’t work” (Dr.
Jayanta Roy). This was followed with a debate session
on thrombolytic therapy in “Acute Ischemic Stroke”.
The debate was on (1) tenecteplase: “the elephant in the
room?” Can we ignore the evidence anymore? (Dr.
Kameshwar Prasad) versus “Large body of evidence for
Alteplase trumps the evidence in favor for tenecteplase”
(Dr. Subhash Kaul) and (2) “M1 occlusion low NIHSS/
borderline core/delayed window period—One should
consider intervention in this group of patients’ (Dr.
Dheeraj Khurana) versus “I will employ a conservative
approach as they are less likely to benefit” (Dr. Rohit
Bhatia). The problem scenarios discussed were “Reversing NOAC effect prior to thrombolysis (Dr. Kenneth
Butcher),” “MI and Stroke—How to save the brain and
the heart? (Dr. Binay Kumar),” “Sherlock Holmes and
Doctor Watson in Scarlet: the Dooms day; a case of
aortic dissection and stroke (Dr. Srinivasan Paramasivam),” “Thrombolytic therapy and ICH—What can one
do?” “Scientia potential est” and “Legs giving way—Is
it the Brain or the Spine; cranial and spinal dural arteriovenous fistula presenting with spinal cord ischemia” (Dr.
Rajsrinivas Parthasarathy), and “Visual loss—role for
thrombolytic therapy; rule out the mimic” (Dr. Aviraj
Deshmukh). The 16th session was on intracranial hemorrhage and the talks were on ‘Hematoma expansion—Is
it of concern? & Intensive Blood pressure control—Is it
Vol. 10, No. 1, pp. 45–46. Published June, 2018.
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Journal of Vascular and Interventional Neurology, Vol. 10
overemphasized” and “clotting factors in ICH, Surgery
in ICH & tPA in Intraventricular hemorrhage?” (Dr.
Rohit Bhatia). The brain teaser themes were “Since the
time of the Mummies; cocaine vasculopathy induced
hemorrhage” (Dr. Anand Vaishnav), “The Pandora’s
box; cranial dural arteriovenous fistula presenting as
subarachnoid hamorrhage, recurrent brain stem bleed,
rapidly expanding vasogenic oedema mimicking dural
sinus thrombosis, obstructive hydrocephalus & seizures”
(Dr. Aviraj Deshmukh and Dr. Vipul Gupta), “Sulcal
hemorrhage—what could it be?, a case of Takayasu
arteritis” (Dr. Mahesh Kate) and “The bleeding heart!
‘Sublata Causa, tollitur effectus’, mycotic aneurysm
with ICH” (Dr. Aviraj Deshmukh). The inauguration
speech was by Dr. Ashok Panagariya on: future direction
for young aspiring neurologists—“The Road not Taken.”
The first session after lunch was on carotid disease and
the following topics were debated: “Argue the toss:
Asymptomatic carotid stenosis: I intervene in this subset?” (Dr. Vipul Gupta), “Clearance for surgery in carotid disease? CABG and other!” “Dr. P. N. Sylaja” and
“CREST 2 trail—Hear it from the investigator” (Dr.
Jordi Blasco). The dilemma themes discussed was
“Blind following carotid revascularisation—‘What went
wrong?’ (Ocular ischemia resulting in neovascularity
which then resulted in Ocular hyperperfusion and glaucoma following revascularisation)” (Dr. Rajsrinivas Parthasarathy), “APLA and stroke—My head is spinning!”
and “When the power house malfunctions!” (Dr. Anand
Vaishnav). Then, the treatment concept in basilar artery
occlusion was discussed by Dr. Jordi Blasco. The day
ended with simultaneous workshops for two hours each
(1) neuroimaging workshop (early ischemic signs,
ASPECTS scoring, posterior circulation ASPECTS, collaterals: leptomenineal, willisian and external to internal
carotid, carotid plaque and stenosis, intracranial stenosis,
and dissections) and (2) botox in spasticity (live hands
on workshop on patients with upper and lower limb
spasticity).
The second day started at 8 am with flow model based
endovascular workshop demonstrating the technique of
carotid revascularisation and mechanical thrombectomy.
This was followed with talks on wake up and interventional management in stroke; the subject matter discussed was “Wake up stroke: My approach” (Dr.
Dheeraj Khurana), “BGC—my first choice: Why? What
do I resort to when it fails?” (Dr. Jordi Blasco),
“ADAPT, SOLUMBRA, TRAP—Technical Nuances &
How effective is it?” (Dr. Aquilla Turk), “Tandem occlusions—ICA stenosis and M1 occlusion & ICA dissection with M1 occlusion—My approach” (Dr. Vipul
Gupta) and “Concurrent stenting in acute ischemic
stroke—Expert opinion” (Dr. Jordi Blasco). The 12th
session was a panel discussion on fellowship opportunities which included platform presentation of the top 4
abstracts by Dr. Arun, Dr. Charandeep Singh, Dr. Sai
Sripad Rao, and Dr. Daniel Sweetson. The panellist were
Dr. Ashfaq Shuaib (University of Alberta), Dr. Adnan
Qureshi (Zeenat Qureshi Stroke Institute), Dr. Kenneth
Butcher (University of Alberta), Dr. Vijay Sharma
(National University of Singapore), Dr. Bijoy Menon
(University of Calgary), Dr. David Liebeskind (UCLA),
and Dr. Bernard Yan (Royal Melbourne hospital). The
next session was on secondary prevention and the topics
discussed were “Refractory symptomatic carotid artery
dissection: I reconstruct parent artery in this subset” (Dr.
Vipul Gupta), “Vertebral artery stenosis—When to
stent?” (Dr. Adnan Qureshi) and “Intracranial atherosclerosis—Technical Considerations” (Dr. Vipul Gupta).
The 14th session was on “Mechanical thrombectomy
and Carotid & Intracranial stenting—complications
encountered & how I handled them?” (Dr. Adnan Qureshi) and the brain teaser theme was “On the edge”––
“trust your instinct––should you?” (Dr. Tariq Matin).
This was followed with a session on dural sinus thrombosis; the subject matter for discussion was (1) “Technical considerations: compare techniques for opening the
outflow pipes” (Dr. Rajsrinivas Parthasarathy and Dr.
Srinivasan Paramasivam) and “NOAC in CVT” (Dr.
Kenneth Butcher). The preworkshop session on neurosonolgy included the following topics: “Insonation ‘Tips
and Tricks’—Trade secrets revealed” (Dr. Amit Batra),
“Interpretation of Waveform; ‘The laws guiding flow
pattern’; Pulsatility Index: what is it?”(Dr. Arvind
Sharma), “Pattern Recognition: ‘Proximal occlusion,
High resistance pattern etc.—The underlying basis!’”
(Dr. Vijay Sharma) and “My management decision was
influenced by flow monitoring”—“Vasomotor reserve
testing & HITS” (Dr. Vijay Sharma). Post lunch was the
endovascular workshop during which a live carotid
artery stenting procedure was transmitted from Artemis
hospital to the venue. The delegates had a chance to
view the live surgery and discuss their questions (90
min). The last session was a work shop on transcranial
Doppler. Normal and waveforms in pathological condition such proximal occlusion, and focal and long segment stenosis were demonstrated on live patients