Are you reaching the recommended
daily step goal of 10,000 steps for achieving a desirable level of physical
activity? During routine daily activities, this is already considered a
difficult task, and it becomes harder when having to deal with activity
impairments. People living with stroke spend only half of the recommended time
being active as compared to healthy individuals and are subsequently at high
risk of developing sedentary behavior. Since prolonged sedentary behavior can
damage your physical and mental health, it is important to gain insight into
these unhealthy movement behavior patterns of people living with stroke. As the
authors suggest, this provides health care providers with important information
regarding the identification of the right persons with specific behaviors for
targeted interventions.
Name: Elena Zapata-Arriaza, MD Hometown: Sevilla, Andalucía, Spain Current Position: Interventional Neuroradiologist in the Radiology Department in Virgen del Rocio University Hospital; Stroke Neurologist Researcher in the Institute of Biomedical Research of Seville (IBiS)
Q:
What made you interested in a career in stroke?
A: Near the
end of my residency in neurology, there were fundamental changes in the acute
treatment of ischemic stroke, which changed the paradigm of disease management,
as well as the role of the neurologist in the stroke. The possibility of
expanding the therapeutic options, whose indication depended on the combination
of clinical-radiological knowledge, motivated me to focus more on the stroke,
in which the neurologist became an active part of its outcome. Likewise, the
wide variety of topics to investigate about stroke, together with the existence
of quality researchers in my center who trusted me to develop studies on
stroke-associated pneumonia, further boosted my interest in the field.
Thrombus is a dynamic structure with constantly
changing size, morphology and location over time, to variable extent in each
patient, before recanalization occurs. Recently, there is interest in
understanding dynamic clot features, especially regarding thrombus movement —
defined as change in the occlusion site — between initial (typically CT
angiogram) and follow-up vascular imaging (usually catheter angiogram for
mechanical thrombectomy). Whether thrombus migration before recanalization is
of any clinical or functional significance remains under investigation. The
thrombus migration was studied in the past.1 It underlies a clinical
phenomenon called “spectacular shrinking deficit,” in which a patient with
major hemispheric syndrome shows rapid (over minutes to hours) and dramatic
improvement or disappearance of most clinical deficits.1 Use of
regular “vascular imaging” now allows investigating the concept in reverse
order, i.e., the incidence thrombus migration and correlate it with clinical
change or functional outcome. Different factors determine the dynamic behavior
of the clot, including source of thrombus (etiology of stroke), composition of
the thrombus, initial thrombus location within arterial tree (for example,
proximal vs distal occlusion), angioarchitecture around the thrombus and use of
intravenous thrombolysis (IVT).1-4
Neuroprotective treatments aim to prevent cellular death,
particularly neuronal cell death, during ischemic/hypoxic conditions such as in
acute ischemic stroke. Maintenance of neuroprotection long-term requires a
return of blood and oxygen to the ischemic territory area, not regularly
achieved in previous clinical trials. Yet, with recanalization rates of greater
than 80%, afforded by the advent of mechanical thrombectomy following ischemic
stroke, the return of flow to the ischemic territory is now more consistent.
Nevertheless, following the return of blood flow to this area, cellular damage
continues to spread and grow due to the phenomenon of “ischemic-reperfusion
injury.” This progressive increase in damage indicates a continued need to
investigate neuroprotective treatments that could be used alongside
recanalization, both thrombolysis and thrombectomy, to recover/prevent
long-term cellular damage.
It is well established that calcium (Ca2+) overload
plays a key role in neuronal death during ischemic/hypoxic events. In addition
to voltage-gated and receptor-mediated Ca2+ influx, there is a
further route of entry into the cell, a route switched on in response to
depleted intracellular Ca2+ stores. This additional entry route is
called capacitative or store operated Ca2+ entry and is thought to
contribute to the stabilization of both cytosolic Ca2+ concentration
and intracellular Ca2+ stores.
A conversation with Professor Eric E. Smith, MD, Ph.D., Professor of Neurology, Cumming
School of Medicine, University of Calgary, Canada, and Professor Hugh Markus,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
Interviewed by Shashank Shekhar, MD, MS, Assistant
Professor, Division of Vascular Neurology, University of Mississippi Medical
Center, USA; @ArtofStroke.
Dr. Shekhar:I
would like to thank Prof. Smith and Prof. Markus for agreeing to do this
interview. In this interesting review
paper, you have discussed in detail the new treatment approaches to modify the
course of small vessel disease. Could you tell the readers why you decided to
write about this topic?
Prof. Smith: Cerebral small vessel disease is a
common condition of aging. We now know that it can cause cognitive decline and
stroke. When I chaired a writing group for the American Heart Association that
produced a scientific statement on stroke prevention in persons with silent
cerebrovascular disease (Smith
et al, Stroke 2017; 48:e44-e71), one of the interesting things
we found is that there were few clinical trials that focused on small vessel
disease. There are no medications specifically indicated for cerebral small
vessel disease. The time seemed ripe to review progress in this area, and
indeed we found emerging evidence for new treatment strategies in early phase
trials.
Prof. Markus: Cerebral small vessel disease is an
enormous health problem — it causes a quarter of all strokes and is the most
common cause of vascular dementia. Despite this, there are few, if any,
treatments for established disease, and it remains one of the great therapeutic
challenges in stroke. We wanted to summarize where we were and describe a pathway
forwards.
Name: Shashank Shekhar, MD, MS Hometown: Jackson, MS, USA Current Position: Assistant Professor, StrokeNet Co-PI, University of Mississippi Medical Center Twitter:@artofstroke
Q: What made you interested in a career in stroke?
A: I was
always interested in neurosciences. While I was doing my master’s thesis on a
stroke topic, I had the opportunity to do a clinical rotation in a stroke unit
at Helsinki University Central Hospital, Finland, with an excellent door to
need time averaging 20 minutes. By that time, I had a solid understanding of
basic science and clinical knowledge of stroke, but I was not exposed to the
real-time workflow leading to thrombolysis. I get to learn the process from
beginning to end, including aftercare of the stroke patient all the way to
discharge. The experience was extremely fascinating and immersive. That’s when
I decided that I will do vascular neurology.
Q: What has been your career path into this field?
A: I received
my medical degree from Government Medical College & Hospital in Chandigarh,
India. Soon after, I pursued a master’s degree in neurosciences from the
University of Helsinki in Finland. I was involved in several basic stroke
research projects at Helsinki University Central Hospital, and later, the
clinical birth cohort project (FinnBrain) studying cognition in infants using
Near-Infrared Spectroscopy at the University of Turku. I moved to the USA for
the neurology residency, followed by a Vascular Neurology fellowship at the
University of Mississippi Medical Center (UMMC), where I am currently working
as an Assistant Professor. I am active in various clinical projects as PI and
StrokeNet co-PI for the UMMC satellite center. I have a particular interest in
neurocognition and the identification of biomarkers for acute ischemic stroke.
I am also heavily involved in research education for residents and fellows.
The primary therapeutic target of mechanical thrombectomy defined by
the salvageable tissue at risk is minimized in patients with low Alberta Stroke
Program Early CT Score (ASPECTS). In contrast, the risk of developing malignant
infarctions is maximized in patients with a large early ischemic core, which
can lead to severe complications by progressive ischemic edema within the first
days after stroke onset. Low ASPECTS (≤5) still represents a limitation for
stroke thrombectomy performance. But what happens in those patients with low
ASPECTS and good collaterals after endovascular treatment? Do these cases have
the potential to achieve good functional results? Broocks and colleagues have
employed these questions as the starting point in the present paper.
Name: Lina Palaiodimou, MD Hometown: Athens, Greece Current Position: Neurologist, Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
Q: What made you interested in a career in stroke?
A: Until the recent past, the following
playful dogma prevailed: “Neurologists know everything, but do nothing.” Stroke
and the recent therapeutic advances regarding acute treatment really changed
that scenery. Rapid information processing, accurate critical thinking,
effective cooperation, and, of course, the adrenaline rush constitute the core
of acute stroke management and actually describe my dream job. So, when I first
got involved with an acute stroke patient being thrombolyzed and getting
dramatically better, I was determined that a stroke career would suit me. That
has not changed a bit since then.
Q: What has been your career path into this field?
A: I
graduated from Medical School, Aristotle University of Thessaloniki, in Greece,
and the Military Medical Academy in Thessaloniki, Greece. In late 2019, I
completed the neurology residence in Attikon University General Hospital of
Athens. Currently, I am a PhD student in Medical School, National and
Kapodistrian University of Athens, and my thesis is focused on stroke
management and prognosis. I am also working with a team of dedicated stroke
neurologists in the Division of Cerebrovascular Diseases of Attikon University
General Hospital of Athens, where more than 600 stroke patients are being
evaluated per year, in an inpatient and outpatient setting.
One of the most common discussions on any given stroke service involves
the balance of preventing ischemic strokes (IS) and preventing intracranial
hemorrhage (ICH). Whether it is about resuming anticoagulation in a hemorrhage
patient or resuming aspirin in a patient with cerebral amyloid angiopathy there
is always much debate on timing and decisions.
The decision to resume aspirin in a patient with an MRI full of cerebral
microbleeds (CMBs) is often difficult. This paper looks into an alternative
agent, cilostazol, for reducing hemorrhage risk in patients who warrant
anti-platelet therapy. The background of the study is that cilostazol has shown
to have less hemorrhagic events than aspirin among patients with ischemic
stroke.
The PICASSO trial (Prevention of Cardiovascular Events in Asian
Ischemic Stroke Patients with High Risk of Cerebral Hemorrhage) was an Asian
trial that aimed to determine which antiplatelet agent is more effective and
safe in patients with prior hemorrhagic stroke or multiple CMBs. Cilostazol is
an antiplatelet agent with additional vasodilatory effects. The trial, published
in 2018, showed that cilostazol was noninferior to aspirin in preventing a
composite of major vascular events; however, it failed to reduce ICH. This
paper reviews the subgroup analysis to identify patients who would show greater
benefit with cilostazol.
Name: Dr. Piyush Ojha, MBBS, MD, DM Hometown: Neemuch, Madhya Pradesh, India Current Position: Stroke Neurologist, Jabalpur, Madhya Pradesh, India
Q: What made you interested in a career in stroke?
A: During my neurology residency, I
attended the World Stroke Congress held in Hyderabad, India, where I presented
two papers. I also got a chance to meet some of the best brains working in the
field of stroke. Looking at the recent developments in the area of stroke over
the last five years, I was inclined towards making stroke my future career.
Q: What has been your career path into this field?
A: After finishing my neurology
residency, I worked at a hospital at Jabalpur, India, where I tried to create stroke
awareness by conducting many talks and public awareness programs. Then, I was
lucky enough to be selected as a stroke fellow with the prestigious Calgary
Stroke Program, where I got an opportunity to work with an excellent team of
dedicated stroke neurologists and fellows.
Mohammad Anadani, MD*
Elizabeth M. Aradine, DO
Rohan Arora, MD
Bahar M. Beaver, MD*
Anusha Boyanpally, MD
Alan C. Cameron, MB ChB, BSc (Hons), MRCP*
Pamela Cheng, DO
Kat Dakay, DO*
Danielle de Sa Boasquevisque, MD*
Reyes de Torres Chacon, MD
Victor J. Del Brutto, MD*
Rachel Forman, MD
Alejandro Fuerte, MD*
Parneet Grewal, MD
Deepak Gulati, MD*
Jennifer Harris, MD
Mausaminben Hathidara, MD
Kathryn S. Hayward, PhD, PT
Yan Hou, MD, PhD
Richard Jackson, MD*
Wayneho Kam, MD
Gurmeen Kaur, MBBS*
Muhammad Taimoor Khan, MD
Abbas Kharal, MD, MPH*
Grace Y. Kuo, MD, MS, BA
Stephanie Lyden, MD, BS
Piyush Ojha, MBBS, MD, DM
Adeola Olowu, MD
Lin Kooi Ong, PhD*
Raffaele Ornello, MD*
Matthew Maximillian Padrick, MD, BA
Lina Palaiodimou, MD*
Robert W. Regenhardt, MD, PhD*
Shashank Shekhar, MD, MS*
Kristina Shkirkova, BSc
Ravinder-Jeet Singh, MBBS, DM*
Burton J. Tabaac, MD*
Melissa Trotman-Lucas, PhD
Tamaya Van Criekinge, PT
Elena Zapata-Arriaza, MD*
Charlotte Zerna, MD, MSc
*Senior Blogger
