An interview with Dr. Noortje Maaijwee, MD, PhD, a neurologist specializing in neurorehabilitation. She is a full-time faculty member in the Department of Neurology and Neurorehabilitation at the Lucerne Cantonal Hospital in Switzerland. She completed her medical school and residency at Radboud University Nijmegen Medical Centre in the Netherlands. Her primary area of research interest includes stroke in young adults, long-term consequences of stoke, and quality of life issues after suffering a stroke. During her PhD, Dr. Maaijwee defended a thesis on “Long-term neuropsychological and social consequences after stroke in young adults.”
Interviewed by Dr. Rohan Arora, MD, Assistant Professor of Neurology, director of stroke fellowship at the Hofstra Northwell School of Medicine and medical director of the stroke program at LIJ Forest Hills, a part of Northwell Health, New York.
In this interview, Dr. Maaijwee discusses highlights from the European Stroke Organization Conference, held May 22–24 in Milan, Italy.
Dr. Arora: At ESOC 2019, what were some major breakthroughs?
Dr. Maaijwee: The indications and contra-indications for acute treatment of ischemic stroke by IV thrombolysis and endovascular therapy are ever-changing. For example, the time-window when treatment is successful. In the Large Clinical Trials session on the first day of ESOC, a meta-analysis was presented that showed that intravenous thrombolysis increases the percentage of good clinical outcome (modified Rankin Score (mRS) 0-1) at 3 months, if treatment is started between 4.5–9 hours after onset of symptoms in select patients with CT or MRI perfusion mismatch.1
Dr. Arora: Can you give some examples of what you learned from the sessions on secondary stroke prevention and how they would change your clinical practice?
Dr. Maaijwee: I am always curious for the newest updates on primary and secondary prevention, since we are still developing the best strategies for different subgroup of patients with ischemic stroke. A couple of years ago, secondary stroke prevention was quite easy: oral anticoagulation for patients with a clear cardio-embolic stroke (for example, atrial fibrillation) and antiplatelet-aggregation-therapy for every other cause of stroke.
I attended the session on extracranial and intracranial large vessel disease. What was new for me is that addition of low dose rivaroxaban to aspirin in patients with atherosclerosis might reduce the rate after ischemic stroke in certain groups of patients with large vessel disease. (Patients who required anticoagulation or had a stroke within 1 month, previous lacunar stroke, or intracerebral hemorrhage were excluded in this study).2
Also, in certain cases, treatment of asymptomatic carotid stenosis may be beneficial for reducing risk of ischemic stroke. Usually, this group of patients was being treated based on the multidisciplinary opinion of the neurologist and surgeon. By attending ESOC, I learned some useful tips on how to select patients, with the help of some patient characteristics (for example, history of contralateral stroke), plaque characteristics (for example, the progression of the plaque on follow-up, degree of stenosis (60-99%), echolucency of the plaque), and results of other ancillary investigations (for example, microemboli on transcranial Doppler).
Furthermore, the concept of embolic stroke of unknown source (ESUS)3 is a topic of recent interest exploring if patients might benefit from oral anticoagulation as compared to antiplatelet therapy for secondary stroke prevention. While some significant trials on this topic4, 5 were negative, there is still a lot of research going on certain subgroup of patients which might actually benefit from this strategy.6, 7 I am looking forward to more results, which will follow in the next couple of years.8
Dr. Arora: Are there any new developments in your area of interest, neurorehabilitation and long-term prognosis after stroke?
Dr. Maaijwee: Of course, since I am currently working in the field of neurorehabilitation, and always on the lookout on how to improve the outcome of our rehabilitation programs. Fortunately, this year, some interesting research was presented at the plenary large clinical trial session. A self-management program called ‘Take Charge Session’ (TCS) intervention was studied in a randomized controlled trial.9 This intervention is an interviewing technique aiming to engage the stroke patient more actively in the process of recovery. This intervention, conducted in New Zealand, led to an improvement in quality of life measured 12 months after stroke. Another trial was presented on a technique in which robot-assisted upper arm training was used, which unfortunately did not result in significant differences between the treatment and control group.10
I find it very interesting that it sometimes seems to be the technically less complex interventions that show more positive effects on outcome. This might, of course, be an advantage, as these techniques may be implemented more globally, since these techniques can be made available more widely than the technically more complex interventions.
When it comes to long-term prognosis after suffering a stroke, in young patients, the long-term prognosis is not that favorable as quoted in prior studies. For example, mortality risk is much higher than in the healthy population, and risk remains high for cognitive impairment.11
Dr. Arora: What topics could be interesting for the next conference?
Dr. Maaijwee: Being my topic of interest, I hope we will come out with data regarding long-term prognosis of stroke in young patients. I hope that more research in this field will eventually enable us to ameliorate the prognosis. In my opinion, it is very important that outcome will not only be measured as mRS, but also on more functional end points, such as quality of life and return to work after suffering a stroke.
1. Campbell BCV MH, Ringleb PA, Parsons MW, Churilov L, Bendszus M, Levi CR, Hsu C, Kleinig TJ, Fatar M, Leys D, Molina C, Wijeratne T, Curtze S Dewey HM, Barber PA, Butcher KS, De Silva DA, Bladin CF, Yassi N, Pfaff JAR, Sharma G, Bivard 4, Desmond PM, Schwab S, Schellinger PD, Yan B, Mitchell PJ, Serena J, Toni D, Thijs V, Hacke W, Davis SM, Donnan GA; EXTEND, ECASS-4, and EPITHET Investigators. Extending thrombolysis to 4·5-9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. Lancet. 2019.
2. Sharma M HR, Connolly SJ, Bosch J, Shestakovska O, Ng KKH, Catanese L, Keltai K, Aboyans V, Alings M, Ha JW, Varigos J, Tonkin A, O’Donnell M, Bhatt DL, Fox K, Maggioni A, Berkowitz SD, Bruns NC, Yusuf S, Eikelboom JW. Stroke Outcomes in the COMPASS Trial. Circulation. 2019; 139: 1134-45.
3. Hart RG DH, Coutts SB, Easton JD, Granger CB, O’Donnell MJ, Sacco RL, Connolly SJ; Cryptogenic Stroke/ESUS International Working Group. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet neurology. 2014; 13: 429-38.
4. Diener HC SR, Easton JD, Granger CB, Bernstein RA, Uchiyama S, Kreuzer J, Cronin L, Cotton D, Grauer C, Brueckmann M, Chernyatina M, Donnan G, Ferro JM, Grond M, Kallmünzer B, Krupinski J, Lee BC, Lemmens R, Masjuan J, Odinak M, Saver JL, Schellinger PD, Toni D, Toyoda K; RE-SPECT ESUS Steering Committee and Investigators. Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source. NEJM. 2019; 380: 1906-17.
5. Hart RG SM, Mundl H, Kasner SE, Bangdiwala SI, Berkowitz SD, Swaminathan B, Lavados P, Wang Y, Wang Y, Davalos A, Shamalov N, Mikulik R, Cunha L, Lindgren A, Arauz A, Lang W, Czlonkowska A, Eckstein J, Gagliardi RJ, Amarenco P, Ameriso SF, Tatlisumak T, Veltkamp R, Hankey GJ, Toni D, Bereczki D, Uchiyama S, Ntaios G, Yoon BW, Brouns R, Endres M, Muir KW, Bornstein N, Ozturk S, O’Donnell MJ, De Vries Basson MM, Pare G, Pater C, Kirsch B, Sheridan P, Peters G, Weitz JI, Peacock WF, Shoamanesh A, Benavente OR, Joyner C, Themeles E, Connolly SJ; NAVIGATE ESUS Investigators. Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. NEJM. 2018; 378: 2191-201.
6. Healey JS GD, Swaminathan B, Eckstein J, Mundl H, Epstein AE, Haeusler KG, Mikulik R, Kasner SE, Toni D, Arauz A, Ntaios G, Hankey GJ, Perera K, Pagola J, Shuaib A, Lutsep H, Yang X, Uchiyama S, Endres M, Coutts SB, Karlinski M, Czlonkowska A, Molina CA, Santo G, Berkowitz SD, Hart RG, Connolly SJ. Recurrent Stroke With Rivaroxaban Compared With Aspirin According to Predictors of Atrial Fibrillation: Secondary Analysis of the NAVIGATE ESUS Randomized Clinical Trial. JAMA Neurol. 2019.
7. Kasner SE SB, Lavados P, Sharma M, Muir K, Veltkamp R, Ameriso SF, Endres M, Lutsep H, Messé SR, Spence JD, Nedeltechev K, Perera K, Santo G, Olavarria V, Lindgren A, Bangdiwala S, Shoamanesh A, Berkowitz SD, Mundl H, Connolly SJ, Hart RG; NAVIGATE ESUS Investigators. Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. Lancet neurology. 2018; 17: 1053-60.
8. Geisler T PS, Meisner C, Schreieck J, Zuern CS, Nägele T, Brachmann J, Jung W, Gahn G, Schmid E, Bäezner H, Keller T, Petzold GC, Schrickel JW, Liman J, Wachter R, Schön F, Schabet M, Lindner A, Ludolph AC, Kimmig H, Jander S, Schlegel U, Gawaz M, Ziemann U. Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): Rationale and study design. Int J stroke. 2017; 12: 985-90.
9. Fu VWY WM, McNaughton H. The Taking Charge After Stroke (TaCAS) study protocol: a multicentre, investigator-blinded, randomised controlled trial comparing the effect of a single Take Charge session, two Take Charge sessions and control intervention on health-related quality of life 12 months after stroke for non-Māori, non-Pacific adult New Zealanders discharged to community living. BMJ Open. 2017; 7.
10. Rodgers H BH, Krebs HI, van Wijck F, Howel D, Wilson N, Aird L, Alvarado N, Andole S, Cohen DL, Dawson J, Fernandez-Garcia C, Finch T, Ford GA, Francis R, Hogg S, Hughes N, Price CI, Ternent L, Turner DL, Vale L, Wilkes S, Shaw L. Robot assisted training for the upper limb after stroke (RATULS): a multicentre randomised controlled trial. Lancet. 2019.
11. Ekker MS VJ, Vaartjes I, Jolink WMT, Klijn CJM, de Leeuw FE. Association of Stroke Among Adults Aged 18 to 49 Years With Long-term Mortality. JAMA : the journal of the American Medical Association. 2019.