Aurora Semerano, MD
European Stroke Organisation Conference
September 1–3, 2021
Session: “Acute Stroke Treatment in Difficult Clinical Situations: In-Hospital Strokes and Other Challenges,” September 2, 2021
Making decisions in stroke medicine is a difficult task and may turn to be really challenging in selected cases, which, however, are quite frequent in our clinical practice. These daily challenges were the focus of the discussion in the session chaired by Daniel Strbian (Finland) and Silke Walter (Germany). Also, some useful tips for more confident decisions were proposed.
When deciding about thrombolysis in patients with recent surgery, existing studies are mostly retrospective and heterogenous, thus evidence for the best practice is very low. Gordian J. Hubert (Germany) suggested a comprehensive approach, which includes the evaluation of the risk of bleeding in the surgical wound (in terms of size, time from surgery, vascularization of the tissue), the damage of a potential bleeding in that site, and the possibility of measures to efficiently stop the bleeding (i.e., compressibility, surgical intervention). Similarly, in patients with recent trauma, the evaluation of the bleeding risk at the trauma site can be crucial, whereas estimating the damage of a potential bleeding may be challenging since location of trauma is often unknown.
In our daily practice, we often deal with older stroke patients with extensive medical history. According to Marjaana Tiainen (Finland), treatment decisions in the elderly population cannot be based solely on patient age, and a comprehensive evaluation taking into account pre-stroke functional outcome and comorbidities is required. The Clinical Frailty Scale may represent a useful tool to complement this evaluation in older patients. Considering the risk-benefit balance and the cost-effectiveness of our decisions is fundamental in this frail population. She concluded that time is brain, but taking extra minutes to gather more data about very old patients before acute treatments might be time worth spent.
We moved to the cath lab with Rajiv Advani (Norway). Despite the low incidence of stroke related to cardiovascular procedures (namely, Percutaneous Coronary Interventions – PCI, Transcatheter Aortic Valve Replacements – TAVR, and electrophysiological procedures), the absolute numbers can be very high, and it is not uncommon to be consulted on these strokes. A systematical approach is suggested for the best decision-making process in these patients: getting a complete overview of the history with the help of the treating cardiologist, establishing a timeline for symptom onset, precisely identifying the antithrombotic drugs which are in play, assessing the coagulation status. In the setting of large vessel occlusion stroke, a direct approach to endovascular thrombectomy should be considered.
Although not currently used in clinical practice, a potential help to juggle stroke challenges in the future will likely be thrombus analysis. Marco Bacigaluppi (Italy) presented new insights and put into perspective the analysis of cerebral thrombi retrieved by endovascular thrombectomy. Indeed, thrombus features may adjuvate in defining stroke etiology: cases are presented of emboli from atherosclerotic plaques, cardiac papillary fibroelastoma and calcific valves, in which histopathology of the thrombus univocally revealed the cause of stroke. Presence of neutrophil extracellular traps (NETs) in cerebral thrombi suggests the possibility of alternative lytic approaches. Finally, blood and imaging biomarkers of thrombus composition may adjuvate the decision-making process even in the acute stroke setting.
Claudio Baracchini (Italy) comprehensively discussed the big, unprecedented challenge of the last two years: COVID-19. He dissected the negative impact of COVID-19 in stroke care. Indeed, several reports have been released about the conversion of stroke units and the relocation of stroke staffs in COVID-19 units, the reduction of acute stroke admissions, and the significant increase in intervention times. Despite the pandemic difficulties, following some recommendations is fundamental to preserve the high quality of stroke care: guaranteeing protected stroke pathways, increasing stroke awareness among the population to avoid treatment delays, and prospecting a combined rehabilitation for COVID-19 positive stroke patients.