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ESOC 2022: ESC-ESO Joint Symposium: Evaluation of Cardiac Source of Stroke

Aurora Semerano, MD
@semerano_aurora

European Stroke Organisation Conference

May 4-6, 2022

The European Society of Cardiology (ESC) – European Stroke Organization (ESO) Joint Symposium, chaired by Marta Rubiera (Spain) and Wolfram Döhner (Germany), was a special occasion at ESOC 2022 to discuss both the heart-brain interactions in stroke and the precious collaborations with our closest cousins, the cardiologists.

Theodoros Karapanayiotides (Greece) introduced the basics of POCUS (Point of Care Ultrasound), a handheld device for rapid ultrasound cardiac investigation that could become a useful additional instrument for stroke neurologists. In the busy hospital setting with limited daily slots for echocardiography, indeed, POCUS could represent an extension of physical examination, that can rapidly answer specific questions and help to establish the timing of subsequent diagnostics, before referring to the cardiology service for full cardiac investigation.

By |May 11th, 2022|clinical, Conference|Comments Off on ESOC 2022: ESC-ESO Joint Symposium: Evaluation of Cardiac Source of Stroke

ESOC 2022: “Scientific Communications 10 – Prognosis and Outcome After Stroke”

Andy Lim, MBA FACEM GAICD
@ALim0211

European Stroke Organisation Conference
May 4-6, 2022

Pictured, left to right: Ann-Cathrin Probst (Germany), Andy Lim (Australia), Lynda Lisabeth (US).
Pictured, left to right: Ann-Cathrin Probst (Germany), Andy Lim (Australia), Lynda Lisabeth (US).

Sadly, we reached the final day of the 8th European Stroke Organisation Conference in Lyon, France.

My time was spent in the Gratte-Ciel 1-3 room, where we presented the outcomes of eight new studies. Here are eight learning points from our session.

By |May 11th, 2022|clinical, Conference|Comments Off on ESOC 2022: “Scientific Communications 10 – Prognosis and Outcome After Stroke”

ESOC 2022: ISNI-ESO Joint Symposium: Update on Stroke Immunology

Aurora Semerano, MD
@semerano_aurora

European Stroke Organisation Conference

May 4-6, 2022
Scientific Session – ISNI-ESO Joint Symposium: The immunology of stroke – an update

This year, ESOC hosted a Joint Symposium with the International Society of Neuroimmunology (ISNI), to discuss the most recent advances on the immunology of stroke. The session, chaired by Craig Smith (United Kingdom) and Corinne Benakis (Germany), was conducted by a great line-up of speakers, who discussed the role of inflammation in stroke both in the brain and at the systemic level, the important consequences of immune involvement, and the perspectives of immunotherapies in stroke.

Adam Denes (Hungary) focused on the close interactions between microglial cells and the neurovascular unit: Among their heterogenous functions in health and disease, indeed, microglia have been discovered to have close contact with cells of cerebral blood vessels (smooth muscle cells, astrocyte, pericytes, endothelial cells). As a result, it is likely that microglia have an influence on neurovascular coupling by sensing hypercapnia, whereas microglial dysfunction may impair hypercapnia-induced vasodilation in the cerebral cortex. This newly recognized function might be pivotal in stroke, especially in contributing to the so-called no-reflow phenomenon. Importantly, variants of microglial or microglia-regulated genes show strong associations with disturbance in cerebral blood flow. Further investigations, including genome wide association studies in humans, are warranted to explore correlation between gene variants in microglia and small vessel and neurodegenerative disorders.

By |May 10th, 2022|clinical, Conference|Comments Off on ESOC 2022: ISNI-ESO Joint Symposium: Update on Stroke Immunology

ESOC 2022: “Large Clinical Trials 2 – Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST)”

Tolga D Dittrich, MD
@to_dittrich

European Stroke Organisation Conference
May 4-6, 2022

About one in four ischemic strokes occurs during sleep. Previous studies have shown that such patients can still benefit from IV thrombolysis with alteplase if they exhibit a DWI/FLAIR mismatch on MRI.

The randomized TWIST trial investigated the effect of IV thrombolysis with tenecteplase (0.25 mg/kg) on functional outcome in patients with wake-up stroke. Advanced neuroimaging was not required for inclusion in the trial. The key eligibility criteria were a minimum NIHSS of 3 points and a possible treatment initiation within the first 4.5 hours after awakening. The study excluded patients with high NIHSS (>25 points) and premorbid functional impairment (mRS >2).

By |May 10th, 2022|clinical, Conference|Comments Off on ESOC 2022: “Large Clinical Trials 2 – Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST)”

ESOC 2022: Presidential Symposium Awards & Large Clinical Studies & Trials

Andy Lim, MBA, FACEM, GAICD
@ALim0211

European Stroke Organisation Conference
May 4-6, 2022

The 8th European Stroke Organisation Conference continued into the second day on Thursday, May 5. Seven large clinical studies and trials were presented at the Presidential Symposium Awards & Large Clinical Studies & Trials session. For those who missed out, here is a summary of take-home learning points.

ESOC 2022, Centre de Congrès de Lyon, May 5, 2022
ESOC 2022, Centre de Congrès de Lyon, May 5, 2022

INTERSTROKE: Influenza vaccination may confer a relevant potential to lower stroke risk (both ischemic and hemorrhagic).

By |May 10th, 2022|clinical, Conference|Comments Off on ESOC 2022: Presidential Symposium Awards & Large Clinical Studies & Trials

ESOC 2022: Official Welcome and Large Clinical Trials

Ammad Mahmood, MBChB, BMedSci
@AMahmoodNeuro

European Stroke Organisation Conference
May 4-6, 2022

For the first time since 2019, the European Stroke Organisation Conference was able to meet again in person in Lyon, France, with over 4,000 delegates joining in person and virtually.

Tenecteplase in AIS
Much anticipated tenecteplase phase III trial results were top of the bill to open the conference. First up were the results of the Canadian AcT trial comparing tenecteplase 0.25mg/kg to alteplase in 1600 patients routinely eligible for IV thrombolysis. Non-inferiority margins were met, and safety outcomes were comparable between groups. This was a substantial addition to the body of evidence in favor of non-inferiority of tenecteplase 0.25mg/kg compared to alteplase. Adaptation of guidelines in light of these findings may be on the horizon, though results from further trials such as the ATTEST-2 trial will be of great value.

By |May 10th, 2022|clinical, Conference|Comments Off on ESOC 2022: Official Welcome and Large Clinical Trials

Article Commentary: “Tailored Sitting Tai Chi Program for Subacute Stroke Survivors”

Farah Aleisa, MD

Zhao J, Chau JPC, Chan AWK, Meng Q, Choi KC, Xiang X, Zhao Y, He R, Li Q. Tailored Sitting Tai Chi Program for Subacute Stroke Survivors: A Randomized Controlled Trial. Stroke. 2022.

Ancient Chinese medicine suggests that Chi is aligned with our body fluids and stability of the nervous system, and it delivers functional and healing resources to all parts of the body, including the brain. It believes in the resting alert status of the body to activate circulation and facilitate oxygenation to the organs and cells. Its main outcome is harmonizing the nervous system. There are many energy channels connecting organs, glands, and cells, which are equivalent to the chemical and nervous signals. One of the modern definitions of Chi is the functionality of the chemical interactions in different body systems through enzymes, hormones, and even neurotransmitters; the methodology of Chi depends on the mind focus, breathing exercise, and specific body movements that all collaborate to enhance the efficiency of the inner chemical activities.

Dr. Zhao and his team studied the efficacy of a tailored Tai Chi rehabilitation program among stroke survivors who suffered from residual disabilities post-stroke events. The best time for rehabilitation for stroke patients is the first few days, post-stroke event, and the highest rate of recovery is up to 6 months. Beyond the 6 months period, recovery is still possible but in a much slower rate. This is the first study designed as an assessor-blind randomized controlled trial looking for the benefits of tailored Tai Chi exercises in the subacute stroke population. It enrolled patients from April 2020 to August 2020. Four separate inpatient neurology units of two tertiary A-level traditional Chinese medicine (TCM) hospitals in Kunming, China, included stroke survivors aged over 18 years, with a clinical diagnosis of ischemic stroke, with history of first-ever stroke, in the subacute stage of stroke, who can sit independently with or without cushions, use and raise at least one arm while sitting, and who are able to communicate. Few exclusion criteria were applied, like severe stroke with NIH stroke scale >16, cognitive impairment, hearing or visual disabilities, and pregnant women. Participants were randomized on a 1:1 ratio to the intervention or control groups with a block size of 8 stratified by NIHSS score (< 6 or ≥ 6) by an independent statistician according to a computer-generated randomization sequence.

By |May 6th, 2022|clinical, rehabilitation|Comments Off on Article Commentary: “Tailored Sitting Tai Chi Program for Subacute Stroke Survivors”

ESOC 2022 Official Welcome and Large Clinical Trials

Andy Lim, MBA, FACEM, GAICD
@ALim0211

ESOC 2022 Amphithéâtre, Centre de Congrès de Lyon, Wednesday, 4 May 2022, 10:30 – 12:30 CEST

Here we are, officially welcomed to the 8th European Stroke Organisation Conference! Results of nine large trials were released this morning, and social media is already buzzing with excitement from these results. Here are the key findings for those who might have missed out.

Three tenecteplase trial results were released today. The AcT trial, a Canadian trial of 1600 patients with acute stroke, demonstrated that tenecteplase was noninferior (5% margin) to alteplase in acute ischaemic stroke with comparable functional outcomes and no significant safety issues. NOR-TEST 2A, a Norwegian trial of 1036 stroke patients up to 4.5 hrs inclusive of wake-up stroke, could not show that tenecteplase is non-inferior. Tenecteplase yielded worse safety and functional outcome compared with alteplase. Dose chosen was 0.4mg/kg, and part B intends to test the reduced dose of 0.25mg/kg. The Australian TASTE-A trial of 104 patients demonstrated significantly smaller CT perfusion lesions in patients treated with tenecteplase compared to alteplase, indicating earlier reperfusion, with no safety concerns.

Six additional studies were presented:
• The Paramedic Norwegian Acute Stroke Prehospital Project demonstrated significantly better functional outcome in an intervention group that trained paramedics in the use of NIHSS in the pre-hospital setting at the cost of longer on-scene time.
• SPRINT showed that a structured SMS message, education video, workbook, and telephone follow-up improved lifestyle and medication adherence.
• ATTICUS, stopped early for futility, showed us that apixaban not superior to ASA with switch to apixaban in case of AF in prevention new ischaemic lesions during 12 months follow-up of an enriched embolic stroke of undetermined source population.
• SETPOINT2 taught us that early versus late tracheostomy in ventilated stroke patients did not lead to better functional outcome at six months.
• AMETIS revealed similar rates of functional independence and major periprocedural complications when comparing procedural sedation versus GA in endovascular management of stroke.
• Finally, the Chinese ATTENTION trial demonstrated significantly improved functional outcome and secondary efficacy outcomes, as well as lower overall disability and mortality, when EVT was compared with best medical management in acute basilar artery occlusion within <12hrs from the estimated time (defined as the sudden onset of stroke symptoms consistent with acute basilar occlusion, excluding previous minor prodromal symptoms, or time the patient was last known to be well).

This sets the 8th ESOC off to a great start this Wednesday 4th May in Lyon, France!

By |May 5th, 2022|Conference|Comments Off on ESOC 2022 Official Welcome and Large Clinical Trials

Article Commentary: “Early Deterioration, Hematoma Expansion, and Outcomes in Deep Versus Lobar Intracerebral Hemorrhage”

Karissa C Arthur, MD
@KCArthurMD

Kuohn LR, Witsch J, Steiner T, Sheth KN, Kamel H, Navi BB, Merkler AE, Murthy SB, Mayer SA. Early Deterioration, Hematoma Expansion, and Outcomes in Deep Versus Lobar Intracerebral Hemorrhage: The FAST Trial. Stroke. 2022.

Intracranial hemorrhage (ICH) accounts for more than two-thirds of mortality from all stroke subtypes. ICH can be deep or lobar, and it is unclear if these subtypes differ in complications such as hematoma expansion (HE) or early neurologic deterioration (END). It is important to identify these differences as it may lead to different monitoring and treatment approaches. The authors hypothesized that HE and poor functional outcomes would occur more frequently in deep ICH, and END would be more common in patients with lobar hemorrhage.

The authors performed a secondary analysis using data from the FAST trial (Factor VII for Acute Hemorrhagic Stroke), a large, randomized trial with serial neuroimaging and blind volume measurements to assess for differences in HE, END, and functional outcomes between deep and lobar ICH. There were several exclusion criteria of the FAST trial, including GCS of 5 or less, known anticoagulant use or coagulopathy, known thrombotic disease within 30 days, and several others. CT imaging was done within 3 hours of symptom onset, at 24 hours, and 72 hours, and was evaluated by two individual blinded neuroradiologists. HE included hematoma expansion > 33% or 6 mL from baseline in 24 hours. END was defined as GCS decrease by 2 points or increase in NIHSS by at least 4 within 24 hours. Modified Rankin Scale (mRS) was used to assess functional outcome.

Graphic abstract
By |May 4th, 2022|clinical|Comments Off on Article Commentary: “Early Deterioration, Hematoma Expansion, and Outcomes in Deep Versus Lobar Intracerebral Hemorrhage”

Long-Term Consequences of Stroke-Heart Syndrome

Praveen Hariharan, MD

Buckley BJR, Harrison SL, Hill A, Underhill P, Lane DA, Lip GYH. Stroke-Heart Syndrome: Incidence and Clinical Outcomes of Cardiac Complications Following Stroke. Stroke. 2022.

Over the last two decades, an increasing body of evidence has recognized various cardiovascular complications following ischemic stroke collectively known as the stroke-heart syndrome. Ischemic stroke can cause impaired autonomic cardiac reflexes, repolarization abnormalities, myocardial injury and cardiomyopathy resulting in myocardial infarction, cardiac arrhythmias including atrial fibrillation, new-onset or exacerbation of heart failure, recurrent stroke, poor functional outcomes, and increased mortality. Many studies have explored the short-term consequences, but there is a paucity of data on long-term clinical outcomes.

In this study, the authors have utilized retrospective observational data obtained from a global federated health research network called TriNetX. Patients with an incident acute ischemic stroke from 2002-2021 with at least 5 years follow up were included. Ischemic stroke patients with newly diagnosed cardiovascular complications within 4 weeks post-stroke were 1:1 propensity score-matched (for baseline demographics and comorbidities) with ischemic stroke patients without cardiovascular complications for comparison of 5-year MACE (major adverse cardiovascular events) outcomes.

By |May 2nd, 2022|clinical|Comments Off on Long-Term Consequences of Stroke-Heart Syndrome