American Heart Association

clinical

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”

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

Childhood Ischemic Stroke and SARS-CoV-2

Kevin O’Connor, MD

Beslow LA, Agner SC, Santoro JD, Ram D, Wilson JL, Harrar D, Appavu B, Fraser SM, Rossor T, Torres MD, et al. International Prevalence and Mechanisms of SARS-CoV-2 in Childhood Arterial Ischemic Stroke During the COVID-19 Pandemic. Stroke. 2022.

Over the last two years, data have shown an increased risk of ischemic stroke in the setting of SARS-CoV-2 infection. Beslow et al. explored the relationship between SARS-CoV-2 and childhood (age 29 days to 18 years) ischemic stroke based on data from multiple sites across 21 countries.

The sites reported 373 acute ischemic strokes from June to December 2020 during the same time that they recorded 7,231 pediatric SARS-CoV-2 hospitalizations. Of 335 (89.8%) childhood ischemic strokes that underwent testing for SARS-CoV-2, 23 (6.9%) were positive for the virus, and clinical information was available for 22 cases. The overall risk of childhood ischemic stroke in children hospitalized for SARS-CoV-2 was low at 0.32% (95% binomial exact CI, 0.20%-0.48%), but this may include children in whom the infection was found incidentally.

By |April 27th, 2022|clinical|Comments Off on Childhood Ischemic Stroke and SARS-CoV-2

Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”

Hannah Roeder, MD, MPH

Hahn M, Gröschel S, Hayani E, Brockmann MA, Muthuraman M, Gröschel K, Uphaus T, on behalf of the German Stroke Registry—Endovascular Treatment (GSR-ET) Study Group. Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy. Stroke. 2022.

For working-age stroke patients, returning to work (RTW) is a yardstick for functional recovery and is associated with improved well-being. Patients who suffer large vessel occlusion (LVO) are at greater risk for persistent neurological deficits; however, in the mechanical thrombectomy era, even patients with LVO may have a favorable outcome allowing RTW. Hahn and colleagues used data from the German Stroke Registry Endovascular Treatment (GSR-ET) to explore the likelihood and predictive factors for RTW with particular attention to sex differences.

The investigators included patients in the GSR-ET who were known to be employed prior to their stroke and were less than 65 years of age (the retirement age in Germany), and excluded patients who did not receive thrombectomy or were deceased by day 90. After application of inclusion/exclusion criteria, about one-tenth of patients in the GSR-ET were eligible (606 out of 6635). Of eligible patients, 35.6% (216) were re-employed at 3 months post-stroke.

By |April 25th, 2022|clinical, outcomes, prognosis|Comments Off on Article Commentary: “Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy”