American Heart Association

Conference

ESO-WSO 2020: Prognosis After Acute Stroke Interventions

Aurora Semerano, MD
@semerano_aurora

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020
Session: Scientific Communications 16: Prognosis After Acute Stroke Interventions

Revascularization therapies, including intravenous thrombolysis and endovascular thrombectomy, have shown to reduce mortality and disability after stroke in randomized clinical trials, as well as in the real world. However, even when the revascularization treatment is effective, a significant amount of patients experiences poor outcome. Investigating the mechanisms and the predictors of poor prognosis despite acute stroke interventions was the goal of the 8 lectures of this interesting session, chaired by Prof. Mike Charma from Canada and Prof. Else C. Sandset from Norway.

Dr. Chen Chen, from China, illustrated her work aimed at determining patient characteristics of Asian and non-Asian patients with acute ischemic stroke included in the ENCHANTED study: Compared to non-Asian patients, Asian patients were at increased risk of hemorrhagic transformation and neurologic deterioration during hospitalization after thrombolysis treatment, potentially suggesting that distinctive monitoring for complications is needed in subgroups of patients after acute stroke intervention.

ESO-WSO 2020: Vagus Nerve Stimulation Paired With Rehabilitation for Upper Limb Motor Recovery After Stroke

Kate Hayward, PhD PT
@kate_hayward_

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

ESO-WSO 2020 Large Clinical Trials & Awards
Presenter: Professor Jesse Dawson
Presentation title: Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-Rehab): A randomised, blinded, pivotal, Phase III device trial

There is much work occurring to identify adjuvants that may boost post-stroke motor recovery — particularly upper limb recovery, which often remains an unmet need for many stroke survivors long-term. The current work focused on vagus nerve stimulation (VNS) as an adjunct to motor rehabilitation and built upon two prior pilot randomized controlled trials of this intervention.1,2 The pilot trials suggested potential for a functional benefit of VNS when combined with intensive motor rehabilitation. The mechanistic rationale put forward to underpin this intervention was that VNS activates release of neuromodulators, which may facilitate behavioral and physiological changes that support motor recovery.

In this randomised, blinded, Phase III trial,3 eligible participants had to have experienced a unilateral ischemic stroke 9 months to 10 years prior to enrolment and demonstrated a Fugl Meyer Assessment Upper Extremity (FMA-UE) score of 20 to 50 points (out of 66 points). This is consistent with moderate to moderately-severe impairment as all participants would be expected to demonstrate some movement if scoring within this range. All enrolled participants had a VNS device implanted and were randomized to receive an active or sham stimulation protocol. Of note, all participants received 5 active stimulations (varying intensities) at the commencement of each in-clinic session, which was designed to expose everyone to a very small volume of VNS and to maintain blinding. All participants received 6 weeks of in-clinic rehabilitation (3 session per week for 2 hours aiming for >300 repetitions) followed by 90 days of at home-rehabilitation (daily therapist prescribed home exercises). Follow up occurred at 1, 30, and 90 days post completion of in-clinic rehabilitation.

ESO-WSO 2020: Three Rounds of Controversies in Recovery and Brain Repair After Stroke

Aurora Semerano, MD
@semerano_aurora

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

The Controversies sessions during the ESO-WSO 2020 Conference are intriguing live Q&A sessions focused on grey zones in stroke care, with stroke experts defending their points of view and facing each other in interesting rounds of discussion. On the second day of the conference, the session addressed the following topics about recovery and brain repair after stroke.

Round 1:

Brain Repair is the Right Target to Improve Outcome — John Krakauer (United States of America)
Basing on primate experimental stroke, Dr. Krakauer showed that a certain rate of spontaneous recovery exists after stroke; however, training helps to amplify, rescue, and maintain spontaneous recovery. The main question remains: How does it happen? According to Dr. Krakauer, training-induced recovery in monkeys is not driven by cortical reorganization. Conversely, brain repair occurs via training-induced strengthening of pre-existing alternative cortico-subcortical connections. The recipe for brain repair after stroke is traced: an integrated interaction between behavior, residual architecture, and plasticity.

Brain Repair Does Not Work, Reorganisation is Key — Belen R. Ballester (Spain)
Dr. Ballester dismantled in 15 minutes three common pessimistic beliefs about recovery after stroke. Behavior drives functional and structural reorganization and can meaningfully interact with spontaneous recovery. For this purpose, high repetitive task-oriented and task-specific training is needed. Possibilities for recovery extend well beyond the classical time window of 3-6 month, and plasticity by means of structural and connectivity changes is still present beyond 1 year after stroke. Finally, it is not an invariable destiny of stroke patients to deteriorate in the chronic phase; learning and training can prevent deterioration.

ESO-WSO 2020: “Novel Imaging in Stroke”

Ammad Mahmood, MBChB
@AMahmoodNeuro

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

This session covered a number of novel techniques used in stroke imaging with a number of distinguished speakers. Cutting-edge advances in pre-hospital imaging in the ambulance, imaging used in making decisions about reperfusion therapies, and diagnostic imaging used in aetiological classification were all discussed.

Pre-hospital imaging – Jeffrey Saver
Advantages of triage in the field of patients into ischemic (LVO and non-LVO) and hemorrhagic stroke enables routing to the most appropriate facility, minimizing delays to treatment access and the need for inter-hospital transfers. Quasi-imaging approaches involving innovative approaches such as radio frequency, infrared, or EEG ‘stroke helmets’ may help identify patients with LVO in the future. Ultrasound assessment of vessel patency in the field yielded 91% accuracy in identifying LVO in one study. Mobile stroke units with CT capability are already in use and allow CT, CTA, and possibly CTP in the field. Automated image processing software can aid in interpretation of CT results quickly. Future technologies may include mobile stroke units in helicopters or small aircraft, mobile neuro-intervention suites, and mobile MRI imaging. Prof. Saver presented some cases from the Los Angeles mobile stroke unit experience highlighting the optimization of patient management achieved through early triage. Lastly, he highlighted the ongoing BEST-MSU trial, which will evaluate the benefit of MSUs in stroke management in several cities in the United States.

ESO-WSO 2020: “COVID-19 Related Stroke”

Ericka Samantha Teleg, MD

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

Navigating through this time of a pandemic is challenging enough as we attempt to seek and learn knowledge to compensate for how COVID-19 changes our lives. The special part of the scientific session “COVID-19 Related Stroke,” held during the ESOC-WSO 2020 conference on November 9, was structured brilliantly, led off by Dr. Bernard Yan’s opening.

The session by Karl Shurr and Annie McCluskey of Australia was titled “Rehabilitation for Serious COVID: Physiotherapist as Patient.” Karl’s experiences with COVID teaches us that one can be resilient at this time. He informed us how he used his time in the hospital to motivate himself and hopefully will motivate others, as well. Goal-setting as a motivation is the key in this session. We always ponder on what we cannot do, but his valuable insight as he recovered was “find what the person can do.” Empowerment and kindness are key.

ESO-WSO 2020: “Large Clinical Trials and Welcome”

Ammad Mahmood, MBChB
@AMahmoodNeuro

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

Welcome
Profs. Jesse Dawson and Michael Brainin welcomed all the delegates to the virtual conference and a chance to bring stroke care back into focus after a difficult year focusing on the COVID-19 pandemic. They spoke about the hard work that has gone into the rearrangement of this year’s conference into a virtual experience, and we thank them and their teams for their efforts in bringing the conference to us in these difficult times.

Fluoxetine after stroke
The first two presentations focused on the use of fluoxetine after stroke to assess any benefit in stroke rehabilitation and functional outcome. These trials came from an international collaboration of 3 trials focusing on this topic. First, Erik Lundstrom from Sweden presented the results of the EFFECTS trial. 1500 patients, at 35 Swedish centers, with ischemic or hemorrhagic stroke in the last 2-15 days but no history of depression were randomized 1:1 to receive either fluoxetine or placebo. The primary outcome of modified Rankin scale at 6 months demonstrated a neutral result with odds ratio 0.94 (0.78-1.13) at 6 months. Secondary outcomes demonstrated a small decrease in depression after stroke but a small increase in rates of fractures. Next, Graeme Hankey from Australia presented the 12-month results from the AFFINITY trial, which had also shown neutral results when the main trial results for 6 months outcome were previously published. The 12-month outcomes also showed a neutral effect of fluoxetine in functional outcome showing there is no delayed benefit. A small reduction in the rate of recurrent ischemic stroke in the fluoxetine group was seen in the AFFINITY trial, but not in the two other larger trials; therefore, this was felt to be a random effect. Overall, the results of the EFFECTS, AFFINITY, and FOCUS trials demonstrated that there is no benefit of fluoxetine after stroke in improving rehabilitation and functional outcome.

Dual Antiplatelet Therapy: Shotgun or Aiming at Precision Targets?

Thomas Raphael Meinel, MD
@TotoMynell

Amarenco P, Denison H, Evans SR, Himmelmann A, James S, Knutsson M, Ladenvall P, Molina CA, Wang Y, Johnston SC, on behalf of the THALES Steering Committee and Investigators. Ticagrelor Added to Aspirin in Acute Nonsevere Ischemic Stroke or Transient Ischemic Attack of Atherosclerotic Origin. Stroke. 2020.

Short-term dual antiplatelet therapy (DAPT) has emerged as a powerful treatment option in patients with non-severe ischemic stroke or high-risk TIA.1 However, the efficacy of antithrombotic therapy might vary according to etiology of the ischemic event.2 Amarenco et al. aimed to investigate whether the efficacy and safety of DAPT with Aspirin plus Ticagrelor as compared to Aspirin differed in the subgroup of patients with minor stroke or TIA due to atherosclerotic vascular disease.

For this purpose, the authors conducted a substudy of the THALES trial including patients aged 40 years or older with non-severe non-cardioembolic ischemic stroke (NIHSS ≤5) or high-risk TIA (ABCD2-Score ≥6 or vascular stenosis ≥50% in the suspected vascular territory). Main exclusion criteria were atrial fibrillation, suspicion of cardioembolic cause, high bleeding risk and — importantly — planned carotid revascularization that required halting study medication within 3 days of randomization. or the main prespecified analysis, atherosclerotic ipsilateral stenosis was defined as presence of narrowing of the lumen of ≥30% ipsilateral to the ischemic event as assessed by CT- or MR-angiography or neurovascular ultrasound. The primary efficacy endpoint was time from randomization to the first subsequent event of stroke or death. The primary safety endpoint was occurrence of a severe bleeding event according to the GUSTO definition. 11,016 patients underwent randomization (roughly 50% representing a European and 40% Asian population).

ESO-WSO 2020: Stroke Imaging: Improved Decision-Making Through Machine Learning?

Tolga D. Dittrich, MD

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

Scientific Session: “Artificial Intelligence in Stroke Imaging,” Sunday, November 8, 2020
Speakers: Susanne Wegener, Roland Wiest, Paul Bentley, Kim Mouridsen, Sook-Lei Liew
Chairs: Kim Mouridsen, Susanne Wegener

Machine learning (ML) methods as a component of artificial intelligence are a growing field in stroke imaging research. We are already familiar with such automated evaluation systems, such as ASPECT scoring or mismatch volume calculation. Nevertheless, clinicians are often confronted with a complex mixture of different clinical, laboratory, and radiological parameters that must be weighed against each other to make an individual therapeutic decision.

“Machine learning is a precise mathematical way in which we can do this in a reliable, objective manner,” said Paul Bentley, of Imperial College London. Unlike conventional image interpretation, an algorithm can evaluate radiological source data to derive applicable rules. ML approaches are particularly promising for objectifying imaging results and detecting subtle changes in the context of intricate radiological findings in acute ischemic stroke. However, to provide additional information, ML methods need a relatively large set of initial data. This limitation especially becomes relevant in the context of imaging-based prediction of stroke recovery and rehabilitation response, where imaging does not constitute a common clinical component, as Sook-Lei Liew from the University of Southern California emphasized in her lecture.

The potential of ML in both acute stroke and stroke rehabilitation imaging is broad. In the future, ML-based techniques, for example, in ischemic core imaging in the extended time window, could help us to identify better patients who could benefit from endovascular treatment.

ESO-WSO 2020: “Young Stroke Physicians and Researchers: Research Design Workshops”

Tamaya Van Criekinge, PT
@tamayavc

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

Professor Karin Klijn from the Radboud University Medical Center started the session by providing young researchers with key steps when planning a career as a clinical scientist. With a little help from John F. Kennedy, she used a very relevant quote multiple times: “Those who dare to fail miserably can achieve greatly.” This advice continued throughout all the steps as she emphasized that it is important for you, as a young researcher, to take the initiative to further your own career. “Things do not happen, things are made to happen,” you, as a researcher, need to take the first step and take responsibility, while maintaining your own standards when finding a mentor, a supportive environment, and training.

The importance of a mentor was clarified by Prof. Peter Sandercock from the University of Edinburgh, who defined a mentor as an experienced, high-regarded empathic person who guides a young researcher throughout his or her career. When seeking a supervisor, you should look for someone who is already performing independent research but has a genuine interest in your academic career, who you can trust and have a good personal relationship with. Avoid bad mentors who exploit you, steal your ideas, or claim authorship for your work. Try and plan consecutive meetings with your mentor where you not only discuss work but how you tackle problems and how to overcome the pitfalls and downsides of an academic career. Yes, we have all received rejection letters! Yes, we have all had our own ups and downs! No, it’s nothing to be ashamed of.

ESO-WSO 2020: Three Rounds of Controversies in Stroke Thrombectomy

Aurora Semerano, MD
@semerano_aurora

European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020

The Controversy sessions in the ESO-WSO 2020 Conference are intriguing live Q&A sessions focused on grey zones in real-world stroke care, with stroke experts defending their points of view and facing each other in interesting rounds of discussion. On the first day of this ESO-WSO 2020 Conference, the session addressed the following hot topics about endovascular thrombectomy.

Do We Need Perfusion Imaging to Guide MT In Extended Time Window?

YES: Götz Thomalla (Germany) presented the pros of using advanced perfusion imaging for patient eligibility to mechanical thrombectomy (MT) in the extended time window (>6h from onset). He invited us to remember that, first of all, we should rely on current evidence. According to the evidence, whereas perfusion techniques are not required in the early time window, the DAWN and DEFUSE III clinical trials firmly base on advanced imaging for patient selection in the late time window. As a consequence, also AHA/ASA guidelines, ESO consensus, and ESMINT guidelines recommend advanced imaging for patient eligibility. He also pointed out that we cannot reliably trust the ASPECTS score for estimating viable tissue. In addition, against the opinion that perfusion techniques are time-consuming and difficult to interpret, Prof. Thomalla reassured that just a few minutes are needed to perform reliable perfusion imaging and that simple parameters are required for map interpretation: Tmax> 6 seconds identifies penumbra and CBF<30% works for infarct core. This little extra time is well invested to effectively guide reperfusion treatments.