American Heart Association


ISC 2021: COVID-19 and Acute Ischemic Stroke: Adding Fuel to the Fire

Isabella Canavero, MD

International Stroke Conference 2021
March 17–19, 2021
Presentation LB15

Srivastava PK, Zhang S, Xian Y, Xu H, Rutan C, Alger HM, Walchok J, Williams J, de Lemos JA, Decker-Palmer MR, et al. Acute Ischemic Stroke in Patients With COVID-19: An Analysis From Get With The Guidelines–Stroke. Stroke. 2021.

Actually, both COVID-19 and stroke represent pandemic diseases: To date, they account for the most frequent illnesses worldwide. In addition, upcoming evidence from medical literature suggests that the ultimate overlap of COVID-19 with the everlasting stroke “pandemic” has led to increasing rates of adverse outcomes.

In this paper, Srivastava et al. investigated clinical features and outcomes of patients with acute ischemic stroke and COVID-19 in the United States in the first 4-months period of the COVID-19 outbreak, by using data from the Get With The Guidelines-Stroke network. Nearly 42,000 acute ischemic stroke patients, hospitalized in 458 GWTG-Stroke hospitals, were identified: Of them, about 1,150 were also affected by COVID-19. Comparing acute ischemic stroke patients with or without COVID-19, younger age, Black, Hispanic and Asian ethnicity, higher NIHSS scores, and large vessel occlusions were found to be significantly more represented in the COVID-19 subgroup, supporting the negative impact of the infection on stroke outcome. Furthermore, acute ischemic stroke patients with COVID-19 were featured by longer times to evaluation and treatment, and worse morbidity and mortality compared to COVID-19-free patients.

ISC 2021: COVID-19 Pandemic: Collateral Damage in Stroke Quality of Care

Elena Zapata-Arriaza, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P846

Balucani C, Carhuapoma JR, Canner JK, Faigle R, Johnson B, Aycock A, Phipps MS, Schrier C, Yarbrough K, Toral L, et al. Exploring the Collateral Damage of the COVID-19 Pandemic on Stroke Care: A Statewide Analysis. Stroke. 2021.

The morbidity and mortality effects of COVID-19 are well demonstrated and are a global health priority. The collateral effects of the pandemic on other pathologies that will continue to harm when SARS-CoV-2 becomes endemic have growing evidence. Balucani et al. have performed a retrospective analysis of an existing prospective stroke registry reported by stroke centers in the state of Maryland, between March 1 and September 30, 2020 (pandemic) and the same time period in 2019 (pre-pandemic), in order to explore the effect of the COVID-19 pandemic on transient ischemic attack (TIA) and stroke care.

ISC 2021: Article Commentary: “Association Between Stroke and Subsequent Risk of Suicide”

Nurose Karim, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P237

Vyas MV, Wang JZ, Gao MM, Hackam DG. Association Between Stroke and Subsequent Risk of Suicide: A Systematic Review and Meta-Analysis. Stroke. 2021.

“What remains in diseases after the crisis is apt to produce relapses.”
— Hippocrates, Aphorisms

This article very well summarizes the impact of stroke on mental health. Stroke survivors, overall, struggle with the adjustment not only due to the illness itself, but the overall impact of it on their lifestyle. Stroke survivors are more likely to be unemployed, have greater lost productivity, and have higher disability from physical, cognitive and mental sequalae of stroke, which may confer the observed higher risk of suicide.

ISC 2021 Session: Substance Abuse in Stroke

Setareh Salehi Omran, MD

International Stroke Conference 2021
March 17–19, 2021
Session: Substance Abuse in Stroke (153, OnDemand)

The session “Substance Abuse in Stroke” at the International Stroke Conference 2021 included several presentations on the risk of stroke from a wide range of substances, including cannabis, tobacco cigarettes, e-cigarettes, alcohol, methamphetamine, and cocaine.

Marijuana and Synthetic Cannabinoid by Dr. Stephen Sidney:

Dr. Sidney discussed the potential mechanisms of cerebrovascular disease associated with cannabis use. Cannabis can lead to cerebrovascular disease through direct toxic effects on the vascular bed, altered hemodynamics (increased heart rate, increased supine blood pressure, postural hypotension), incident atrial fibrillation and atrial flutter, and endothelial dysfunction. Several studies have shown an association between cannabis exposure and increased risk of stroke. However, these studies have several major limitations, including cross-sectional study design, inability to stratify analysis by confounders (cigarette smoking, cocaine use), and lack of granular clinical information pertaining to the stroke and cannabis use (dose, composition, possible contaminants, various modes of consumption).

As it stands, it is unclear whether cannabis use is associated with stroke. It is important for clinicians to notify patients of limited data on cannabis use and stroke risk, and to advise against cannabis use in patients with known cardiovascular disease.

ISC 2021: Framework for a Pediatric Thrombectomy Center

Kevin O’Connor, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P589

Lauzier DC, Galardi MM, Guilliams KP, Goyal MS, Amlie-Lefond C, Hallam DK, Kansagra AP. Pediatric Thrombectomy: Design and Workflow Lessons From Two Experienced Centers. Stroke. 2021.

The lack of evidence-based guidelines for endovascular thrombectomy (EVT) in children with acute ischemic stroke has forced institutions to develop their own policies and procedures based on trials in adults and limited pediatric studies. Lauzier et al. describe the framework of their pediatric EVT-capable practices in Seattle and St. Louis. Their joint ventures include co-located (connected structures; St. Louis) or nearby (Seattle) pediatric hospitals and adult comprehensive stroke centers that are guided by interdisciplinary teams comprising pediatric neurologists, radiologists, neurointerventionalists, anesthesiologists, and pediatric intensivists, among others.

Strong collaboration among the multidisciplinary group and advocacy for pediatric stroke patients are integral components of the programs. Their efforts led to formalized and streamlined workflows, including initial triaging of a pediatric stroke case, rapidly acquiring and reviewing imaging studies with MRI/MRA protocols prioritizing DWI and time-of-flight sequences, initiating acute interventions as needed (including intravenous alteplase), and consulting a neurointerventionalist using a pre-specified script. Candidates for pediatric EVT are selected based on consensus inclusion and exclusion criteria developed by the group.

ISC 2021: Daily Step Count in Stroke Rehabilitation: A Useful Tool That Predicts Future Physical Activity

Csilla Manoczki, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P198

Handlery R, Regan EW, Stewart JC, Pellegrini C, Monroe C, Hainline G, Handlery K, Fritz SL. Predictors of Daily Steps at 1-Year Poststroke: A Secondary Analysis of a Randomized Controlled Trial. Stroke. 2021.

With wearable technologies becoming widely available, daily step count can be easily measured and utilized to track the patient’s physical activity in the home environment. Understanding which factors contribute to achieving a higher daily step count can help with tailoring interventions in the individual’s rehabilitation process.

A previous study showed that achieving a step count of at least 6000 steps a day decreases the risk of future cardiovascular events in patients after stroke; hence, the authors selected 6000 steps as target at 1 year post stroke with the potential of improved long-term health outcomes.

ISC 2021: Ischemic Stroke is Not Only a Rankin Scale: Endovascular Treatment and Quality of Life

Raffaele Ornello, MD

International Stroke Conference 2021
March 17–19, 2021
Poster P521

Joundi RA, Rebchuk AD, Field TS, Smith EE, Goyal M, Demchuk A, Dowlatshahi D, Poppe AY, Williams DJ, Mandzia JL, et al. Health-Related Quality of Life Among Patients With Acute Ischemic Stroke and Large Vessel Occlusion in the ESCAPE Trial. Stroke. 2021.

Measuring modified Rankin scale (mRS) scores 90 days after endovascular treatment (EVT) has become the mainstay of any trial on the acute phase of ischemic stroke. mRS is easy to assess and gives a clear idea of post-stroke dependency; however, it does not encompass all the dimensions of quality of life.

To fill in the gap of knowledge about health-related quality of life after EVT for ischemic stroke, the ESCAPE trial investigators randomized 315 patients to EVT or no EVT. Outcomes assessed at 90 days included mRS scores and the EuroQol-5D (EQ-5D) for quality of life. Compared with patients not receiving EVT, those receiving EVT had better mRS and EQ-5D scores at 90 days from stroke onset. In detail, the improvement was related to self-care, usual activities, mobility — only for those aged 60-79 years — and pain/discomfort — for women — while there was no association with anxiety/depression.

ESO-WSO 2020: Prognosis After Acute Stroke Interventions

Aurora Semerano, MD

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

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

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.