<p>The post Navigating the Frontiers of Stroke Management (like a true Viking!): Insights from the ESOC 2018, Gothenburg, Sweden first appeared on European Stroke Organisation.</p>

<p>The post Important studies presented at ESOC 2018 first appeared on European Stroke Organisation.</p>

A preclinical study by Anfray et al., University of Caen, investigated the effects of single chain (sc) tPA versus two chain (tc) tPA. These forms are contained at variable rates in commercial tPA. Thrombolytic activity is equivalent but only sc-tPA displays excitotoxicity. However, sc-tPA was superior to tc-tPA in reducing lesion size and behavioral deficits after thromboembolic stroke in mice.

Okar et al., Hacettepe University, Ankara, reported the surprising finding of cerebral volume loss in the contralateral hemisphere of ischemic stroke patients. In a prospective study they included 31 patients with stroke in the MCA territory, which showed 1.26% monthly volume reduction in the contralateral hemisphere associated with stroke severity and inflammation.

Several studies investigated the features of thrombi from ischemic stroke patients after endovascular treatment. Di Megio et al, Inserm, Paris, analyzed 164 thrombi by immunohistology and 17 thrombi by scanning electron microscopy. They found common traits related to the composition with a red blood cell-rich core surrounded by a compact shell-like structure made of fibrin(ogen), vWF, platelets, and neutrophil extracellular traps, that could participate in thrombolysis resistance. In contrast, after studying 27 thrombi, Semerano et al., Hospital San Raffaele, Milan, Italy, reported macroscopic heterogeneity of thrombi in terms of consistence, dimensions, color and gross appearance, and the pattern of red blood cells, platelets, fibrin and vWF. Thrombi composition correlated with the density of the occluded vessel on CT scan. A large international consortium, the Curam and Mayo Clinic international acute ischemic stroke clot registry, presented results of a preliminary study with 50 patients. They found no correlation between the number of passes for clot retrieval or final TICI score with the suspected clot etiology and components. Again, they concluded that non-contrast CT may indicate histological characteristics of AIS clots.

Fani et al. reported results from the Rotterdam study where CBF was investigated in 5,289 persons (46-98y) free of stroke. Measures were associated with risk of stroke and TIA and markers of SVD, retinal vessel diameters and markers of large vessel disease. Lower total brain perfusion was associated with higher risk of stroke or TIA. However, indicators of failing autoregulation were only associated with TIA, which was suggestive of a different pathophysiology underlying TIA and stroke.

Several studies investigated atherosclerotic plaques in patients with ischemic stroke. Sharma et al., National University Hospital, Singapore, performed an imaging study with 18F-fluorodeoxyglucose PET/CT and high-resolution MRI in 85 patients within 30-days of recent stroke onset and ipsilateral carotid stenosis greater than 50%. 14% of the patients showed recurrence in the stenosed carotid territory and showed distinct imaging features predictive of recurrence. Leung et al., Chinese University, Hong Kong, studied intracranial atherosclerotic plaques in 173 patients using 3-dimensional rotational angiography. Patients with ulcerative plaques had more acute and chronic infarcts. Finally, Murphy and colleagues, Dublin, Ireland, compared blood cell counts and platelet activation and dynamics in asymptomatic versus symptomatic carotid stenosis patients (Heist study). They concluded that increased platelet counts and reticulated platelets could increase the risk of cerebrovascular disease.

<p>The post ESOC 2018 – Pathophysiology and Mechanisms first appeared on European Stroke Organisation.</p>

During the  2018 ESOC Scientific Session on  “Sex Influences and Stroke” , the first-ever “Paola De Rango Award” was  presented to George Dunn, the current  Sentinel Stroke National Audit Programme (SSNAP) Project Manager within the School Of Population Health & Environmental Sciences at King’s College London. George Dunn  was chosen over the other  highly qualified candidates, for his ongoing research contributing to a greater stroke care access for women. Through his initiative, the registry since early 2015 has collected  extensive data on sex differences   particularly related to quality improvement and equality in stroke care access.  George Dunn  reported, during his ESOC presentation, that preliminary data coming from SSNAP  suggests that women were less likely to   receive  thrombolysis therapy, have  considerably  longer door-to-needle times and  receive less physiotherapy within 72hrs from index stroke. The award  selection  committee based its decision on the overwhelming relevance, to clinical care decisions regarding priority choices, of the SSNAP results.

About George Dunn:

“George Dunn is the Sentinel Stroke National Audit Programme (SSNAP) Project Manager within the School Of Population Health & Environmental Sciences at King’s College London. SSNAP is a national stroke registry for England, Wales and Northern Ireland. He graduated from Lancaster University with a BA (Hons) degree in Politics, Philosophy and Economics. George has worked in the registry since early 2015 and has a keen interest in research, particularly related to quality improvement and equality in stroke care.

About Paola De Rango

In order to honour Paola De Rango’s (1966-2016) https://www.ejves.com/article/S1078-5884(16)00114-3/fulltext  unflagging dedication to  reaching  the highest standards of research ethics and scientific methodology to the sole  benefit of  the patient. As a  licensed vascular surgeon for more than two decades, she gained  worldwide respect and admiration for her body of research that impacted  international guidelines on  stroke prevention in patients with carotid stenosis.  Between 2007 and  2016, she lead authored more than 20 published papers on the management of carotid stenosis in women. Her dedication to this  specialization was a pioneering influence on what later would become a highly popular field of research.

<p>The post Paola De Rango Award Recognises Improving Stroke Care Access for Women first appeared on European Stroke Organisation.</p>

Media Release

Gothenburg, 18 May 2018

ESOC 2018 closes with novel research and guidelines to improve stroke care worldwide

The final day of the 4th annual European Stroke Organisation Conference (ESOC) featured new research which identified how to improve stroke care worldwide – from simple measures in low to middle income countries, through to refinement of advanced techniques for acute and preventative stroke treatments.

• Interstroke: Demonstrated large ongoing discrepancies in the availability of stroke units in low- and middle-income countries, and the significantly improved functional outcomes that are achieved where stroke units are accessible.
• Gore-REDUCE: Showed that closure of a patent foramen ovale (PFO) prevents recurrent, potentially disabling stroke.
• Phast-Trac: Showed that electrical stimulation of the throat muscles in patients with a tracheostomy after stroke improved the rate at which patients were ready for early removal of the tracheostomy and shortened the length of hospital stay.
• ESO guidelines: Provided new Europe-wide recommendations on the optimal management of acute stroke by mechanical thrombectomy, secondary prevention of stroke, treatment of unruptured aneurysms and reversal of novel anticoagulants to support physicians in the face of the recent revolution in stroke treatment options.

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INTERSTROKE: Practice patterns and outcomes after stroke across countries at different economic levels

The Interstroke study reported the pattern and effects of variations in clinical practice and access to services of 12,342 patients from 108 hospitals in 28 countries between 2007 and 2015 across a range of low-, middle- and high-income countries.

Patients in low-income and middle-income countries more frequently had severe strokes and had poorer access to clinical services. However, in all countries, access to a stroke unit and use of antiplatelet medications was associated with better access to high quality clinical care and improved survival without major disability.

The Interstroke study demonstrates that there remains a large variation in the quality of stroke care across the world, but that opportunities exist to improve clinical outcomes through the implementation of changes to the mode of delivery of stroke care.

This paper is published in the Lancet today: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30802-X.pdf

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Gore-REDUCE: Recurrent ischaemic strokes after closure of a patent foramen ovale

The Gore-REDUCE study, originally presented at ESOC 2017, demonstrated a significant reduction in all recurrent strokes in 664 patients randomised to closure of a patent foramen ovale (PFO) versus best medical treatment within 180 days of a cryptogenic stroke.

The results of the detailed assessment of recurrent ischaemic events were reported today. The majority of recurrent strokes were still cryptogenic in both the treatment arm and control patients, with a similar reduction in recurrent cryptogenic stroke rate in the treatment arm compared to best medical management. Importantly, there was a significant reduction in potentially disabling recurrent strokes in the closure arm compared to the best medical management arm (0 vs 4 strokes, p=0.004).

The Gore-REDUCE study demonstrates that not only does closure of a PFO in selected patients with cryptogenic ischaemic stroke reduce all recurrent strokes, but that there is a significant reduction in potentially disabling recurrent strokes.

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PHAST-TRAC: Pharyngeal electrical stimulation for early decannulation in tracheostomised stroke patients

In this study, 69 patients with a tracheostomy after stroke and persisting dysphagia were randomised to receive three days of electrical stimulation to the pharynx compared to a sham procedure.  The trial was stopped early for efficacy as more patients undergoing electrical stimulation were ready for early removal of the tracheostomy tube (48.6%) than patients in the control arm (8.8%), p=0.0008. Treatment responders were discharged significantly earlier than non-responders.

This study shows that for the relatively few patients requiring a tracheostomy after stroke, pharyngeal electrical stimulation shortened the time until removal of their tracheostomy.

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ESO releases guidelines to guide our management of all phases of stroke care in Europe.

In the clinical guidelines session today, ESO released the principal guidelines covering stroke care in Europe:

• Optimal treatment to prevent recurrent stroke.
• Which treatments should be used to reverse anticoagulation in patients developing an intracerebral haemorrhage.
• Mechanical thrombectomy should be made available to all appropriate patients presenting within 6 hours, regardless of age or stroke severity, and may be considered after longer delays with appropriate imaging.
• Optimal management for unruptured intracranial aneurysms.

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Issued by the ESOC 2018 public relations office

For more information or to schedule interviews, please contact a member of the team:

Dr Alastair Webb (alastair.webb@ndcn.ox.ac.uk)
Dr Mira Katan (Mira.Katan@usz.ch)
Lynnette van Heerden (LvH.ESOC2018@gmail.com)

<p>The post ESOC 2018: Media Release 18 May 2018 first appeared on European Stroke Organisation.</p>

The Thursday afternoon session “Rare Causes and Stroke“ provided a very intriguing and fascinating overview of several uncommon causes of stroke. Christian Weimar from Germany presented an interested overview on coagulopathies providing clear indication for treatment. Abi Hietaharju from Finland resumed the most important issues on the diagnosis and treatment of Primary angiitis of CNS, underlyining the importance of lumbar puncture and of cerebral other than vessel neuroimaging. Michelangelo Mancuso, from Italy, resumed the main clinical features and indication for management of mitochondrial disorders and particulalry MELAS, highlighting the importance of lactate peak in diagnosis of MELAS. Karin Klijn from Netherlands reviewed data on Moyamoya European series. For MA although surgery is recognised to reduce stroke risk, therapeutic indications are still not supported by clinical trials. Lastly, Stephanie Debette illustrated updated data on extracranial artery dissection treatment and management. rTPA was shown to be safe and anticoagulants were demonstrated to be not superior to antiaggregants and should discontinued after 6-12 months, depending of degree of artery recanalisation.

The high quality of the talks and the high rate of participation and enthusiasm of the audience made this session an highlight of this year’s ESO conference.

<p>The post ESOC 2018: Rare Causes of Stroke first appeared on European Stroke Organisation.</p>

Rustam Al-Shahi Salman, professor of neurology at the University of Edinburgh gave a talk on the uses of brain CT in identifying underlying causes of intracerebral haemorrhage. He recommended the CT-based DIAGRAM prediction score (http://jnnp.bmj.com/content/early/2018/01/17/jnnp-2017-317262) for rational use of further imaging, and proposed the CT/APOE-based Edinburgh CAA criteria (https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(18)30006-1/fulltext) as an example of how underlying cerebral small vessel diseases can be identified with simple tests. He encouraged researchers to investigate these criteria for their association with outcome in cohort studies and modification of treatment effect in randomised controlled trials.

Carlos Molina, neurologist at the University Hospital of Vall d´Hebron, Barcelona gave a talk on the spot sign of contrast extravasation in CT angiography. CTA spot sign is a strong and validated predictor of early ICH growth However, sensitivity to predict ICH growth is low, CTA is not widely available 24/7 and it may potentially delay decision making. Multiphase CTA may improve sensitivity and discriminates between arterial from venous spot signs. Other non-contrast CT markers are potentially useful, but still require further validation and standardization

Jonathan Rosand, Professor of Neurology at Harvard Medical School and Massachusetts General Hospital, discussed current and future opportunities for the application of genetic testing to improve the care of patients with intracerebral hemorrhage. He noted that while physicians traditionally consider genetic testing in young patients, or those with a strong family history, there are likely to be many opportunities where genetic testing will inform management decisions for ICH survivors in the future, such as selection of long-term blood pressure targets.

Nicolas Raposo, MD from the department of Neurology at Toulouse hospital, France gave a talk on amyloid PET in diagnosing cerebral amyloid Angiopathy (CAA), as the underlying cause of intracerebral hemorrhage (ICH). He summarized the studies investigating amyloid PET tracers in CAA patients. He discussed the diagnostic accuracy, the advantages and limitations of PET amyloid imaging in CAA patients. His take home message is that amyloid PET is a promising imaging that may help in diagnosing CAA in patients with ICH, but larger studies with standardized criteria for PET positivity and pathologically proven CAA cases are needed to assess its diagnostic value.

Candice Delcourt, Neurologist and senior research fellow at the George Institute in Sydney spoke on long-term outcome after intracerebral haemorrhage. She summarised the meta-analyses and cohort studies looking at outcome data on death, disability and quality of life. Her take-home messages were that: death rate after ICH remains high at up to 50%, recurrence of ICH and ischaemic stroke is at least 2% per year. Patients are at risk of late seizures, depression and dementia. The main predictors of bad outcome are age, ICH volume and clinical severity. Treatment of blood pressure is beneficial.

<p>The post ESOC 2018: Intracerebral Haemorrhage (II) Joint ESO – SSA Session first appeared on European Stroke Organisation.</p>

by Dr Kailash Krishnan

Given trials including DAWN and DEFUSE-3 heralding a new era in acute ischaemic stroke, the updated guideline session this morning generated huge interest. Although assessed as moderate level of evidence, experts strongly recommend mechanical thrombectomy and best medical therapy in acute ischaemic stroke patients with large artery occlusion presenting within 6 hours. The experts found no reason to exclude patients over aged 80 within 6 hours and even consider treating those presenting between 6-24 hours. It was highlighted that both interventions should be offered as soon as possible and neither should delay the other. The experts also recommended mechanical thrombectomy and best medical therapy in those patients with high ASPECTS score and absence of extensive infarct core and the quality of evidence as high. In older patients with AF after TIA or acute stroke, DOACS are recommended over warfarin and the evidence extends to those with mild to moderate renal impairment.

The much-anticipated session also included anticoagulation early screening and impact of dysphagia after stroke, and reversal of haemorrhage related to anticoagulant use and recommendations on whether to use the ‘mother-ship’ model over transferring to a primary stroke centre. Although no RCT’s exist comparing early screening and no screening after stroke, early screening is shown to reduce mortality, pneumonia and length of stay and therefore strongly recommended. No recommendation is made when to start anticoagulation, small vessel disease and after intracerebral haemorrhage and ongoing trials will hopefully provide answers. We heard latest evidence that the use of DOAC’s is increasing and in ICH related to their use, neither PCC or FFP was favoured but in anticoagulation related to warfarin, vitamin K in addition to PCC is recommended. Idarucizimab is recommended in ICH from dabigatran and the quality of evidence to use Andexanat alpha in bleeding from apixaban or rivoroxaban was assessed to be low. The panel found no evidence to support the use of r-VIIa or tranexamic acid in ICH related to anticoagulation.

The session identified an unmet need in managing patients with unruptured intracranial aneurysms. The prevelance was reported to affect about15 million patients in the EU and it is anticipated that about 50,000 will suffer a subarachnoid haemorrhage. Whether endovascular closure compared to none, lifestyle modification or medications might help are pressing questions of future research and more trials in this area are warranted. All the new guidelines will be published in the European Stroke Journal!

<p>The post ESOC 2018: ESO Guidelines Session 2018 first appeared on European Stroke Organisation.</p>

This session covered a number of topics in stroke imaging that ranged from carotid/aortic imaging, young stroke recurrence, CTP thresholds, perviousness and  computerized interpretation using artificial intelligence/machine learning algorithms.

Several presentations highlighted potential novel imaging risk markers.

Carotid plaque inflammation imaged with FDG-PET (Camps-Renom) showed an association with early stroke recurrence. However, most patients with recurrence in the study had carotid stenosis >50%, leaving uncertainty as to how the carotid inflammation finding could help with risk stratification and treatment.

Proximal aortic arch stiffness on 4D flow MRI (Wehrum) was associated with large (>4mm) aortic plaques. Aortic stiffness was also more common in stroke patients compared to controls. Small cortical DWI lesions were found in 1.8% of young stroke cases at MRI follow-up many years after stroke, and this was also associated with markers of cerebral small vessel disease, suggesting alternative potential mechanisms for cerebral SVD (van Dongen).

High signal lesions on MR “black blood” imaging of carotid arteries had significant less short-term residual stenosis despite no post-stent balloon dilatation during the initial procedure (Tanno). This could imply absorption of plaque haemorrhage with time, lessening the degree of stenosis.

Several studies described the performance of software based on artificial intelligence paradigms, concluding prognostic value from automated ASPECTS in a selected group of ENCHANTED cases (Nagel), good agreement with expert detection of large artery occlusion (Barreira) or collateral scoring (Pfaff). Some future role for radiologists might remain amidst all of the automation, at least as beta testers for software.

Andrew Bivard presented a case-control study that sought to critically evaluate the current CBF threshold for ischaemic core prediction in the context of much more rapid and reliable reperfusion with endovascular therapy, concluding that a threshold of CBF <20% of contralateral optimally predicted irreversible injury (with AUC 0.89 compared to 24h DWI) when reperfused rapidly with endovascular treatment, compared to  the 30% threshold derived from intravenous thrombolysis studies.

Manon Kappelhof used pooled HERMES data to investigate thrombus perviousness, concluding that higher perviousness of the occlusive thrombus (measured as thrombus attenuation increase, TAI, on co-registered CTA compared to non-contrast CT) was linked to favourable outcome with intravenous thrombolysis , but not with endovascular treatment. The parameter may identify non-responders to IV therapy. Further evaluation combining perviousness measurements with other indices such as clot length will clarify its future role.

<p>The post ESOC 2018: Imaging first appeared on European Stroke Organisation.</p>