Welcome to the WSC 2022 Interactive Program

Background and Aims

When a patient who complains of persistent severe headache of abrupt onset comes to the hospital, we, neurologists, usually focus on intracranial pathology as well as a primary headache. However we can overlook or miss other systemic causes of headache.

Methods

A 53-year-old man was hospitalized due to severe headache occurred abruptly three days before presentation. Headache persisted. The patient denied a recent history of infection and had not received any recent vaccination. He only had a medical history of diabetes mellitus. Neurological examination did not show any specific findings. Serum exams were normal, as well as liver and renal function tests. To rule out intracranial lesions, brain MRI and angiography were performed, MR Venography was performed subsequently to rule out Cerebral venous sinus thrombosis. No specific findings were found in these examinations. CSF study was unremarkable. Severe headache persisted with excessive sweating was seen.

Results

In computed tomography (Figure1. (A), (B)), about 4cm diameter left adrenal gland mass was detected. A MIBG scan (Figure 1. (C)) was performed, increased uptakes at the left adrenal mass. The patient started taking alpha-blocker under the diagnosis of pheochromocytoma. After surgical removal of pheochromocytoma, he returned to normal with his symptoms subsided.

Conclusions

A triad symptom of paroxysmal headache, excessive sweating, and heart palpitations raise suspicion of a pheochromocytoma. As above, not only neurological problems but other causes can cause headache as the only symptom. Therefore, if symptoms persist or get worse, further evaluation should be required to find out other systemic causes that can cause severe headaches.

Background and Aims

NeuroAiD (MLC601 and MLC 901) is a combination of natural products shown to have neuroprotective and neuroproliferative properties which were elucidated in various preclinical and clinical studies. NeuroAID Safe Treatment Registry (NeST) aims to assess the use and safety of NeuroAiD in real world settings.

Methods

Patients taking or prescribed NeuroAiD and have agreed to participate were included in the study. Clinical data were prospectively entered through an online system and collected at baseline and month 1 to 3. Outcome measures included National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), modified Rankin Scale (mRS) and Short Orientation Memory-Concentration Test (SOMCT). Primary Outcome included safety through the reporting of adverse events, while compliance and neurological status are the secondary outcome measures.

Results

A total of 735 patients were enrolled. Mean age was 58.9±15.4yr,58% were male. Comorbidities included hypertension (70 %), diabetes (23%), hyperlipidaemia (33%), cardiac disease (16%), and smoking (13%). Stroke accounts for 69%, intracerebral haemorrhage 15%, traumatic brain injury 7.6%. 60 -80 % were compliant. At month 3, the mean NIHSS is 5 (± 5.47), the mean mRS 1.9 ±1.5 with greater proportions of patient achieving improvement in mean score from baseline. The SOMCT however, showed decline from baseline to month 3.

Conclusions

Real world data showed MLC601/MLC901 is safe and has therapeutic potential, with good compliance.

Background and Aims

Recurrent stroke remains high and is associated with an increased risk of death. While there are a variety of community rehabilitation services, facilities, and volunteer support, the health-seeking behaviours of stroke survivors have a strong influence on their knowledge and use of such services. This study was conducted to explore the health-seeking behaviours and attitudes of Chinese stroke survivors.

Methods

Fifty stroke survivors were recruited for the study through convenience sampling and individual semi-structured interviews were conducted. Participants were asked about their health conditions post-stroke, rehabilitation and healthcare services used, and desired community health services. Interviews were audio-recorded and transcribed verbatim. Thematic analysis of the resulting data was carried out according to the method by Braun and Clarke (2006).

Results

Participants modified harmful habits such as smoking and drinking, and paid more attention to their diet in order to protect their health. However, they were less proactive with regard to using community health services. This was driven by a combination of factors including low awareness, accessibility issues, and attitudes such as the acceptance of their health circumstances as an inevitable result of old age. Participants were likely to be more active in taking action if encouraged by a comprehensive social support network.

Conclusions

In general, the health-seeking behaviours of stroke survivors were restricted to actions which were directly under their control, such as the cessation of harmful habits and diet modifications. Behaviours linked to seeking healthcare services were limited by poor knowledge, accessibility, and personal attitudes about health.

Background and Aims

Patients with structural cardiac abnormalities had considerable delays in the contrast bolus reaching and transiting the brain vessels on computed tomography perfusion (CTP). We hypothesized that impaired left ventricular ejection fraction (LVEF) resulted in ischemic core overestimation.

Methods

Patients with large vessel occlusion in anterior circulation presenting within 16 hours after ischemic symptom onset who received initial CTP evaluation and achieved successful reperfusion were retrospectively analyzed. To determine the cardiac function, LVEF was dichotomized as either normal (≥50%) or decreased (<50%). Admission infarct core was considered as tissue with a relative reduction of cerebral blood flow <30%, as compared with contralateral hemisphere. Final infarct volume was measured on 24 to 48 hours non-contrast CT. Ischemic core overestimation was considered when CTP-derived core was larger than final infarct.

Results

133 patients were included into the analysis. Median CTP-derived core and final infarct volume were 16 mL (interquartile range, 8-33) and 24 mL (interquartile range, 16-43), respectively. Thirty-four patients (25.6%) presented ischemic core overestimation (median overestimation, 8 mL, interquartile range, 5-13). Multivariable logistic regression analysis showed that decreased LVEF (odds ratio, 7.48; 95% CI, 2.10-26.6, P=0.006) and earlier onset to imaging time (per 30 minutes earlier, odds ratio, 1.13; 95% CI, 1.02-1.24, P=0.012) were independently associated with core overestimation. A multivariable predictive model including all significant parameters yielded the highest diagnostic ability with an area under the curve of 0.81 (sensitivity 82.4%, specificity 71.7%).

Conclusions

Impaired left ventricular function induced higher rates of ischemic core overestimation on CTP, especially in patients in earlier window time.

Background and Aims

Anticoagulation is underutilized in older AF patients. We aimed to examine the long-term effectiveness of switching appropriate older AF patients to anticoagulation in a real-world setting.

Methods

We conducted a multi-centered, prospective, single arm, interventional study from 5/2016 to 4/2019, recruiting 1002 older Chinese patients with non-valvular AF (NVAF) from specialist geriatrics and cardiology outpatient clinics from 6 hospitals in Hong Kong. Patients who were taking no antithrombotics or only antiplatelet (AP) agents at baseline were considered for switching to anticoagulation (AC). Outcomes included mortality, stroke or death, major adverse cardiovascular events (MACE), and major bleeding at 1-year.

Results

Of 1002 patients at baseline (mean age 84±7 years, 60% female, mean CHA₂DS₂-VASc 5.1, mean HAS-BLED 2.3), 530 (53%) were already taking AC (34% DOAC and 18% VKA). Of 472 patients who were not on AC (36% AP only and 11% none), 136 (29%) were switched to AC (93% DOAC, 7% VKA). Switching to AC was predicted by younger age, no prior ischaemic or haemorrhagic stroke, higher haemoglobin and renal function, fewer co-morbidities, and lower CHA₂DS₂-VASc. Compared to patients who were never on AC, those who were switched to AC had lower mortality (p<0.001), stroke or death (p<0.001), MACE (p<0.001), and non-significant trend of lower major bleeding (p=0.118), with results similar to those who were on AC from baseline. Switching to AC remained an independent predictor of mortality after adjusting for casemix.

Conclusions

From our real-world data, switching older NVAF patients to anticoagulation in the outpatient setting is feasible and associated with improved clinical outcomes at 1-year.

Background and Aims

Post-stroke cognitive screening is widely recommended, yet few studies have investigated the predictive value of domain-specific function for longer-term cognitive outcome. This study sought to determine the prevalence of domain-specific cognitive impairment acutely and at 6 months, assess change in cognitive performance, and examine the predictive value of acute domain-specific screening.

Methods

A prospective cohort of 430 stroke survivors was assessed using the Oxford Cognitive Screen acutely (<2 weeks) and 6 months post-stroke. Cognitive impairment was defined as impairment in ≥1 domain, characterized by a deficit in ≥1 domain subtask relative to normative data. Demographic/clinical candidate predictor variables were collected acutely. Hierarchical regression analyses were performed to predict overall and domain-specific impairment at 6 months.

Results

Cognitive impairment in ≥1 domain was found in 423 (98%) patients acutely and 293 (68%) at 6 months. Attention and language impairments were most prevalent at both timepoints. Prevalence of impairment decreased across all domains from acute to 6 months. Proportion of recovery was highest in praxis and number processing, while impairments in language and memory were most persistent. Impairment at 6 months was best predicted by the addition of acute cognitive impairment (adjusted R²=0.298, p<0.0001) over conventional risk factors alone (adjusted R²=0.085, p<0.0001). Acute cognitive function (β=0.414, p<0.0001) was the strongest predictor of 6-month cognitive performance.

Conclusions

Cognitive impairment is highly prevalent following stroke in language, attention, memory, executive function, number processing and praxis, with varying trends towards recovery, stability and decline at 6 months. Overall and domain-specific cognition significantly contribute to predicting longer-term cognitive performance.

Background and Aims

Large-scale genomic study on ischemic stroke (IS) patients is crucial for driving and generalizing precise medical prevention and treatment. Compared to the previous array-based studies, whole genome sequencing (WGS) provides essential knowledge for individual and rare variants. Here, we present the STROMICS Phase I genome study by analysis of 10241 deeply sequenced IS patients from the Third China National Stroke Registry.

Methods

Each patient was sequenced to ~40x coverage. After quality control and variation calling, genomic characteristics were explored by analyzing the allele frequencies and comparison with other biobanks. Population structure was evaluated by PCA and ADMIXTURE. Loci involved in adaptive evolution were identified by EigenGWAS. Genetic association and mendelian risk burden were analyzed.

Results

135,589,210 biallelic variants were identified, including 125,769,898 SNVs and 9,819,312 Indels. Most variants (96.18%) have allele-frequency ≤5%, and STROMICS provides 57,125,553 novel variants. A finer scale population structure was obtained for the inclusion of the low-frequency variants, and the first two principles components reflect latitude (r=0.74) and longitude (r=0.42), respectively. 18 gene loci demonstrate allele frequency adaptation across the latitude including the MTHFR-C677T polymorphism that alters folic acid and homocysteine level. Common and rare variant association study unravel 10 novel loci and 6 functional variants contributing to 6 stroke-related traits. Pathogenicity analysis on NOTCH3 loss-of-function and cysteine-altering variants explicit a broad neuro-imaging spectrum.

Conclusions

Our study establishes a large-scale and deep genomic resource of IS patients from East Asia. The findings provide opportunities for novel genetic discoveries and potential therapeutic targets of IS.

Background and Aims

High blood pressure is common in stroke and is associated independently with increased recurrence and dependency or late death. Nitric oxide (NO) donors such as glyceryl trinitrate (GTN) are candidate treatments for acute stroke. Whether GTN improves outcome through reducing expansion and recurrence, or worsens it through reducing cerebral blood flow remains unclear.

We aim to assess the feasibility of recruitment and safety GTN against sham to inform the design of a definitive trial for a period of 24 months.

Methods

120 adult stroke patients (100 ischaemic stroke, 20 intracerebral Haemorrhage), with systolic BP >120mmHg and compatible CT/MR scans, will be recruited within 3-5 hours of onset. Exclusion criteria include; seizure, mRS≥4, glucose <3mmol/l, GCS<8, known stroke mimic, life expectancy <6months, known sensitivity to Duoderm and contraindications to GTN.

Patients will be randomised (1:1) to receive 5mg GTN or matching comparator Duoderm patch placed on back or shoulders applied for 2 days. Patients, relatives, researchers and outcome assessors will be masked to treatment allocation.

Results

Feasibility outcomes include recruitment of 100 is patients and 20 ICH patients, rate of recruitment, proportion of patients approached being randomised, adherence to treatment and follow up. Secondary outcomes include BP, heart rate over the 1^st 2 days, discharge destination, disability, cognition, mood, quality of life up to day 90, serious adverse events up to day 2 and fatal SAE up to day 90, death.

Conclusions

This study is funded by NUH Charity, grant code CRF-BATH-NOV 2019 (fund number Q7010).

Background and Aims

Acute internal carotid artery (ICA) stenosis/occlusion with tandem occlusion of middle cerebral artery (MCA) hampers distal access for mechanical thrombectomy (MT) demanding controversial decision for simultaneous ICA stenting. The purpose of this paper is to evaluate the safety of emergency ICA stenting in combination with MT for acute ischemic stroke with tandem occlusions.

Methods

Retrospective analysis of 5 patients in whom emergency ICA stenting with MT was done from October 2021 to March 2022. All the patients with acute ischemic stroke (AIS) within 24hours of last seen well were included. CT angiogram was done in all the patients. IV thrombolysis was done in 2 patients. Dual anti-platelets were given in all the patients.

Results

Successful revascularization (Thrombolysis in cerebral infarction scale [TICI] ≥2c) was achieved in 5(100%). Good outcome at discharge (mRS ≤2) was achieved in all 5(100%) patients. None of the patients had symptomatic intracranial hemorrhage (sICH). Asymptomatic hemorrhage was noted in the infarcted area in one patient. Four out of five patients (80%) were treated with MT first followed by ICA stenting. Balloon angioplasty was attempted in all the patients. Four patients had >90% ICA stenosis and one had complete occlusion.

Conclusions

Emergency carotid stenting appears to be safe in patients with hemodynamically significant stenosis/complete occlusion especially if it hampers the process of concomitant distal MT.

Background and Aims

Intra-arterial thrombolysis with r-TPA is advised as per guidelines, however Intra-arterial Tenectaplase is still not utilised. This case report helps us to understand the utility of intra-arterial Tenectaplase in acute ischemic stroke due to large vessel occlusion.

Methods

A 63 Year old male presented to ER with acute onset right hemiplegia and aphasia of two hour onset. NIHSS was 12. His MRI brain showed left MCA territory infarct with Left MCA total occlusion. Patient was administered Inj Tenectaplase 16 mg IV bolus and taken up for Mechanical Thrombectomy. His initial cerebral DSA showed the left MCA was still occluded and there was 80% stenosis of left supraclinoid ICA. When the guiding catheter was advanced upto left ICA, subsequent left ICA angiography showed that left MCA had partially recanalised with residual thrombus and Right ACA was filling adequately. There was a financial constraint to perform mechanical thrombectomy hence a decision to perform Intra-arterial thrombolysis was taken.

Results

Microcatheter was advanced close to left MCA residual thrombus and 2 mg Tenectaplase was administered intra-arterial via microcatheter. Subsequent Left ICA angiography showed complete TICI3 recanalisation of left MCA, however Left ACA did not opacify. Hence Right ICA angiography was done which showed that Left ACA fills via Acomm artery.

Conclusions

EXTEND IA TNK trial has shown that Intravenous thrombolysis with tenectaplase results in 22% chance of recanalisation in large vessel occlusion. If Intra-arterial Tenectaplase can result in complete recanalistion in LVOs then it can be utilsed in resource limited settings where mechanical thrombectomy can be avoided.

Background and Aims

Due to the development of endovascular devices and clinical experience, the recanalization rate after intraarterial thrombectomy (IA-Tx) has increased. However, in some patients, recanalization is not always beneficial for clinical outcomes. The purpose of this study is to determine which method, CT- or MR-based P/D-mismatch image evaluation, results in better clinical outcomes.

Methods

This study analyzed 143 patients with anterior circulation large vessel occlusion (LVO) treated by IA-Tx. In the MRI group (n = 80), an image was obtained after IV-tPA before the IA-Tx; in the CTP group (n = 63), a CTP image collected as an initial study was analyzed. In the CTP group, the authors analyzed P/D-mismatching both in visual analysis and in digitalized programed analysis (Syngo.via program). The neurologic outcomes were compared according to the presence of mismatch by image analysis method.

Results

Favorable outcome (mRS: 0~2), mortality, recanalization, and clinically significant hemorrhage rates were 56.3% (45/80), 6.25% (5/80), 81.3% (65/80), and 25% (20/80) in the MRI group, respectively; and 38.1% (24/63), 4.8% (3/63), 96.8% (61/63), and 47.6% (30/63) in the CTP group (p = 0.023, 0.498, 0.003, and 0.004). Compared to CTP analysis, digitized analysis showed more favorable outcome in the P/D-mismatch group (p=0.000) than in the visual mismatch group (p=0.237).

Conclusions

Recent papers reported that digitized CTP image analysis is as good as MR-based P/D-mismatch image analysis for patient selection in additional IA-Tx. However, in our study, P/D-mismatch from an MR image was better than CTP-based patient selection for those requiring additional IA-Tx to improve clinical outcomes.

Background and Aims

Hyponatremia is the most common electrolyte disorder in patients with intracerebral hemorrhage (ICH) and a risk factor for in-hospital mortality. Falls are common in the first month after a stroke, causing damage, decreased activity, dependency, and fear of harm. This study aims to determine the relationship between hyponatremia and the risk of falling as assessed by the Morse Fall Scale (MFS) in ICH patients.

Methods

This cross-sectional study enrolled all moderate-grade ICH patients between September and November 2021. Patients' MFS scores and electrolyte parameters, as well as baseline characteristic data, were collected. The Spearman rank was used to assess the variables' relationship to the MFS score. SPSS 22 was used to analyze the data. The local ethics committee approved the study.

Results

The rate of hyponatremia was 68.9% among the 45 patients who met the criteria (mean age of 55.44 [±15.75], male [32; 71.1%], subcortical hemorrhage location [28; 62.2%]. The mean MFS score of the hyponatremia and non-hyponatremia groups was 60.65 (±13.58) and 52.14 (±8.48), respectively. The analysis showed that hyponatremia (r=0,306, p=0,041), and body weight (r=-0,368, p=0,013) were correlated with MFS score. Hyponatremia severity was also correlated with MFS Score (r=0.304, p=0.042).

Conclusions

Our investigation revealed that hyponatremia, alongside its severity, was correlated positively with greater fall risk as assessed by MFS in ICH patients in our population. It is considered that the greater risk of falling is attributed to various mechanisms involving gait disturbance and cognitive impairment in a such population.