Welcome to the WSC 2022 Interactive Program

Background and Aims

Mortality following major stroke due to large vessel occlusion (LVO) is high, even after receiving mechanical thrombectomy (MT). Predictors of mortality following MT are available, yet, often do not distinguish between inhouse fatality and lethal outcome after hospital discharge. We aim to identify factors associated with post-discharge lethal outcome within 90 days after MT.

Methods

Of 6635 patients enrolled in the German Stroke Registry Endovascular Treatment from June 2015 to December 2019, data of 4349 patients who survived acute LVO care and were discharged from treating hospital were compared by survival status at day 90 follow-up. Univariate analyses, multiple logistic regression and AUC-analyses were performed to identify predictors of lethal outcome.

Results

We report 13.6% (n=581, median age: 82.0 years, 54.0% female) of discharge survivors with lethal outcome at 90 day follow-up. Multiple regression modelling resulted in high discriminative ability (AUC=0.852, 95%CI:0.837-0.865, p<0.001) with sensitivity/specificity of 79.4%/77.5% for prediction of lethal outcome by optimal criterion value. Significant independent predictors of post-discharge lethal outcome with adjusted odds ratios are displayed in Figure 1. In univariate analysis, strongest predictors of post-discharge lethal outcome were older age (AUC=0.743, 95%CI:0.725-0.760, sensitivity/specificity 67.6%/67.7% for age>78 years) and higher discharge mRS (AUC=0.789, 95%CI:0.772-0.805, sensitivity/specificity 84.2%/61.4% for mRS>3).

Conclusions

Multiple regression modelling predicted lethal outcome after hospital discharge within 3 months after MT with high accuracy. Predictors of stroke-associated mortality following discharge from hospital may serve patients, families and healthcare professionals with regard to risk assessment for post-discharge complications or an advance-care planning process evaluating goals of future care.

Background and Aims

Psychoeducational intervention is a common approach for improving stroke survivors’ and their families’ health outcomes. However, little attention or effort has been paid to a dyadic (stroke survivor-family caregiver) approach to psychoeducation targeting at both of them as active participants. This study aimed to test the effects of such a family-focused dyadic psychoeducational intervention (FDPEI) for stroke survivors’ and family caregivers’ psychosocial and functional health outcomes.

Methods

This randomised controlled trial was conducted from March to June 2021 in two general hospitals and one rehabilitation hospital in China. Totally, 162 family dyads were recruited and randomly assigned to either the FDPEI or control group using block randomisation (four per block). The intervention group received 3-session face-to-face education in hospital and four weekly post-discharge telephone counselling. The control group received the usual care only. The study outcomes were measured at baseline, immediately, and 3-month post-intervention.

Results

The GEE models revealed significant effects of FDPEI on caregivers’ burden and caregiving competence, and survivors’ depressive symptoms and dyadic relationship at immediate and 3-month post-intervention. A significant effect was also indicated on survivors’ coping ability at 3-month post-intervention. Otherwise, the effects on other outcomes, including survivors’ functioning, and caregivers’ depressive symptoms and coping ability, and dyads’ family functioning, favoured the FDPEI, but were not significant.

Conclusions

The findings support that the FDPEI benefits both stroke survivors’ and their family caregivers’ psychosocial well-being over 3 months follow-up. Further research on the FDPEI with families from diverse sociodemographic characteristics and stroke conditions and a longer-term follow-up is recommended.

Background and Aims

Research on stroke rehabilitation often addresses either gait, balance, upper limb function or physical activity, a fragmentation that contrasts the complexity encountered in clinical practice. New interventions should aim to enhance recovery. The purpose of this study was to investigate the effects of a comprehensive low-cost physiotherapy intervention, I-CoreDIST, versus usual care on postural control, balance, physical activity and gait during the first 12 weeks post-stroke.

Methods

This prospective, assessor-masked randomized controlled trial included 60 participants from two stroke units in Norway. Participants were randomized to I-CoreDIST (n=29) or usual care (n=31) physiotherapy, received 5 sessions/week when in-patient or 3 sessions/week as out-patients. Baseline and 12-week assessments included: Primary outcomes; Trunk Impairment Scale-Norwegian version and activity monitoring (ActiGraphsWgt3X-BT). Secondary outcomes; Postural Assessment Scale for Stroke-Norwegian version, MiniBesTEST, 10-meter walk test, 2-minute walk test and force-platform measurements. Linear regression and non-parametric tests were used for statistical analysis.

Results

Five participants were excluded, seven were lost to follow-up, leaving 48 participants in the intention-to treat-analysis. There were no significant between-group effects for primary outcomes at 12 weeks: Trunk Impairment Scale-Norwegian version p=0,857; daily average minutes of sedative, p=0.662, light p=0.544, moderate activity p= 0.239 and steps p=0.288. There were no significant between-group effects on secondary outcomes. Within-group changes were significant for all outcome measures in both groups except for activity levels that were generally low and force-platform data favoring the intervention group only.

Conclusions

Physiotherapy treatment with I-CoreDIST improved postural control, balance, physical activity and gait during the first 12 weeks after a stroke but is not superior to usual care.

Background and Aims

Previous studies have suggested seasonal variation in ischemic stroke subtype. Several research indicated that cardioembolic stroke occurred more frequently during winter. However, exact cause of such seasonal variation in ischemic stroke is unknown so far. In this study, we investigated seasonal variation in ischemic stroke subtype focused on its association with the blood pressure at admission.

Methods

From a multicenter nationwide stroke registry, we identified patients with ischemic stroke older than 18 years old and were admitted to one of 16 hospitals during 2009-2020. Patients’ characteristics were compared by admitting season. Ischemic stroke was classified as large-artery atherosclerosis (LAA), small-vessel occlusion (SVO), cardioembolism (CE), or undetermined etiology (UDE)/other determined etiology (ODE) using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification with slight modification.

Results

Of 72,301 stroke patients who met the eligibility criteria, 25.6% of them admitted in summer, followed by fall (25.1%), spring (25.0%), and winter (24.4%). Seasonal variation in ischemic stroke subtype was significant and LAA is most frequent during summer while CE was most frequent during winter (P<0.001). Seasonal variation in blood pressure was also significant (for systolic blood pressure, 145.7±26.9 mmHg (summer) vs. 148.7±28.0mmHg(winter), P <0.001).

Conclusions

In Korea, LAA subtype of ischemic stroke was most frequent during summer when the blood pressure at admission was lowest while cardioembolic stroke was most common during winter when the blood pressure at admission was highest. Keeping blood pressure constant regardless of ambient temperature may help prevent ischemic stroke regardless of mechanism of ischemic stroke.

Background and Aims

More than half of patients with embolic stroke of undetermined source (ESUS) suffer from recurrent ischemic strokes despite absence of atrial fibrillation (AF) on invasive cardiac monitoring (ICM). We investigated the predictors and prognosis of recurrent stroke in ESUS without AF on ICM.

Methods

This prospective study included patients with ESUS at 2 tertiary hospitals from 2015 to 2021 who underwent comprehensive neurological imaging, transthoracic echocardiography and inpatient continuous electrographic monitoring for ≥48-hours prior to ICM for definitive exclusion of AF. Recurrent ischemic stroke, all-cause mortality, and functional outcome by the modified Rankin scale (mRS) at 3-months were evaluated in patients without AF.

Results

Of 185 consecutive patients with ESUS, AF was not detected in 163 (88%) (age 62±12years, 76% men, 25% prior stroke, median time to ICM insertion 26[7-123]days), and stroke recurred in 24 (15%) patients. Stroke recurrences were predominantly ESUS (88%), within the first 2-years (75%) and involved a different vascular territory from qualifying ESUS (58%). Pre-existing cancer was the only independent predictor of recurrent stroke (adjusted hazard ratio[AHR] 4.86, 95% confidence interval[CI] 1.20-19.32), recurrent ESUS (AHR 4.82, 95%CI 1.20-19.32) and higher mRS-score at 3-months (ß 1.27, 95%CI 0.23-2.42). All-cause mortality occurred in 17 (10%) patients. Adjusting for age, cancer and mRS-category (≥3 vs <3), recurrent ESUS was independently associated with >4-times higher hazard of death (AHR 4.66, 95%CI 1.76-12.34).

Conclusions

Patients with recurrent ESUS are a high-risk subgroup. Studies elucidating optimal diagnostic and treatment strategies in non-AF related ESUS are urgently required.

Background and Aims

Research on prevalence and early prediction of post-stroke fatigue several years after stroke is limited. Our aims were to describe the prevalence of, and to identify baseline predictors that are associated with, post-stroke fatigue five years after stroke.

Methods

This is a follow-up of stroke survivors from the 504 consecutively included participants in the observational “The Fall Study of Gothenburg”, conducted between 2014-16. The dependent variable, fatigue, was assessed using the Swedish version of the Fatigue Assessment Scale (S-FAS) and defined as having a S-FAS score ≥24. Potential participants were sent a postal invitation with the S-FAS together with a pre-stamped reply envelope. The independent variables collected previously from medical records included age; sex; comorbidities; stroke severity; hospital length of stay; body mass index; number of medications and lifestyle factors at index stroke. To identify predictors of post-stroke fatigue, univariable and multivariable logistic regression analyses were performed.

Results

Of the 305 eligible participants, 119 (39%) responded. Mean age at index stroke was 70.5 (SD 10.4) years and 41.2% were female. At a median timepoint of 4.9 years after stroke, the prevalence of fatigue was 52.1%. Higher body mass index was a predictor of post-stroke fatigue with an odds ratio of 1.25 (95% CI: 1.11-1.41, p<0.01).

Conclusions

More than every other participant reported post-stroke fatigue five years after index stroke. Higher body mass index was the only predictor. The findings from this study are important for healthcare practitioners, for planning health-related efforts and rehabilitation of stroke survivors.

Background and Aims

The study aims to assess added advantage of kinematic over clinical measures for predicting post-stroke Upper Extremity (UE) recovery by developing a regression model comprising of both. Meticulously formulated prognostic models could be used by specialists for improving prediction accuracy of motor recovery in stroke survivors.

Methods

This study included 89 acute to early sub-acute stroke survivors (58.9 ± 11.8; 62 males: 27 females). Baseline characteristics, demographics, grip and pinch strength were measured within 7 days and 3D kinematic analysis of a simulated drinking task was performed within 1-month post-stroke. The Fugl Meyer assessment-upper extremity (FM-UE) was assessed at 3-months. Kinematic variables such as time, displacement, velocity, shoulder and elbow angles and reaction time were determined.

Results

A moderate-to-strong correlation was found between FM-UE scores at three months with shoulder abduction finger extension (r=0.84), Nottingham sensory assessment (r=0.84), motricity index (r=0.82), national institutes of health stroke scale (r=0.75), pinch strength (r=0.69) and grip strength (r=0.62) measured within 7 days post-stroke. We found a weak correlation between FM-UE scores at three months with velocity (r=0.53), time (r= -0.43) and displacement (r=0.38). However, on combining clinical and kinematic variables, the linear regression model was found to have an R² value of 0.85. The model was validated using the Leave-One-Out Cross Validation method.

Conclusions

This model would help us predict UE motor impairment at 3 months post-stroke for 85% stroke survivors with similar characteristics. Therefore, kinematic variables could be used as an adjunct to clinical variables in order to comprehensively predict UE motor recovery in stroke survivors.

Background and Aims

Ayurveda, a traditional Indian medical system, has been shown to aid in the rehabilitation of stroke patients. The project focuses on gathering evidence-based data in order to develop a standardized rehabilitation program involving two different systems of (modern medicine and ayurveda) that will help a larger population of patients, which may help to build a cross-referral practice to support an integrative treatment strategy. The trial was initiated under the INSTRuCT Network and funded by ICMR, New Delhi.

To summarize the trial implementation challenges that were encountered, as well as the process through which solutions were identified and executed during the RESTORE study's early stages.

Methods

The difficulties encountered during study implementation are classified into six major categories: 1) Protocol standardization involving two distinct treatment streams, 2) Set-up of ayurveda treatment facility, 3) Challenges in ayurveda medicine standardization and its logistics, 4) Ethical issues with regard to the ayurveda treatment, 5) Issues pertaining to participant trial insurance, and 6) Site-specific concerns.

Results

Possible implications of identified problems and solutions developed to manage these problems are discussed within the context of these six areas. We explain how these implementation lessons can be extended and applied to the trials which involve two different systems of medicine.

Conclusions

Despite the fact that the study involves two different medical systems, timely problem identification and early planning have greatly helped in the successful implementation of this trial. We believe that our research will serve as an eye-opener, proving that studies involving two different medical systems can be implemented effectively.

Background and Aims

The increase burden of stroke and dementia provides strong evidence that currently used primary prevention strategies are not enough and 80% of strokes occur in people with low to moderate risk. The purpose is to test whether a polypill used alone or in combination with lifestyle modification will reduce the incidence of stroke and cognitive impairment in a population of individuals with low to moderate risk of stroke.

Methods

Randomized Clinical Trial, prospective, placebo controlled of 12,268 subjects followed by 3 years. 60 Health Units will be randomized (clusters) to use or not the approach of community health workers with the Stroke Riskometer. After a run-in phase (30 days, all participants with active drug), patients will be randomized to receive the polypill (valsartan 80 mg, anlodipina 5 mg e rosuvastatina 10 mg) or placebo (dose adjustment of amlodipine 2,5 for patients with adverse events). It will be included: (1)adults aged 50-75 years; (2) no previous history of stroke, TIA or cardiovascular disease; (3)systolic blood pressure (BP) 121-139 mmHg; (4) one or more lifestyle risk factors (smoking, overweight, physical inactivity or inadequate diet. It will be excluded patients with hypercholesterolemia or diabetes or take other antihypertensive drugs or open label statins. Subjects will be randomized under a minimization process using age, sex, BP, education level, total cholesterol.

Results

28 patients were included in the study in this ongoing trial. We will describe the steps for implementation of the trial and the challenges.

Conclusions

We expect to change the public prevention policies in primary care.

Background and Aims

When treating patients with acute stroke, physicians will make complex decisions within defined time constraints. Clinicians are concerned about the risk of cerebral hemorrhage, which is the most critical factor that may require discontinuation of antiplatelet therapy. We aims to investigate the most important factors affecting physician decision-making regarding antiplatelet therapy.

Methods

We retrospectively gathered patients of minor ischemic stroke from 2010 to 2018. The population was divided into four groups: aspirin monotherapy (AM), dual antiplatelet therapy with aspirin and load-clopidogrel (clopidogrel loading dose of 300 mg on the first day, DAPT-ALC), dual antiplatelet therapy with aspirin and unload-clopidogrel (clopidogrel 75 mg daily with no loading dose, DAPT-AUC), and clopidogrel monotherapy (CM).

Results

The mean age was higher in patients receiving dual antiplatelet therapy than mono therapy(63.7%-65.7% vs. 59.6%-61.4%). The initial systolic blood pressure level was higher in the DAPT-ALC group than the other groups (all P < 0.05). Compared with AM, patients who age under 75 years old, initial SBP level lower than 180 mmHg, a history of AM, CHD, no history of ICH, onset year after guideline recommendations were updated, onset to arrival time within 24 hours, initial NIHSS score ≤ 3 have a higher chance to accept DAPT-ALC. Compared with DAPT-ALC, the choice of DAPT-AUC was associated with an initial SBP lower than 180 mmHg, smoking, hypertension, no history of ICH, previous antihypertensives and onset year after recommendations were updated.

Conclusions

Many factors affect the decision-making of doctors regarding antiplatelet therapy, especially guidelines, age, admission SBP level, and hypertensive disease.

Background and Aims

The National Institutes of Health Stroke Scale (NIHSS) is a widely used tool to evaluate the acuity and severity of a stroke, give a quantitative measure to aid treatment, and track the progress of recovery. The NIHSS requires the ability to read English and assumes familiarity of Western objects, thus making over 80% of the world’s population is unable to utilize it without adaptation into other languages. This systematic review examines the current state of validation of the NIHSS in other languages.

Methods

We performed a systematic review of published literature of translated, validated, and adapted NIH stroke scales. Using the PubMed and Scopus search engines, our search strategy resulted in 169 papers. After exclusion of non-related literature, 13 papers were included in our study.

Results

13 studies validated the NIHSS in their respective languages: German, Chinese, Spanish, Portuguese, Italian, Thai, Hindi, Korean, Arabic, Latvian, Malay, Persian, and Polish. All studies found that their adapted NIHSS has a strong inter-rater agreement. Eleven studies used the intra-class correlation coefficient for statistical analysis with results ranging from 0.738 to 0.99, one used Cronbach's alpha (0.81), and one used mean kappa (0.80).

Conclusions

A reliable version of the NIHSS is available in 13 non-English languages. These translated tools have improved standardization in assessing neurological deficits in stroke throughout the world. This ultimately highlights the need for further adaptation to reflect other cultures and languages, especially in regions such as those in sub-Saharan Africa that have a large stroke burden and insufficient awareness.

Background and Aims

Studies on endovascular treatment (EVT) have reported conflicting results on sex differences.

Methods

PubMed and Embase were systematically searched for studies looking at sex-specific EVT rates for acute ischaemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT rates. To estimate sex differences in functional outcomes, the female:male ratio of ORs and 95% confidence intervals (CIs) for functional outcomes after EVT were obtained.

Results

6,396 studies were identified through database searching, of which 594 qualified for full review. A total of 52 studies (36 non-RCT and 16 RCTs) that reported the rate of EVT stratified by sex were included, and 10 among them estimated the sex disparities of EVT on functional outcomes. There was no significant difference of EVT rate in women compared to men both in non-RCTs (OR 1.03, 95% CI [0.95-1.11]) and RCTs (1.01 [0.89-1.16]). The pre-specified subgroup analyses were consistent across different study designs, the year of publication and region of study conduction, except that in Europe the EVT treatment rate was higher in women than men (1.15 [1.13-1.16]). No sex disparities were found in the functional outcome by both ordinal and binary analysis according to modified Rankin Scale (OR 0.95 [0.68-1.32] and OR 0.90 [0.65-1.25], respectively).

Conclusions

There was little evidence of sex disparities in EVT overall and functional outcomes after acute ischaemic stroke.

Background and Aims

Background: Clinical practice guidelines (CPGs) for stroke rehabilitation provide high-quality evidence-based recommendations which inform and guide physiotherapy practitioners to achieve optimal clinical outcomes for stroke survivors.

Problem Statement: There is currently a lack of systematic evaluation of existing CPGs for physiotherapy interventions in stroke rehabilitation.

Objective: To evaluate and synthesize the CPGs reporting evidence-based recommendations of physiotherapy management for people with stroke.

Methods

A systematic search of guideline repositories and electronic databases including Web of Science, Scopus, CINAHL, Medline (via Ovid) and Embase (via Ovid) was conducted in 2020 and 2021. Contemporary CPGs with detailed physiotherapy interventions for stroke, published within the last 10 years were included. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to appraise the methodological quality of the included CPGs. Content analysis was used to synthesize the evidence-based recommendations from CPGs.

Results

Six CPGs from Australia, Canada, Netherlands, America, United Kingdom and Scotland were included for final synthesis. We found consistent recommendations across all CPGs supporting the following interventions: strength training for paretic lower limb; use of treadmill for gait training to improve cadence and speed; robot-assisted gait training; use of ankle foot orthoses to facilitate gait training; and patients and caregiver education about falls prevention.

Conclusions

Regardless of the variability in the guideline development process identified in each CPGs, the scope and purpose of the guidelines were clearly stated including clear description of recommendations. Overall, it is evident that more robust primary studies of physiotherapy interventions are required to increase the strength of evidence.

Background and Aims

Apolipoprotein-E (ApoE) alleles have been associated with the risk of Hemorrhagic stroke (HS). We conducted a meta-analysis to determine the association of ApoE alleles with HS risk

Methods

Literature search was performed till April 07, 2022, in various databases using the keywords: (‘Apolipoprotein E’ OR ‘ApoE’ OR ‘ApoE genotype’) AND (‘Single Nucleotide polymorphisms’ OR ‘SNP’) AND (‘Hemorrhagic stroke or ‘HS’ or ‘Intracerebral Cerebral Hemorrhage’ or ‘ICH’). Pooled Odds Ratio (OR) and 95% Confidence Interval (CI) were determined. Statistical analyses were performed using STATA version 13.0.

Results

Twenty-two studies with 7209 HS and 23625 controls were included in the study. Pooled analyses revealed a significant association of ApoE 3.3 with overall HS risk [OR = 1.11, 95% CI = 1.03 – 1.19]. However, significant protective association of ApoE 2.2 [OR = 0.52, 95% CI = 0.35 – 0.77], ApoE 2.4 [OR = 0.54, 95% CI = 0.33 – 0.89], ApoE 2 [OR = 0.89, 95% CI = 0.80 – 1.00], ApoE 4.4 [OR = 0.63, 95% CI = 0.48 – 0.82, I² = 0%], and ApoE 4 [OR = 0.78, 95% CI = 0.66 – 0.93, I² = 65.9%] was observed with HS occurrence. Population sub-group analyses revealed significant association of ApoE 3.3 with HS risk in Caucasians [OR = 1.11, 95% CI = 1.01 – 1.22].

Conclusions

The meta-analysis indicates HS risk is associated with only ApoE 3.3, and ApoE 2.2, 2.4, 2, and 4.4 had a protective association with HS, suggesting the significant role of ApoE SNPs in the occurrence of HS.

Background and Aims

Spinal cord infarction is a rare but debilitating condition. While significant functional recovery may occur in some patients, most suffer permanent and disabling neurologic deficits. While there has been an increasing trend of case reports using recombinant tissue-plasminogen activator (r-tPA) in the treatment of spinal cord infarction, there remains a paucity of data evaluating its efficacy. Therefore, we performed the first comprehensive meta-summary in literature to characterise and review the efficacy of using r-tPA in patients with spinal cord infarction.

Methods

We searched for articles published in Embase, PubMed and Cochrane Library from inception to 18 November 2021 using an appropriate keyword/MeSH term search strategy. The outcome measured was a favourable functional outcome at three months (modified Rankin scale 0-2).

Results

Fifteen studies comprising 36 patients (17 female, mean age: 67.0 ± 16.5 years) with spinal cord infarction who had received r-tPA were included in the analysis. There were 70.6% of patients with hypertension (n=12/17) and 41.2% with dyslipidemia (n=7/17). The most common presenting complaints were paraparesis or paraplegia in 44.4% of patients (n=8/18), hemiparesis or hemiplegia in 33.3% of patients (n=6/18), neck or back pain in 33.3% of patients (n=6/18) and para-anaesthesia in 27.8% of patients (n=5/18). At 3-months follow-up, 19 (55.9%) patients achieved a favourable functional outcome. The only reported complication was one case of hypotension at the end of rt-PA infusion.

Conclusions

The use of r-tPA may have a role in the treatment of patients with spinal cord infarction. Further larger studies are needed to evaluate its safety and efficacy.

Background and Aims

Ischemic stroke (IS) causes significant mortality worldwide and has higher incidence among men than women. In this study, we investigated the risk-association of endogenous sex hormones in males and females with ischemic stroke.

Methods

Comprehensive literature search was performed in various electronic databases, including PubMed, Embase, Cochrane Library, Worldwide Science, and Google Scholar up to 10^th April 2022. Pooled Standard Mean Deviations (SMDs) with 95% Confidence Intervals (CIs) for males and females were calculated, along with subgroup analysis based on ethnicity (Caucasian vs. Asian). Sensitivity analysis was performed to detect the heterogeneity between studies and Begg’s funnel plot assessed any publication biases.

Results

We included 10 case-control studies with 2026 IS cases and 7688 control subjects, including 6 from Caucasian and 4 from Asian population. Our findings revealed a significant protective association of total testosterone (SMD=-1.23, 95% CI=-2.02 to - 0.44) and free testosterone (SMD=-2.53, 95% CI=-4.77 to -0.30) levels with the risk of IS in the overall male population. Additionally, significant protective association was also observed in the Caucasian population regarding total testosterone (SMD=-1.34, 95% CI=-2.46 to -0.22) and free testosterone (SMD=-3.39, 95% CI=-6.18 to -0.59) levels with IS risk. However, no significant relationship was observed in ­­­­­­­­estradiol, progesterone, and luteinizing hormone levels for both the sexes with IS risk.

Conclusions

Our meta-analysis is the first one to highlight the necessity to conduct clinical investigations on endogenous sex hormones to determine IS risk in patients. Sex hormones could be significant biomarkers to determine IS risk based on gender.