Welcome to the WSC 2022 Interactive Program

Background and Aims

Identifying pseudoocclusion (PO) of the proximal internal carotid artery (ICA) from true distal ICA occlusion has implications on successful recanalization and outcome after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). The aim of this study was to identify the CT angiographic patterns in differentiating a true occlusion from PO and to analyze the rate of successful recanalization after EVT.

Methods

This was a retrospective cohort study of patients with AIS and proximal ICA occlusion who underwent mechanical thrombectomy from 2014 to 2021. The patterns of carotid occlusion in CT angiogram (beak, dome or flat pattern) were reviewed and correlated with Digital subtraction angiography (DSA) images and categorized into PO and true occlusion. The rate of successful recanalization in PO and true occlusion were analyzed

Results

Of the 24 patients 16 (66%) had proximal ICA PO and 8 (33%) had true occlusion in DSA. A beak pattern of the proximal ICA on CTA was significantly higher in the PO group (87.5% vs. 25%, p value = 0.005), and a flat pattern was significantly higher in the true occlusion group (50% vs. 12%, p value = 0.005). A gradual contrast decline of the proximal ICA on CTA images was seen only in the PO (85.7%, p value = 0.05). There was no significant difference in the rate of successful recanalization between PO and true occlusion (81.25% vs 62.5%, p= 0.362)

Conclusions

The imaging patterns of proximal ICA in CTA can differentiate PO from true occlusion. This can help in planning intervention strategies and prognostication

Background and Aims

Stroke is the second-leading global cause of death behind heart disease and is a major cause of permanent disability. Acute stroke management needs extended time window in Indian setting. Hence we looked at DWI/FLAIR mismatch (DFM) beyond the 4.5 hour window.

To identify DFM in acute ischemic stroke upto 9 hours after onset.

Methods

This is a hospital based prospective observational study over a period of 12 months. The study subjects were enrolled after informed consent. Consecutive patients of acute ischemic stroke patients within 9 hours, confirmed by MRI, attending the neurology department of Ramesh hospital, Guntur were studied.

Results

A total of 108 participants were included in the study. The mean age was 60.29 ± 14.27 years. Males were predominant in the study population (61.11%). Majority of the participants had hypertension(75%), diabetes mellitus(51%) and hypercholesterolemia(18%). 82.41% of participants had DFM. Majority of the participants had middle cerebral artery occlusion(71.30%). 79.63% of eligible participants were thrombolysed. The mean NIHSS score was 8.78 ± 5.34. In people with symptom to ER time <4.5 hours 95.29% of participants had DFM, and 4.71% of participants had no mismatch. Among people with symptom to ER time 4.51 to 9 hours, 38.46% of participants had DFM, and 61.54% of participants had no mismatch. Whereas, in > 9 hours, 30% of participants had DFM, and 70% of participants had no mismatch.

Conclusions

A significant proportion of patients had DWI and FLAIR mismatch outside the 4.5 hour window. Extending thrombolysis beyond 4.5 hours may be feasible as per DFM criterion.

Background and Aims

After intracerebral hemorrhage (ICH), the hematoma and resultant edema increases intracranial pressure (ICP), often with fatal consequences. Several physiological compliance mechanisms reduce ICP, including tissue compliance, where brain cells reduce in size and increase in density after severe strokes. We hypothesized that these latter mechanisms would be less effective with age.

Methods

In experiment 1, 12-month-old male rats were randomized to receive either a severe striatal ICH via stereotaxic collagenase infusion (n=10), or a sham procedure (n=10). After euthanasia at 24h post-surgery, neuron and astrocyte volume/density and cortical thickness were evaluated for tissue compliance. In experiment 2, 12-month-old male rats received ICP telemetry probe implants after ICH (n=10) or sham procedure (n=10). ICP was measured for 24h when rats were euthanized to assess cerebral edema.

Results

In experiment 1, there was no evidence of tissue compliance despite severe hematoma sizes (83.2±16.6uL, mean±95%CI). However, Aged-Sham neuron volumes were 28.6% smaller on average versus historical Young-Shams, with larger ventricles, suggesting either lesser need or lack of ability to engage tissue compliance with age. Experiment 2 demonstrated that this age-related tissue compliance deficit is not due to negligible mass effect, as at equivalent ICH severity, ipsilateral and contralateral edema were elevated by 2.0% and 1.7%, respectively (p≤0.05), with significantly higher ICP (mean hourly difference of 6.80mmHg, p≤0.0001); ICP spiking events, however, were 84% less frequent with age versus young animals.

Conclusions

The greater ventricle size and smaller parenchymal brain volume of aged rats may permit better ICP compliance following severe ICH.

Background and Aims

We have demonstrated that sovateltide, an endothelin B Receptors (ETBRs) agonist, effectively treats cerebral ischemic stroke, and its potential to develop as a novel drug for acute cerebral ischemic stroke (ACIS) is being evaluated (NCT04046484). In the present study, we have assessed the effect of sovateltide on neuronal regeneration and repair after ACIS.

Methods

We investigated the effect of sovateltide in permanent middle cerebral artery occluded (MCAO) adult rats. MCAO rats were treated with either sovateltide (5 µg/kg body wt.) or saline (equal volume) through tail vein injection and were assessed at 24 hrs or day 7 post-MCAO.

Results

We observed upregulation of neuronal differentiation markers Doublecortin (DCX) (p=0.00011), HuC/HuD (p=0.0037) along with NeuroD1 (p=0.00002) at 24 hrs post MCAO. Decreased infarct volume and DNA damage in the sovateltide group on day 7 post MCAO was observed. Downregulation of mitochondrial fission marker, DRP1 (p<0.001), increase in fusion marker, MFN2 (p<0.0001), and increase in cross-sectional area x number as well as mitochondrial/tissue area (p<0.05) at 24 hrs and day 7 post MCAO were seen. Increased mitochondrial DNA (MT ATP8; p=0.0418) was observed, indicating better mitochondrial biogenesis at day 7 post MCAO. Sovateltide treated rats had better neurological outcomes and motor functions at day 7 post MCAO. In vitro testing of sovateltide mediated differentiation in cultured rat NPCs demonstrated higher survival and expression of NeuroD1 and NeuN (a mature neuronal marker) after 24 hrs.

Conclusions

Sovateltide promotes differentiation of NPCs and mitochondrial fusion and biogenesis and helps in neuronal regeneration and function restoration following ACIS.

Background and Aims

Treatment with human amnion epithelial cells (hAECs) is neuroprotective within 90 min of experimental stroke. However, the broader therapeutic window is not yet defined. We aim to investigate the therapeutic window of hAECs therapy during chronic stroke in aged mice.

Methods

Male (n=46) and female (n=58) C57BL/6 mice (12-16 months) were subjected to photothrombotic stroke in the left M1 cortex. Mice were treated with saline or hAECs (1x10⁶ i.v.) at day 1, day 7 or both days 14 and 35 post-stroke. Cylinder tests were performed prior to stroke and treatments, and after weeks 5 and 8 to assess motor asymmetry. Mice were euthanised at 8 weeks for infarct analysis.

Results

Preliminary data showed that mice treated with hAECs at day 1 following stroke recovered at a faster rate than those treated with saline (P=0.04, linear mixed analysis), with a tendency for a smaller infarct at 8 weeks (p=0.06). Treatment with hAECs at day 7 following stroke appeared to promote recovery in females (P=0.08, linear mixed model analysis). By contrast, treatment with hAECs on days 14 and 35 following stroke had no effect on motor impairment in either sex as assessed at 8 weeks.

Conclusions

Systemic treatment of aged mice at 1 day (but not from 14 days) after stroke can promote motor recovery. Treatment of females with hAECs as late as 7 days following stroke may be beneficial for long-term functional recovery. Ongoing studies are examining effects of hAECs therapy in males within 7 days of stroke.

Background and Aims

The COVID-19 pandemic led to changes in patient care in health systems in Mexico, including treatment o stroke. Therefore, the aim of our study was to estimate the impact of COVID-19 pandemic on stroke treatment in Mexico.

Methods

We performed an observational, retrospective, multicenter study that included patients with stroke from May 2020 to January 2022. COVID-19 positive status was defined by positive PCR or chest tomography with CO-RADS 4-5. The treatment received was divided according to the type of stroke and the patient´s status in relation to SARS-CoV-2 infection.

Results

1272 patients with stroke were included, 110(8.6 %) had COVID-19 diagnosis, 667(52.4%) were men, the mean age was lower in COVID-19 patients (61.48 +15 years versus 64.97+15 years [16-99]; p=0.022). Comparisons between treatment and the different subtypes of stroke with and without COVID-19 were as follows: in acute ischemic stroke (AIS), reperfusión therapy was more frequent in patients without COVID-19 (149 [16.6 %] versus 6 [7.4 %]; p<0.001), in spontaneous intracerebral hemorrhage, management with only medical treatment in patients with and without COVID-19 was similar (18[100 %] versus 161[87.5 %]; p=0.233), finally, treatment in all patients with transient ischemic attack and cerebral venous thrombosis was only with medical treatment.

Conclusions

In our study, patients with COVID-19 and AIS received less management with reperfusion therapy, without significant changes in treatment in the other subtypes of strokes. With the above demonstrating the negative impact of the COVID-19 pandemic on treatment of AIS in Mexico.

Background and Aims

Intravenous thrombolysis is still underutilized in patients with acute ischemic stroke (AIS) in Sichuan Province. 5G-based telestroke mode, which remains to be widely implemented in China, is a promising strategy for addressing this issue, especially during the COVID-1) . The present study aimed to assess the effects of telemedicine for patients with acute ischemic stroke .

Methods

It's a multiple centers, 2-years observational study. All the data was collected data from 10 hospitals within the Sichuan Telestroke and Telethrombolysis Network. Demographic and clinical characteristics of patients with AIS and those relevant to intravenous thrombolysis were compared between the pre-telestroke and post-telestroke phases, and between the periods before and after declaration of the COVID-19 pandemic.

Results

A total of 11,449 admissions with a primary diagnosis of AIS were recorded. Prior to telestroke implementation, 6.7% of patients (n = 367) received intravenous thrombolysis, and the proportion increased to 7.4% (n = 443; p = 0.084) in the post-telestroke phase. The thrombolysis rate was 7.4% during the COVID-19 pandemic and in the latter half of the year when the viral spread was better controlled in China. The mean door-to-needle (DTN) time was significantly shorter after implementation of the telestroke network (63.76 ± 13.50 vs. 52.66 ± 25.49 min; p < 0.001).

Conclusions

5G-based telestroke mode is effective in improving the rate of intravenous thrombolysis among patients with AIS in Western China. Implementation of the telestroke network should be promoted, especially when access to care is affected by public health emergencies, such as the COVID-19 pandemic.

Background and Aims

During the course of the pandemic, it became clear that COVID-19 should be regarded as a systemic disease, particularly affecting the coagulation system with a high incidence of arterial thrombotic events (ATE). The aim of this study was to investigate the incidence and characteristics of ATE in hospitalized patients with COVID-19 using clinical and imaging data.

Methods

From the beginning of the COVID-19 pandemic in January 2020 to May 2021, databases of five German tertiary-care centers were searched for patients with coincidental ATEs associated with a COVID-19 disease. ATEs were examined regarding their localization, time of occurrence, radiographic characteristics, and associations with clinical data and laboratory parameters.

Results

Out of 3267 COVID-19 patients, 102 patients (110 events; median age 76(11-102)) presented with ATEs (3.1%). Localization included cardiac(n=51), brain(n=43), peripheral(n=7), intestinal(n=3), precerebral arteries(n=3), aorta(n=1), kidney(n=1), and spleen(n=1). Some ATEs showed patterns of massive thrombi with long-floating portions (Figure 1). Elevated CRP (median 45 mg/L) and fibrinogen levels (median 477 mg/dL) prior to ATEs were detected. ATEs occurred a median of 4 (-17-58) days after the onset of typical primary symptoms of COVID-19.

Conclusions

COVID-19 is associated with an increased rate of ATEs generally affecting all areas of the arterial system and partially with an unusual radiographic pattern. Most clinically detectable ATEs occurred in arterial vessels of the brain and heart, although some emboli were detected in atypical locations and in young patients. Approximately the first week after symptom onset seems to be the main critical period for the occurrence of an ATE.

Background and Aims

Acute stroke is a frequent complication of COVID-19 infection. Its relationship with COVID-19 is still unclear. Here, we describe the characteristics of 37 COVID- 19 related strokes.

Methods

This is an observational study of COVID-19 positive patients with stroke, who presented to HN Reliance Foundation Hospital between 1^st January 2020– 28^th February 2022. Their clinical profile, laboratory data, radiological findings, treatment, complications and outcomes were studied.

Results

Of 37 COVID-19 related stroke patients, 18 (48.6%) were males, mean age was 60 ± 15.14 years. Thirty-two (86.48%) had ischemic, 5 (13.5%) had hemorrhagic strokes. Majority of patients had hypertension (70.2%), 45.9% had diabetes, while 56.7% had more than one risk factors. Mean NIHSS score was 10.52 ± 6.24. Ten (27%) had large artery atherosclerosis, 8 (21.6%) had cardioembolism, while 7 (18.9%) had small vessel disease. Four (10.8%) received Intravenous thrombolysis with alteplase. A similar number underwent mechanical thrombectomy. COVID- 19 symptoms were seen in 15 (40.5%). The mean duration from covid symptoms to stroke onset was 1.5 days. High IL-6 and D-dimer levels were seen in 64.86% each. Average duration of hospital stay was 11 days; 5 succumbed and 19 had modified Rankin score of 3–5 on discharge. Complications observed were COVID pneumonia (18.9%), AKI (16.2%), sepsis and acute MI (10.8% each).

Conclusions

Neurovascular complications of COVID-19 are increasingly being recognized in developing countries, like India. Early stroke recognition and strict adherence to Protected Stroke Code may facilitate better stroke management with minimum risk of COVID-19 transmission.

Background and Aims

The COVID-19 pandemic has been hugely affecting access to the health care system and quality of services for people with stroke. It is important to explore the experiences and issues that patients and providers faced during the pandemic to identify deficits in the system and possible strategies that can be used to tailor stroke care. The aim of this study is to explore experiences of people with stroke, therapists’ experiences, patients’ needs and rehabilitation priorities after their stroke during the pandemic.

Methods

Semi-structured interviews of stroke patients and therapists were conducted. Qualitative data were analysed using a reflexive thematic analysis approach. Each interview was coded and categories were developed by two independent researchers and cross checked by a third researcher.

Results

22 participants (12 therapists and 10 patients) were interviewed. The quantity and quality of care post-stroke were affected by the impact of the pandemic to various extents including lack of care in some cases. There was a variability in the organisational and individual responses to the new changes. Patients needed more support to address their physical and mental health issues. Remote rehabilitation and self-management strategies were facilitated by care teams to deliver care for stroke population. Therapists seemed unsatisfied with the quality of care delivered and suggested that the system should be better prepared to deal with similar situations in the future.

Conclusions

Future research is warranted to examine the efficacy of reducing the time for acute care and remote delivery of rehabilitation for people with mild to moderate impairments post stroke.

Background and Aims

Carotid artery stiffness is associated with cognitive impairment and dementia, however, the underlying mechanism remains unknown. We examined the associations of carotid artery stiffness with cerebral small vessel disease (CSVD) markers, cognitive impairment, dementia subtypes, and cognition.

Methods

A total of 272 participants from a memory-clinic underwent carotid ultrasonography, 3T brain MRI and detailed neuropsychological assessment. Carotid ultrasonography was used to assess arterial compliance (AC), pressure-strain elastic modulus (Ep), β-index, augmentation index (AI), and pulse wave velocity-β (PWV-β). Brain MRI were graded for CSVD markers including white matter hyperintensities (WMH), lacunes and cerebral microbleeds (CMBs). Participants were classified as having no cognitive impairment, cognitive impairment no dementia, or dementia subtyped as Alzheimer’s disease (AD) and vascular dementia (VaD). Cognition was assessed using NINDS–Canadian Stroke Network harmonization battery.

Results

β-index (β=0.73, P<0.001), Ep (β=0.86, P<0.001), and PWV-β (β=0.83, P<0.001) were independently associated with WMH. Ep (OR=1.42, 95%CI=1.05–1.93), and PWV-β (OR=1.43, 95%CI=1.05–1.94) were associated with lacunes. Ep was associated with AD (OR=1.59, 95%CI=1.01–2.73) and VaD (OR=2.23, 95%CI=1.04–5.94). PWV-β was also associated with VaD (OR=2.24, 95%CI=1.07–5.62). All carotid artery stiffness measurements, except AI, were associated with worse performance in global cognition, visuomotor speed and memory. These associations became attenuated but remained significant with global cognition after adjusting for CSVD markers.

Conclusions

Carotid artery stiffening is associated with WMH, lacunes, etiologic subtypes of dementia, and global cognition independent of CSVD. Elevated carotid artery stiffness may help identify patients at risk for developing CSVD and dementia.

Background and Aims

Cerebral small vessel disease (SVD) is a key factor in dementia, often manifesting prior to symptom onset. However, sex differences on modifiable and non-modifiable risk factors on cerebrovascular health in healthy midlife adults are not well-documented.

Methods

Cognitively-healthy middle-aged adults (40-59y) underwent 3T MRI (n=630). To assess SVD, we quantified white matter hyperintensity volume (WMHv), enlarged perivascular spaces (EPVS), microbleeds, lacunes, and derived composite scores of global SVD burden, hypertensive arteriopathy and cerebral amyloid angiopathy (CAA-SVD). Modifiable midlife risk factors were based on the 2020 Lancet Commission on dementia prevention (early/midlife: education, hypertension, obesity, alcohol, hearing impairment, head injuries). Sex*risk interactions were analysed using general linear models (predicting individual SVD markers) and structural equation modelling (SEM; analysing latent variables of risk and of SVD).

Results

Sex interacted with APOE4 in relation to WMHv (t=-2.39, p=0.017) and centrum semiovale EPVS (t=-2.19, p=0.029), such that APOE4 related to greater SVD in females but not males (Figure 1). Conversely, sex*age interactions demonstrated that the effect of age on SVD were more pronounced in males than in females (global SVD: t=2.03, p=0.042; WMHv : t=1.97, p=0.049; basal ganglia EPVS: t=2.16, p=0.031, microbleeds: t=3.09, p=0.002) (Figure 2). In SEM, the effect of modifiable risk on CAA-SVD (but not global SVD or hypertensive arteriopathy) was amplified in males (Figure 3) (b=0.21, p=0.002).

Conclusions

As early as midlife, SVD related to differential risk factors in males (age, modifiable risk factors) and females (APOE4), and differed by SVD subtype. Such sex differences could shed light on biological underpinnings and targeted interventions.

Background and Aims

Extracorporeal Membrane Oxygenation (ECMO) is highly associated with arterial ischemic and hemorrhagic stroke, yet there is paucity of biomarkers available to predict such injuries in children. This study aimed at identifying electroencephalographic predictors of stroke in children requiring ECMO.

Methods

We prospectively enrolled children with continuous electroencephalographic recordings requiring ECMO support. We measured maximal hourly seizure burden, interictal epileptiform discharges, and quantitative electroencephalographic features (power in alpha, beta, theta and delta bands, alpha-delta ratio, total power, amplitude, differences between cerebral hemispheres and suppression ratio) obtained during the final 24 hours of recording while on ECMO support. The primary outcomes were the occurrence of ischemic or hemorrhagic stroke. Univariate logistic regression was used to identify predictors of ischemic or hemorrhagic stroke.

Results

Seventy-one children (female, 48%) with a median age of 1.1 [IQR: 0.02 – 10.2] years were enrolled. Of these, 10 patients suffered stroke, including 7 with arterial ischemic stroke and 3 with hemorrhagic stroke. The presence of interictal epileptiform discharges (OR: 26.667, 95% CI [4.251 – 207.707], p<0.001) was predictive of arterial ischemic stroke, whereas differences in alpha (8-13 Hz) power (OR: 110.230, 95% CI [1.414 – 1.645], p= 0.04), total (1-20 Hz) power (OR: 2.872, 95% CI [1.546 – 7.817], p= 0.005) and amplitude (OR: 9.231, 95% CI [2.289 – 202.413], p= 0.03) across each cerebral hemisphere were predictive of hemorrhagic stroke.

Conclusions

The presence of interictal epileptiform discharges was associated with arterial ischemic stroke whereas asymmetry in alpha power, total power and amplitude across each cerebral hemisphere predicted hemorrhagic stroke.