Welcome to the WSC 2022 Interactive Program

Background and Aims

Stroke is the second most common cause of death and disability worldwide. The burden of stroke is increasing in an exponential manner in low- and middle-income countries (LMICs). Despite this fact, the data on actual stroke patients in these countries is nonexistent.

To collect and form a robust database and stratify the risk factors of stroke and call for the attention of the global community to make a common stroke database.

Methods

An electronic Medical Health Record (MHR) was formed. Each patient at admission to the institute was assigned a Unique Identifier Number (UIN) in which all the medical and other details including diagnosis were separately stored under same UINwhich can be retrieved at the desired time.

Results

The study was carried in our institution and the study time period was from 2018 January to 2019 May. An electronic database was established where the information of the patient was stored with each unique identification number. Among the data of total 3942 patients, nearly more than 500 patients were identified as stroke of any type (hemorrhagic or ischemic).Majority was (63%) were identified as ischemic stroke. Hypertension was present in 87.1% in hemorrhagic and 59.3% in ischemic stroke.

Conclusions

This study was a first time ever done in Nepal with a proper electronic database.Our database shows that if common database is established, it is going to accommodate large data entry. Similarly, it is also necessary to have common data elements (CDE) to analyze the risk related with the stroke.

Background and Aims

Systematic data on TIA/stroke in the Philippines is scarce. We aimed to prospectively collect uniform data among patients hospitalized with TIA or stroke.

Methods

All patients admitted at 11 neurology training hospitals are included if they are >/=18 years old and diagnosed with TIA, ischemic or hemorrhagic stroke, or cerebral venous thrombosis. Patients admitted primarily for non-acute stroke-related sequelae/procedures, e.g., infection, gastric tube insertion, are excluded. Anonymized data on socio-demographics, medical history, stroke subtype, in-hospital management and discharge outcomes are entered in a secure online data collection tool. Clinicaltrials.gov NCT04972058.

Results

Conclusions

TIA/stroke admissions in PNA1DB-Stroke hospitals reduced significantly during the pandemic (previous census 10,000-14,000/year) with low revascularization rate. Case-fatality was highest among hemorrhagic strokes (27%). Data collection will continue further for 3 years.

Background and Aims

Majority of stroke patients do not have immediate access to neuroimaging to differentiate haemorrhagic and ischemic stroke. There is a need to develop a clinical score which can differentiate between the two types of strokes with high accuracy.

Methods

All consecutive stroke patients from May 2020 to January 2022 were assessed for clinical parameters with potential discriminant value. The type of stroke was confirmed by CT head or MRI brain. Logistic regression analysis was used to develop the clinical score. We calculated the sensitivity, specificity, PPV, NPV and accuracy of the score.

Results

We enrolled 210 stroke patients, 135 were males and 75 females. The mean age was 61 (SD 11.6) years (range 34-91 years). Ischemic stroke was present in 127 (60.5%) and haemorrhagic stroke in 83 (39.5%) patients. We developed the following score.

Z = 2 x vomiting at onset + 2 x extensor plantar response +

2 x loss of consciousness at onset + 3 x diastolic blood pressure (>90 mm Hg)

The cut off value of the score was ≥ 6 for haemorrhagic stroke, ≤ 2 for ischemic stroke and a score of 3-5 was equivocal. The score had a sensitivity of 65.3%, specificity of 91.2%, PPV of 84.2%, NPV of 79% and accuracy of 80.7% for the detection of haemorrhagic stroke.

Conclusions

A clinical score was developed to differentiate haemorrhagic and ischemic strokes. The score could specifically identify haemorrhagic strokes but had low sensitivity. Validation of the score is required in a large cohort of acute stroke patients.

Background and Aims

Stroke is one of leading causes of death and disability across the world. In developing countries like India, there is a cumulative burden of communicable and non-communicable diseases. Given the epidemic nature of stroke and multiple requirements of stroke survivors there is a critical need for comprehensive multidisciplinary rehabilitation therapy to minimize the disease burden. Purpose of our study was to evaluate efficacy of transition care center(s) providing multi-disciplinary stroke rehabilitation therapy in India.

Methods

Retrospective chart review of patients admitted to stroke rehabilitation care at our Transition Care Centers in India

Results

A sample size of 67 patients was taken from patients admitted to stroke rehabilitation with an average length of stay of 34 days. Mean Barthel scores were 22.55 at admission and 46.42 at discharge. There is significant improvement of 23.87 points with average progress of 0.7 points per day. Change in Barthel scores were positively correlated with increase in length of stay. Mean Motor power was 3.24 at discharge which was significantly higher than admission score of 2.12. Berg balance score was 7.7 at the time of admission and 37.2 at the time of discharge with an average improvement of 29.5 points.

Conclusions

There is a significant improvement of functional status and balance when stroke rehabilitation is done by multi-disciplinary team at transition care centers. As stroke continues to burden health care system and community, there is a need for more transition care centers like these to reduce disability burden for the individual, family and community.

Background and Aims

A prospective, observational study was done at the country leading tertiary care hospital to evaluate etiologies, clinical features, diagnosis, and prognosis of cerebral venous sinus thrombosis (CVST) in the Pakistani population.

Methods

34 patients with clinical and MRI features suggestive of CVST were evaluated. Modified Rankin Score (mRS) was assessed of all patients at presentation.

Results

The mean age of presentation was 30.69 years with female predominance (n=28). Headache was most common presenting symptoms (97%, n=33) followed by seizure (59%, n=20), hemiparesis (56%; n=19), altered sensorium (47%; n=16), vomiting (21%; n-7) and cranial nerve involvement (18%; n=6). 72% of patients (n=23) had thrombosis of superior sagittal sinus, 53% of patients (n=17) had thrombosis of the transverse sinus, 25% patients (n=8) of patients had sigmoid sinus thrombosis, 16 % patients (n=8) had straight sinus thrombosis. The most common cause for provoked CVST was found to be pregnancy/puerperium in 53% (n = 18 patients), followed by previous CVST/DVT in 12% (n = 4), and then OCP and parainfectious causes which were 3% (n=1) for each and elevated factor VIII and protein deficiency were found in 7 patients. MRS between 3-5 was assessed in most patients on presentation (n=23).

Conclusions

CVST is an under-recognized cause of stroke in the young population, especially in the puerperium period. Clinical presentation is highly variable, and correction with magnetic resonance imaging with venography is the current diagnostic modality of choice. Aggressive management with anticoagulants is safe with excellent clinical outcomes.

Background and Aims

Acute ischemic stroke associated with COVID 19 has been reported worldwide. This study aims to predict age wise recovery in COVID 19 associated stroke in a government hospital setting in south India.

Methods

58 patients who presented with stroke and COVID 19 between January 2021 and September 2021 were followed up for a period of 6 months. They were categorised into three groups based on age as group 1(30-45 years), group 2(46-60 years) and group 3(>61 years). NIHSS score and mRS score at admission and mRS scores at 1 month, 3 months and 6 months follow up were noted. Statistical analysis was done using SPSS software. Chi Square test and ANOVA test were used for comparison within the groups and p value of <0.05 was considered significant.

Results

Among the 58 patients, 10 belonged to group 1 (17%), 41 in group 2 (71%) and 7 in group 3 (12%). Baseline and mRS score at 1 month were comparable between groups. There was a statistically significant shift of mRS score from baseline to favourable score at 3 months and 6 months in group 1 and group 2 as compared to group 3 (p=0.016). There was no significant difference in mRS score improvement between groups 1 and 2. 39 patients (67%) achieved favourable mRS score of 0-2 at 6 months. Only 1 patient belonging to group 3 achieved favourable mRS score.

Conclusions

Patients less than 60 years of age had a favourable outcome at 6 months follow up in comparison with those above 60 years of age.

Background and Aims

Stroke is one of the most important causes of disability in young adults in spite of reperfusion therapies and rehabilitation there are conditions poorly studied as predictors of disability. The aim of this study was to describe clinical and radiological variables related with disability after stroke in young adults.

Methods

We conducted a retrospective, single-center study in Mexico City including electronic medical files of hospitalized patients with stroke at the neurology department from January 2019 to March 2022. Patients were allocated in 2 groups at discharge: favorable (mRS 0-1) poor (mRS ≥2) outcome. Demographic, radiological, and clinical variables were obtained.

Results

We enrolled 104 patients with baseline characteristics described in Table 1, 43% were females, and the median age was 37.5 (±8.9). The median NIHSS scored was 7.3 (±7.2), and only 8 patients (7.7%) were treated with rTPA at admission Favorable outcome was obtained from 42 patients (40%). Statistical analysis showed that cardioembolic mechanisms is relate with worse outcome compared with other etiologies (OR 1.08, IC 95% 1.12 -7.7, p=0.024), and Cervical artery dissection was related with favorable outcome when compared with other causes (OR 1.27, IC95% 1.12 – 11.3, p=0.025). Sex, age, vascular territory classified by OCSP, and other clinical variables were no related with outcome

Conclusions

Cervical artery dissection is a condition that could predict a favorable outcome at discharge after stroke in young adult, and conversely cardioembolic mechanism is related with a worse outcome.

Background and Aims

Stroke occurs earlier in low-income countries and results in sensory-motor and cognitive impairments that may be present for life in stroke survivors. The persistence of these impairments generally leads to activity limitations and/or psychological disorders, mainly depression, which appear to impact participation in stroke survivors. Understanding the relationships between these different consequences would be useful to better guide the rehabilitation for stroke patients in their countries. In Benin, a low-income country, very little is known about this. We therefore assessed the impact of depression and activity limitations on participation in stroke survivors in Benin.

Methods

Forty-four stroke survivors (27 males; mean±SD:54.09±11.47 years old; median time since stroke [1st -3rd quartile]:10 [1-38] months) were recruited in Benin. We used the Hospital Anxiety and Depression Scale (HADS-D) to assess participants' depressive symptoms. The ACTIVLIM-Stroke (a questionnaire measuring activity limitations) and the Participation Measurement Scale (PM-Scale) were also used to assess their limitations and participation in daily activities. Bivariate linear regression was performed with HADS-D and ACTIVLIM-Stroke scores (independent variables) and PM-Scale scores (dependent variable) to determine the impact of poststroke depression and activity limitations on participation of stroke survivors.

Results

34.1% of stroke survivors in our sample were depressed. Activity limitations (27.5±8.1) and participation restrictions (34.3±5) were reported. Bivariate linear regression showed that HADS-D scores (β= -0.30; p= 0.012) and ACTIVLIM-Stroke scores (β=0.56; p<0.0001) were associated with PM-Scale scores and explained 44.5% of variances of PM-Scale scores.

Conclusions

Poststroke depression and activity limitations appear to have a negative impact on participation in Beninese stroke survivors.

Background and Aims

Adjusting to stroke often requires that survivors change their occupational performance patterns (OPP). This study describes the occupational adaptation process (OAP) and perceived changes in OPP of stroke survivors (SS) in southwest Nigeria.

Methods

This was a qualitative descriptive study involving 10 SS that were recruited from 2 medical rehabilitation centers of a tertiary health facility in southwest, Nigeria. One-to-one in-depth interviews were conducted with the SS with open-ended questions in reference to the aim of the study. Data were analysed using content thematic analysis. This study was approved by appropriate Ethics and Research committee.

Results

Three main themes emerged from this study. The first theme: “stroke, an unpleasant and unexpected event makes living a struggle” describes how SS struggles with the negative consequences of stroke in order to re-integrate into the society. The second theme: “coping, the new normal after stroke” describes the measures and strategies employed to ease the struggle with varying success through the use of support systems and rehabilitation services; while the third theme “change and motivation for change in performance patterns” highlights the changes in daily routines and habits that was needed to fit-in after the stroke.

Conclusions

Adjusting to life after stroke comes with varying success, as the experience is sudden and often unpleasant for survivors. Improving the available support systems and rehabilitation services for this population is suggested.

Background and Aims

In acute ischemic stroke (AIS), differing mechanisms (thrombotic or embolic) and sites of infarction causes unique clinical patterns. Thus, knowledge of the site and size of the ischemic insult is crucial to determine subsequent diagnostic and therapeutic steps, and prognosis. However, neuroimaging and neurologist expertise are not consistently available in resource-limited settings. We aim to establish the applicability of the Oxfordshire Community Stroke Project (OCSP) for AIS among non-neurologist physicians.

Methods

We conducted a cross-sectional study within a 6-month period. We included AIS patients wherein neuroimaging (CT/MRI) demonstrates acute infarction. Patients were categorized as total anterior (TACI), partial anterior (PACI), lacunar (LACI), and posterior (POCI) circulation infarcts, and compared to neuroimaging to test for sensitivity (Sen), specificity (Spe), positive predictive value (PPV), negative predictive value (NPV), and correct classification rate (CCR).

Results

85 patients were included: TACI (7.1%), PACI (30.6%) LACI (44.7%), and POCI (17.6%). Overall CCR was 84.71%. The OCSP classification is adequate in identifying TACI (Sen 83.33%, Spe 98.73%, PPV 83.33%, NPV 98.73%, CCR 97.65%) and POCI (Sen 72.22%, Spe 97.01%, PPV 86.67%, NPV 92.86%, CCR 91.76%) but is weaker in differentiating lacunar and small-volume supratentorial infarcts such as PACI (Sen 60.00%, Spe 81.67%, PPV 57.69%, NPV 83.05%, CCR 75.29%) and LACI (Sen 72.22%, Spe 75.51%, PPV 68.42%, NPV 78.72%, CCR 74.12%).

Conclusions

For AIS in resource-limited settings, the OCSP classification can be employed to direct the course of diagnostic investigations and therapeutic judgement, to more efficiently uncover relevant risk factors and determine the potential need for a higher level of care.

Background and Aims

Intracranial artery stenosis (ICAS) is one of the leading causes of ischemic stroke, especially in the Asian population. Digital Subtraction Angiography (DSA) is the gold standard for diagnosing ICAS. This study aimed to determine the clinical profile of ICAS in ischemic stroke patients in Surakarta City, Indonesia, who underwent DSA.

Methods

This descriptive research was conducted in Dr. Moewardi Hospital on all patients who underwent the DSA procedure from January 2019 to March 2022 and found ICAS through the DSA examination. The data collected included age, gender, symptoms, risk factors, degree of stenosis, and location of stenosis. The degree of stenosis was grouped into mild, moderate, severe, and critical. The location of the stenosis was divided into anterior and posterior circulation.

Results

Among the 82 subjects, 62 (75.6%) patients were male. Hypertension was the most common risk factor (84.1%). Locations of ICAS were MCA (37.8%), vertebrobasilar artery (35.4%), ACA (13.4%), ICA supraclinoid segment (11%) and PCA (2.4%). Eight cases underwent stenting/angioplasty consisting of five vertebrobasilar artery stenosis, two MCA stenosis, and one ACA stenosis. There were statistically significant results (p < 0.05) in the degree of stenosis and symptoms compared with the stenosis location. No significant difference between the risk factors compared to the variable location of the stenosis and the degree of stenosis.

Conclusions

MCA is the most common location for ICAS, and hypertension is the most common risk factor for ICAS. The clinical profile and location of the stenosis can be used to choose stenting or angioplasty for the treatment.

Background and Aims

SMART INDIA is a multicenter, open-label cluster-randomized trial which assesses whether low cost telestroke model (using SMART INDIA App) is superior to stroke physician model in acute stroke management in resource limited settings. The trial was planned in the pre-covid era and was initiated during COVID pandemic. We aim to describe the challenges faced during implementation of the trial at nodal centres and district hospital

Methods

We reviewed the minutes of SMART INDIA trial meetings, email communications between research staff of various sites, communication with ethics committee and funding agency and video recordings of online meetings to analyse the challenges faced during implementation at nodal centres and district hospitals.

Results

The trial received funding during the first wave of COVID pandemic in India. Several challenges were posed to the trial team during this period like conversion of district hospitals into Covid Care Centers, administrative challenges (ethical clearances, staff shortage, patient accessibility), and technical delays. Many in-person meetings and workshops had to be converted to online meetings. There were delays in the design and development of Smart India app and finally it was developed over eight months (December 2020-July2021). Many site visits were delayed due to the pandemic and online site visits were conducted during the initial implementation phase which was later followed up with in-person site visits.

Conclusions

Despite all the pandemic-associated challenges the app was successfully designed, all target district hospitals and nodal centres were recruited and the trial reached the functional implementation status.

Background and Aims

Stroke affects the cognitive domain, which includes attention, memory, language and orientation. Air pollution is one of a variety of man-made environmental disasters that are currently taking place all over the world. The WHO estimates that air pollution is responsible for over 3million premature deaths each year.

Methods

All strokes: acute (<= two weeks from onset) & chronic (<=one year of event) presenting to the Neurology and Emergency services of AIIMS, were screened & recruited. Gaseous air pollutants and PM2.5&PM10 in diameter were measured in me Delhi designated areas using the help of DPCB at the onset of stroke,15days of enrollment & 3months. Stroke demographics and PHQ-9,GAD-7, SF-36 were correlated with air pollution &climate change.

Results

180 patients were recruited so far. We found that depression and anxiety levels were high among stroke patients. PM2.5& PM10 levels were statistically related to stroke onset and depression & anxiety. The mean PM10 level was high as compared to PM2.5 at all-time points indicating that higher particulate or coarse particles are better measured than the fine particles and it's associated with cognitive decline & anxiety. We observed that the high level of particles affects cognition and causes depression. Multivariate regression analysis keeping age, type of stroke as constant with covariables like the type of fuel, CO, PM2.5 showed R²⁼ 0.119, F =3.92, p=0.057.

Conclusions

We found that cognitive decline &depression are common in stroke patients but its also associated with a high level of air pollution & climate change. We need more results for final conclusion.

Background and Aims

Cerebral reperfusion therapies (CRT) have been shown to improve the functional status of patients with acute ischemic stroke. In developing countries, little data exists on actual experience. The objective of this study was to analyze the experience of patients undergoing CRT in a public hospital without diffusion/perfusion mismatch data.

Methods

Patients older than 18 years with acute ischemic stroke who underwent thrombolysis and/or thrombectomy during the years 2017 to 2021 were included. Factors associated with neurological improvement, neurological deterioration, Intracranial Hemorrhage, and death were analyzed. The differences between the variables were analyzed according to their nature and normality, with the corresponding statistical test. ORs were calculated and logistic regression models were performed according to each outcome.

Results

101 patients with a mean age of 66 years were included, 53.4% were men. 38.6% (39) underwent intravenous thrombolysis, 57.4% (58) thrombectomy, and 3.9% (4) combined therapy. 36.6% presented significant neurological improvement, 28.7% intracraneal hemorrhage (ICH) and 29.2% died. In the analysis for neurological improvement, a statistically significant association was found with gender, diabetes mellitus, ICH, intensive care unit, de novo atrial fibrillation and intravenous thrombolysis. In neurological deterioration was found with glycemia, ICH and intravenous thrombolysis. In ICH was found with NIHSS admission, rural life, TOAST, intravenous thrombolysis and neurological deterioration.

Conclusions

Patients undergoing intravenous thrombolysis, transferred to postprocedural critical care and who do not present cerebral bleeding, are associated with neurological improvement. This highlights the importance of strict implementation of the algorithm for selecting patients with acute ischemic stroke to perform thrombectomy.