Welcome to the WSC 2022 Interactive Program

Background and Aims

Background and aim: The only FDA-approved drug treatment of ischemic stroke relies on the intravenous injection of the recombinant tissue-type plasminogen activator (rtPA, Alteplase/Actilyse®) alone or combined with thrombectomy. By increasing the activity of endothelial and neuronal N-methyl-D-aspartate receptors (NMDAR), tPA is reported to display deleterious effects on neurovascular units and brain parenchyma. To counteract this, we developed a novel strategy relying on a monoclonal antibody, Glunomab, targeting the deleterious effects of both endogenous and recombinant tPA.

Methods

Methods: Glunomab was designed to prevent tPA from interacting with the GluN1 subunit of NMDAR. We then evaluated its efficacy in different animal models of thromboembolic stroke either alone or combined with early or late recombinant tPA-driven thrombolysis, including comorbidity studies such as diabetes. Calcium imaging, Magnetic Resonance Imaging (MRI), laser speckle flowmetry, behavioural tasks and/or immunohistochemistry were used to evaluate treatment efficacy.

Results

Results: Glunomab blocks the tPA-dependent potentiation of NMDAR signalling without disturbing its physiological activity. After a single i.v. administration either in standalone or combined with rtPA-induced thrombolysis, Glunomab reduced brain lesion volumes along with haemorrhagic transformations, translating in improved long-term neurological outcomes. Moreover, the therapeutic synergy of Glunomab with rtPA was also demonstrated in diabetic animals, an important parameter as diabetes is one of the main comorbidity displayed by stroke patients.

Conclusions

Conclusions: Glunomab drastically limits ischemic damages as well as haemorrhage induced by both endogenous and recombinant tPA, and promotes reperfusion. A humanized form of Glunomab is currently under development for clinical application as a potential game-changer treatment for stroke patients.

Background and Aims

Background and aims:

In recent years, robotic rehabilitation training has become widespread in the upper extremity treatment methods in stroke. The aim of this study was to investigate the effect of upper extremity robotic rehabilitation on activity performance in individuals with stroke.

Methods

25 individuals with stroke who agreed to participate and met the inclusion criteria were randomly divided into 3 groups. The 1^st group (n=9) was trained in functional activities with the Armeo®Power upper extremity robot for 6 weeks/ 3 sessions per week/ at 45 minutes. The 2^nd group (n=9) was arranged to be Armeo®Power upper extremity robot (6 weeks/ 3 sessions per week / at 45 minutes) and daily living activities training (6 weeks/ 3 sessions per week / at 45 minutes. The 3^rd group was given daily living activities training for 6 weeks/ 3 sessions per week / at 45 minutes. All individuals were assessed at the beginning of the therapy and the end of 6^th week with COPM, Performance Quality Rating Scale (PQRS), Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) and Upper Extremity Motor Activity Log-28 (UE-MAL-28).

Results

According to data analysis, there was a significant difference in FMA-UE values among all groups after intervention (p<0.001).There was no significant difference between the groups in terms of COPM, PQRS, UE-MAL-28 values (p>0.05).

Conclusions

The application of daily living activities training together with robotic rehabilitation in individuals with stroke provides more gains in terms of motor recovery in the upper extremity.

Background and Aims

Stroke causes weakness with one side of the body commonly effected. This leads to difficulty in mobility and balance. Balance training is an important component of stroke rehabilitation. To improve effectiveness there are different approaches added to conventional therapy at transition care centers.

Our aim is to evaluate effectiveness of adding gamification to conventional balance training activities in stroke patients for improving rehabilitation outcomes.

Methods

A retrospective review of case sheets have been analyzed for progress made on balance training. Sample size of 36 patients were reviewed and observed to have two categories of therapies. One group received conventional therapy and the other group had conventional therapy plus computer assisted gamification. Berg balance score was used to assess the progress in both groups.

Results

Berg balance score of the group that had gamification added to conventional therapy had improvement of 32.7 points (base score of 7.4 to 40.2). For the same duration of therapy, Berg balance score for the group with only conventional therapy improved 28.6 points (base 7.4 to 36.1). There is an average of 4.2 points difference in improvement in the group that had gamification added to conventional therapy.

Conclusions

Balance training is one of the key rehabilitation goals for post stroke patients. As gamification involves dual task focus and there is an improvement of balance training outcomes with addition of gamification to conventional therapy, we need to research further to see if addition of gamification can improve outcomes of overall recovery and possible scope of reducing duration of therapy.

Background and Aims

It has been estimated that 10%–20% of people with Takayasu arteritis(TA) exhibit neurological manifestation.However,acute stroke with large-vessel occlusion as a first manifestation of TA is rare.Few case reports show mechanical thrombectomy being performed through transfemoral access by recanalizing the common carotid artery(CCA).

We aim to describe the technique of direct carotid puncture for mechanical thrombectomy in a young female with occluded innominate,both CCA and right proximal subclavian arteries due to TA.

Methods

Under general anesthesia,with her neck in the extended position,the reformed left distal common CCA was punctured just below the carotid bifurcation by using a 20-gauge Micropuncture needle from the Terumo Radifocus introducer set under ultrasound guidance.Sheath angiogram confirmed the thrombotic occlusion of left M1 MCA.An ACE 68(Penumbra, Inc. USA) aspiration catheter was navigated over a Rebar 18(ev3 Neurovascular,USA)microcatheter and Synchro(Stryker Neurovascular,USA)0.014″microwire.The thrombus was traversed and a Solitaire-2(ev3 Neurovascular,USA)4 × 40 mm stent retriever was deployed across the thrombus by the push and fluff technique.After a dwell time of 5 minutes,both were retrieved simultaneously under negative suction using the Solumbra technique.The puncture to recanalization time was 58 minutes.

Results

Post-procedure neurological examination revealed complete recovery with an NIHSS score of 2.The patient was discharged with a MRS of zero.On 3-month follow-up,she was asymptomatic without any neurological deficits.

Conclusions

Large-vessel occlusion stroke,though rare,can be the first manifestation of TA.The role of IV thrombolysis in this subgroup of patients is not well known.Direct carotid puncture for mechanical thrombectomy is a safe and effective alternative in TA patients with significant proximal carotid disease.

Background and Aims

Approximately in 20 to 40% of all ischemic strokes, the underlying cause remains undertermined following the initial investgations. ParoxysmalAF is a major etiological factor in this group of patients. Trials have shown that longer duration of cardiac rhythm monitoring increases the detection rate of PAF compared to standard 24 hour ECG.

Methods

We collected retrosepctive data from patient's electtonic records. Along with other modalities, 39 patients had implantable cardiac loop recorders between the period of August 2016 and September 2021 for ischemic stroke .Every vascular and neuroimaging was reviewed by a consultant stroke physician and a consultant neuroradiologist to identify potential cardioembolic strokes. AF detection rate was identified from all modalities of rhythm monitoring.

Results

Data analysis revealed 69% of patients had initially missed identifiable aetiology. The pick up rate of PAF on 24 hour Holter and 7 day ECG was approximately 2% which mirrors the finding from CRYSTAL AF and EMBRACE AF trials. In comparison to that, ILR identified AF in 5 patients (All detected beween 6 and 12 months of monitoring).

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Conclusions

This QIP demonstrated that carefully constructed pathway for investigation of ESUS will lead to better detection of PAF. We have now adopted a new pathway with the use of intermediate duration of monitoring (14 days) using adhesive cardiac patch monitors that has replaced conventional 24 hour ECG/ event recorders before requesting for ILR. These devices are now approved by NICE, but with our carefully designed pathway which follows evidence based practice, we hope to improve detection rate and better cost effectiveness.

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Background and Aims

Strokes are commonly caused by atrial fibrillation (AF) and detection of AF is paramount to secondary prevention of stroke. At Tan Tock Seng Hospital, patients presenting with stroke in which a cardioembolic cause is suspected undergo prolonged inpatient cardiac telemetry monitoring ranging from 3 days to 1 week to detect AF. This sometimes increases the length of their hospital stay as some of these patients are otherwise well and able to be discharged. The aim of this project was to reduce the length of stay for acute stroke patients requiring prolonged cardiac monitoring for detection of AF.

Methods

All patients with stroke who did not require prolonged hospitalization, but required prolonged cardiac monitoring, were identified from December 2020 to March 2022. A portable external cardiac monitoring device was attached to their chest and care instructions were given. Upon completion of monitoring, the patients returned the devices and qualitative feedback was obtained from the patients.

Results

There were 72 patients who were enrolled into this project. The median ambulatory cardiac monitoring period was 3 days and one case of paroxysmal AF was detected. This intervention has saved 226 unnecessary hospitalization days. Qualitative feedback obtained from patients were mostly positive with only a few patients having mild skin reactions to the adhesive electrodes

Conclusions

Overall, ambulatory cardiac monitoring has reduced hospitalization for patients. To improve the service, we need to source for lighter devices with better battery life and better adhesive electrodes. It is important to emphasize on skin care during patient education

Background and Aims

Chronic subdural hematoma is common in elderly after a mild or trivial head injury. The standard treatment is surgical with burr holes and drainage and a significant recurrence requiring reoperation occurring in 10-15% of patients. Recently, case series of endovascular embolization through middle meningeal artery had reported high subsequent resolution rate and importantly, less than 5% recurrence rate. Nevertheless, the concern for embolization is the period to wait, as compared to immediate relief of mass effect from surgery. Thus, a combination approach is advocated in our center when in doubt. We here reviewed our initial experience in safety and efficacy.

Methods

We retrospectively reviewed all the patients with chronic subdural hematoma (CSDH) undergoing Onyx middle meningeal artery (MMA) embolization with curative intent and excluded patients for palliative treatment in a neurosurgical center in Hong Kong.

Results

Eight CSDH in 7 patients fulfilled the inclusion criteria. Four (50%) CSDH were treated with MMA embolization alone and 4(50%) CSDH were treated with both surgery and MMA embolization. For the 4 patients with MMA embolization alone, one(25%) achieved significant reduction at 6 weeks and 3(75%) achieved resolution at 3 months. For the 4 CSDH with both surgery and MMA embolization, all have resolution at the first follow-up imaging, two(50%) at 6 weeks and 2(50%) at 3 months. There were no procedure related complications, and there were no recurrence nor reoperation in all CSDH.

Conclusions

In our pilot study, chronic subdural hematoma embolization is safe and feasible within the framework of surgery to treat and prevent recurrence.

Background and Aims

To develop steady state visual evoked potential based brain computer interface communication system (SSVEP-BCI-CS)and improve the quality of life of patients with post-stroke language disorder.

Methods

The theoretical framework of SSVEP-BCI-CS was designed.32 volunteers were selected as the analyzed subjects. The feasibility of the system was evaluated by the system performance.NASA-TLX scale was used to evaluate the psychological load of subjects .Mann Whitney test was used to study the relationship between gender differences and BCI performance.

Results

SSVEP-BCI-CS was developed, including three modes of emergency , instruction and typing.Occipital EEG is collected and decoded by spatio-temporal equalization dynamic window (STE-DW).The verification results show that the ITR of typing single task in healthy controls is 79.92 ± 43.55 bits / min, and the accuracy is 94% (92% - 97%). In instruction single task, the median output speed is 32.44 (11.73-38.64) instructions/min, median accuracy is 95.65% (90.76% - 98.37%).

Among 14 subjects with language impairment, 11 patients (78.57%) were able to use the system. The output rate of instruction single task is 12.95 (9.50-15.11) instructions/minute,and the accuracy rate is71.72% (58.70%-91.48%).The average output rate is 16.51 (8.79-20.34) instructions/min.

The performance index of healthy controls was better than that of language disability group.The performance of female group was better than that of male group in healthy controls.

Conclusions

Healthy participants and most patients with language disorder can use the system to finish the task of emergency call, instruction output and Chinese-English spelling. This system is expected to improve the efficiency of doctor-patient communication in the clinical environment.