Welcome to the WSC 2022 Interactive Program

Background and Aims

Pilot data suggests that organized post-stroke care enhances achievement of secondary prevention goals in stroke patients. We aimed to further investigate whether organized post-stroke care favourably affects stroke recurrence.

Methods

Prospective cohort of consecutive stroke patients admitted at two tertiary stroke centers. According to health insurance provider status, patients were assigned to either 12-months organized post-stroke program or conventional care. The post-stroke pathway was facilitated by certified case managers and included regular home- and phone visits aiming at educational intervention and guideline-based secondary prevention treatment goals. Primary outcomes were stroke recurrence and vascular death at 12-months.

Results

In total, 1109 patients were recruited between 11/2011 and 12/2020. Of these, 1009 patients (91%) were assigned to organized post-stroke care and 100 (9%) to conventional care (mean age 70.6±12.8 years, 54% male, median NIHSS 3 [IQR, 1-5] points, 77.5% AIS, 17.9% TIA and 4.6% ICH). Baseline demographics and clinical characteristics were well balanced between both groups (p≥0.05). At 12-months, recurrent stroke rate was lower in the post-stroke care than in the conventional care group (5.5% vs. 14%; aOR 0.35, 95%CI 0.18-0.66; p=0.001). This association was not modified by stroke severity (TIA/minor stroke versus major stroke). Vascular death occurred in 0.2% in the post-stroke care and 3% in the conventional care group (aOR 0.07, 95%CI 0.01-0.41; p=0.003). Organized post-stroke care more frequently yielded individual treatment goals for hypertension, lipids, HbA1c, body-mass-index and secondary prevention adherence than conventional care (p<0.05).

Conclusions

Our results substantiate the effectiveness of case management-based post-stroke care in unselected stroke patients.

Background and Aims

The program evolved from a meeting to discuss a pre-post study of stroke care to a platform that provides support to researchers in low resource settings (LRS). The aims of this international forum are:

•To critically examine the challenges and quality of research efforts as well as to analyze the outcomes of research collaboration in LRS

•To outline the recommendations specifically tailored to enhance and strengthen the research capacity for the benefit of global citizens

Methods

A diverse, multidisciplinary, multinational research group were assembled and it was the first formal online platform (OSCAIL SYMPOSIUM-November 2020) where we discussed about collaborative initiatives taken in LRS such as the OSCAIL (Organized Stroke Care Across Income Levels), SSO (Stroke Support Organizations), Stroke in Sierra Seone(SISLE). From the initial symposium it was clear that there was high level of need to extend discussion on important topics related to conducting stroke research in LRS.

Results

We have held 4 international forums on topics including; how to sustain change after stroke partnership and research program; advocacy and awareness raising; how to support stroke caregivers; data collection and consent process.Attendance ranges between 20-40 multidisciplinary participants, representing 8 countries. Key messages that have emerged include: stroke care champions are key, stake holder involvement can help to reduce barriers and promote sustainability, support or recognition from the government, partnership with hospitals may be needed

Conclusions

The ultimate goal of the OSCAIL group will be to promote research capacity building in LRS so as to avoid past mistakes and maximize the clinical translation.

Background and Aims

Ischemic stroke causes a lack of oxygen and glucose supply to brain, eventually leads to severe neurological disorders. Retinoic acid is a major metabolic product of vitamin A and has various biological effects. The PI3K-Akt signaling pathway is an important survival pathway in brain. Phosphorylated Akt is important in regulating survival and apoptosis. We examined whether retinoic acid has neuroprotective effects in stroke model by regulating Akt and its downstream protein, Bad. Moreover, we investigated the relationship between retinoic acid and Bcl-2 family protein interactions.

Methods

Animals were intraperitoneally administered vehicle or retinoic acid (5 mg/kg) for four days before surgery and ischemic stroke was induced by middle cerebral artery occlusion (MCAO) surgery. Neurobehavioral tests were performed and brains were collected 24 h after MCAO. Western blot analysis, immunohistochemistry, and immunoprecipitation were performed for further study.

Results

Retinoic acid reduced neurological deficits and histopathological changes, decreased the number of TUNEL-positive cells, and alleviated reduction of phospho-Akt, and phospho-Bad expression caused by MCAO damage. Furthermore, retinoic acid mitigated the increase in Bcl-2/Bad and Bcl-xL/Bad binding levels and the reduction in Bcl-2/Bax and Bcl-xL/Bax binding levels caused by MCAO damage. It alleviated the increases in caspase-3 expression caused by MCAO. We showed that retinoic acid alleviated neurological disorders, attenuated the decrease in phospho-Akt and phospho-Bad expression, modulated Bcl-2 family protein interactions, and ultimately alleviated caspase-3 activation.

Conclusions

Therefore, we demonstrate that retinoic acid prevented apoptosis against cerebral ischemia through phosphorylation of Akt and Bad, maintenance of phospho-Bad and 14-3-3 binding, and regulation of Bcl-2 family protein interactions.

Background and Aims

Background

One of the conceptual frameworks of emergency medical services is a well-performing, trained paramedical workforce who are critical in the accurate differentiation of stroke from mimics to ensure optimal use of limited resources in emergency care, particularly in the era of the pandemic.

Aim

Compare the accuracy of paramedic diagnosis of stroke against the provisional diagnosis made in the emergency department.

Methods

Methods

A retrospective analysis using local data linked to the ambulance and emergency department (ED) databases was collected between the 1^st and the 31^st of August 2021.

All patients identified as TIA/stroke on the ambulance database were included.

The ED diagnosis of stroke/TIA by a senior decision-maker was used as the standard for comparisons with the paramedic diagnosis.

Results

Results and Analysis

A total of 210 patients were identified with a diagnosis of stroke /TIA on the ambulance database in August 2021.

Of these, 75 patients (36%) had ED diagnoses of stroke; 47patients (22%) were diagnosed as TIA, and the remaining 42% were mimics.

Seizures and migraine were the commonest mimics.

The predictive positive value of paramedic diagnosis of stroke/TIA of 58%.

Conclusions

Conclusion

The results suggest a need for the improved recognition of stroke/TIA diagnosis by the paramedics, especially at a time when ED services are overwhelmed globally.

Professional development may be achieved by timely constructive feedback & regular training sessions delivered by the stroke team.

Such strategies may be facilitated by the Integrated Stroke Delivery Networks (ISDNs) as part of National Stroke Service Model in the U.K.

Background and Aims

Recognizing early symptoms of stroke is vital for prompt intervention. However, there are a small cohort of patients who present without the traditional FAST (Facial dropping, Arm weakness, Speech difficulties and Time) symptoms.

Croydon Hospital stroke team aims to investigate the cluster of symptoms common in atypical strokes to help support physicians in their diagnosis and management.

Methods

We reviewed our hospital’s SNNAP (Stroke Sentinel National Audit Programme) data from 2013 to 2022. We looked at the cohort of patients who had radiological evidence of stroke with initial NIHSS (National Institutes of Health Stroke Scale) of 0. We analysed the gender, ethnicity, stroke subtype and the common initial symptoms.

Results

42 patients were analysed. They comprised 23 males (54.7%) and 19 females (45%). The age range was between 30 and 93 (average of 66). Ethnicity: British/Irish (31.8%), Asian (18.2%), Afro-caribbean (15.9%) and Mixed (2.7%).

We identified 9 predominant symptoms on presentation which were: dizziness, nausea/vomiting, headache, loss of consciousness (LOC), unsteadiness, confusion, fall, seizure and vertigo.

Over 70% (30) of strokes were infarcts versus 26% (11) haemorrhage. 67% (20) of the infarcts were in the posterior circulation versus only 13% in the anterior circulation. The remaining 20% were multi-territory (anterior and posterior).

Conclusions

Strokes that present in unconventional ways are likely to be misdiagnosed particularly those involving the posterior circulation. The most common symptoms are dizziness, nausea/vomiting and headache. There needs to be increased awareness among the public, first responders and physicians about the atypical presentations of stroke to improve detection rates.

Background and Aims

There have been several reports of brain insults other than the perisylvian area of the dominant hemisphere that manifested as aphasia. We report a case of motoric aphasia in a patient with large cerebellar infarction.

Methods

Case Summary: A 63-year-old man presents with acute progressive neurological deficits (motoric aphasia, central vertigo, alternating hemiparesis) two days before admission. He was aphasic but fully alert. Non-contrast head CT revealed a large infarction of the left cerebellar hemisphere causing brainstem compression and hydrocephalus. Both perisylvian regions were spared. He was started on antiplatelet, statin, and hyperosmotic mannitol infusion. The next day, there was rapid deterioration of consciousness, and he was transferred to the intensive care unit. Mannitol was tapered over a period of 7 days. The patient started to regain consciousness on the fourth day and was fully alert over 1 week, with partial improvement of aphasia. He was discharged afterwards with significant clinical improvement.

Results

Discussion: There is emerging evidence that cerebellar lesions may cause neurolinguistic deficits. We postulate the aphasic syndrome in this patient may be due to crossed cerebello-cerebral diaschisis; the inhibition of prefrontal dominant hemisphere language functions secondary to disturbance of excitatory impulses of the ascending cerebello-ponto-thalamo-cortical projections. Furthermore, improvement in aphasia may be attributable to relief from the compressive effects of edema on this structure.

Conclusions

Cerebellar lesions may result in aphasic syndromes probably due to interruption of linguistic network from cortical projections.

Background and Aims

Transient receptor potential melastatin 2 (TRPM2) has been postulated to participated in cerebral ischemia/reperfusion (I/R) injury. The present study aimed to investigate the role and possible mechanism of TRPM2 in cerebral I/R injury.

Methods

Western blot was used to detect TRPM2, CaMKIV, pCaMKIV, CREB, pCREB and apoptosis-related protein expression, whereas TRPM2 and apoptosis-related mRNA was examined using qRT-PCR. Flow cytometry and a TUNEL assay were used to detect the percentage of apoptotic cells. The apoptosis-related protein was also analyzed by immunohistochemistry.

Results

In vitro finding revealed that TRPM2 expression was increased in OGD/R group compared with TRPM2-deficient group and control group (P＜0.05). Apoptosis-related protein, pCaMKIV/CaMKIV, pCREB/CREB expression was increased in TRPM2 overexpression group (P＜0.05). TRPM2 damage neurons was significantly reduced following treatment with TRPM2 blocker. TRPM2 overexpression group was added with CAMKIV and CREB inhibitors respectively before OGD/R. Results showed that there was no significant difference between the expression levels of the above-mentioned apoptosis-related protein and the control group(P＞0.05). Our results in vivo suggested that the infarct size in TRPM2-KO mice were smaller than those of wild-type mice following MCAO/reperfusion(P＜0.05). Inhibition of TRPM2 expression can effectively reduce the production of apoptosis-related factors and pCaMKIV/CaMKIV, pCREB/CREB in brain tissue. Inhibition of CAMKIV and CREB expression could achieve the same inhibited apoptosis effect without affecting the expression of TRPM2.

Conclusions

TRPM2-mediated CaMKIV/CREB pathway activation contributed to cerebral ischemia/reperfusion injury. CaMKIV/CREB blockade ameliorated cerebral ischemia/reperfusion injury. CaMKIV/CREB disruption may serve as a novel target for therapy following MCAO.