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Keynote 1 – Wednesday, 31 July 2013 09:00–10:00

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  2. Keynote 1 – Wednesday, 31 July 2013 09:00–10:00
  3. Keynote 2 – Wednesday, 31 July 2013 16:00–17:00
  4. Keynote 3 – Thursday, 1 August 2013 09:00–10:00
  5. Keynote 4 – Friday, 2 August 2013 09:00–10:00
  6. Keynote 5 – Friday, 2 August 2013 13:30–14:30

Strategies to improve vascular risk factor control in underserved racial/ethnic populations

K. Berra

Stanford Prevention Research Center, Stanford University School of Medicine

Stroke is the second leading cause of death worldwide, and the leading cause of acquired disability in adults. In 2011, the United Nations Political Declaration on the prevention and control of non-communicable diseases, led by vascular diseases, was announced. This Global effort has gained significant momentum in the past 2 years. Countries of low and middle income have the largest burden of stroke, accounting for more than 85% of stroke mortality worldwide. Data has shown ten modifiable cardiac and vascular risk factors highly associated with 90% of the risk of stroke. Targeted interventions to reduce blood pressure and smoking, and promote physical activity and a healthy diet, have been shown to substantially reduce the burden of stroke and other vascular diseases.

A disproportionate share of the burden of CVD and metabolic/vascular risk factors falls on racial and ethnic communities secondary to social, environmental, biological, and health care system factors. The challenge is to find effective ways to initiate lifesaving medical therapies and support adherence to difficult lifestyle change in underserved populations as well as for all adults. Significant evidence exists supporting a systematic approach to vascular risk reduction through team-based, nurse-directed case management. Implementation of case management programs holds promise to reduce the personal and societal burden of vascular diseases.

Keynote 2 – Wednesday, 31 July 2013 16:00–17:00

  1. Top of page
  2. Keynote 1 – Wednesday, 31 July 2013 09:00–10:00
  3. Keynote 2 – Wednesday, 31 July 2013 16:00–17:00
  4. Keynote 3 – Thursday, 1 August 2013 09:00–10:00
  5. Keynote 4 – Friday, 2 August 2013 09:00–10:00
  6. Keynote 5 – Friday, 2 August 2013 13:30–14:30

Non-pharmacological reperfusion for acute ischemic stroke

C.A. Molina

Stroke Unit. Hospital Valld'Hebron, Barcelona

Intravenous thrombolysis remains the only approved therapy for acute ischemic stroke. However, it has a short therapeutic window, a strong time-dependency, and has only marginal benefit in strokes due to proximal arterial occlusions. Endovascular therapy has many theoretic advantages over iv thrombolysis. Mechanical thrombectomy reduces and may even preclude the use of chemical thrombolytics and this may further reduce the risk of ICH, allowing faster and sustained recanalization. However, endovascular recanalization techniques have also relevant disadvantages, including delays in initiating treatment, complexity of the procedure, high level of required technical expertise, low availability and risks and expense of an invasive procedure as compared with iv tPA. Nevertheless, given the strong relationship between vessel recanalization and good clinical outcomes, the advantages of endovascular stroke therapy as the most efficacious treatment for recanalization of large vessel intracranial occlusions may outweigh its disadvantages and risks, but this needs yet to be proved.

Novel stent retrievers or “stentrievers”, intracranial stents that are deployed and retrieved snaring the thrombus showed very promising results. Recently, the SOLITAIRE™ With the Intention for Thrombectomy (SWIFT) trial compared two mechanical thrombectomy devices: The MERCI retriever and the SOLITAIRE retrievable stent in the arterial recanalization of patients with acute ischemic stroke. The SWIFT trial has shown in 113 patients that the Solitaire™ FR device is superior to the MERCI® Retriever in achieving successful revascularization (by Corelab, 68% vs 30%, <0.001), inducing less symptomatic intracranial hemorrhage (2% vs 11%, p = 0.06), reducing mortality (17% vs 38%, p = 0.02), and increasing good neurologic outcome 3 months after stroke (58% vs 33%). The IMS-3 was prematurely halted due to futility according to the results of a pre-specified interim analysis. The proportion of patients who achieved a mRS score mRS ≤ 2 at 90 days did not differ significantly according to treatment (40.8% with endovascular therapy and 38.7% with intravenous t-PA). Regarding safety results, mortality at 90 days (19.1% and 21.6%, respectively; p = 0.52) and symptomatic intracerebral hemorrhage within 30 hours after initiation of t-PA (6.2% and 5.9%, respectively; p = 0.83) were comparable between the two groups. There is equipoise on endovascular therapy for acute stroke so far. The ideal thrombectomy trial design should test a single device, randomize patients according to intracranial occlusion, include tPA non-responders and use advanced imaging for patients selection beyond 4.5 hours. In addition, the trial should be conducted in a few centers with high recruitment capacity and neurointerventional expertise to decrease intercenter variability. Finally, the ongoing CLOTBUST-ER study is aiming to demonstrate the effects of ultrasound application -by means of an independent-operator device- on long-term clinical outcome.

Keynote 3 – Thursday, 1 August 2013 09:00–10:00

  1. Top of page
  2. Keynote 1 – Wednesday, 31 July 2013 09:00–10:00
  3. Keynote 2 – Wednesday, 31 July 2013 16:00–17:00
  4. Keynote 3 – Thursday, 1 August 2013 09:00–10:00
  5. Keynote 4 – Friday, 2 August 2013 09:00–10:00
  6. Keynote 5 – Friday, 2 August 2013 13:30–14:30

Systemic effects of stroke as targets for brain protection

U. Dirnagl

Center for Stroke Research, Berlin, Germany

Stroke is a major cause of morbidity and mortality worldwide. For obvious reasons, neuroprotection research over the past decades has almost exclusively focused on the brain. Due to a multitude of reasons, despite tremendous efforts and great progress in our basic understanding of the pathobiology of brain ischemia, therapeutic neuroprotection has not reached patients with a stroke. Only recently, it has become clear that other organ systems, more easily accessible to therapeutic approaches than the brain, also have a tremendous impact on outcome after stroke. For example, stroke affects the normally well balanced interplay of the two supersystems – the nervous and the immune system. Post-stroke infections are important modulators of brain inflammation and plasticity. In addition, the cardiovascular system impacts on post-stroke recovery not only because of the potential of recurring events, but also because it is involved in revascularizing ischemic areas and potentially also in regeneration and repair. Stroke also strongly affects systemic metabolism, with important consequences on body composition and for short as well as long term outcome. In my talk, I will review our current knowledge on the impact of systemic alterations after stroke on brain tissue damage, brain repair, and overall outcome, and speculate about potential novel avenues of therapy which result from these insights.

Keynote 4 – Friday, 2 August 2013 09:00–10:00

  1. Top of page
  2. Keynote 1 – Wednesday, 31 July 2013 09:00–10:00
  3. Keynote 2 – Wednesday, 31 July 2013 16:00–17:00
  4. Keynote 3 – Thursday, 1 August 2013 09:00–10:00
  5. Keynote 4 – Friday, 2 August 2013 09:00–10:00
  6. Keynote 5 – Friday, 2 August 2013 13:30–14:30

Impact of blood pressure changes and course on hematoma growth in acute intracerebral hemorrhage

C.A. Molina

Stroke Unit, Hospital Valld'Hebron, Barcelona

Background: Early increase of blood pressure (BP) is common in acute intracerebral hemorrhage (ICH) and has been associated with poor outcome. Therefore, the current American Heart Association (AHA) guidelines for the management of spontaneous ICH recommend maintaining systolic BP (SBP) below 180 mmHg in the acute period with short half-life intravenous antihypertensive drugs. However, demonstration of the safety of early more intensive BP lowering in INTERACT and ATACH trials may change the management of BP in acute ICH patients in the future.

INTERACT also showed a trend towards lower relative and absolute hematoma growth (HG) at 24 hours in the intensive BP treatment group (SBP below 140 mmHg) compared with the AHA guideline based BP management group without increasing adverse events, suggesting a relationship between BP and HG. Nevertheless, the association of higher BP with the risk of HG in acute ICH has not been clearly demonstrated yet. While several studies have described a relationship between higher BP and HG, others have not found any relationship between them. However, these studies performed only a few BP determinations during the first 24 hours and did not evaluate other variables such as BP variability.

An association between high blood pressure (BP) in acute intracerebral hemorrhage (ICH) and hematoma growth (HG) has not been clearly demonstrated. Little is known about the relationships between different systolic blood pressure (SBP) thresholds and hematoma growth (HG) in acute intracerebral hemorrhage (ICH). Therefore, we aimed to investigate the impact of potential SBP treatment thresholds on HG in patients with acute ICH. Therefore, we aimed to determinate the impact of BP changes and course on HG and clinical outcome in patients with acute ICH.

Methods: One hundred and seventeen consecutive patients with acute (<6 hours) supratentorial ICH underwent baseline and 24-hour computed tomography (CT) scans, CT angiography for the detection of the spot sign, and noninvasive BP monitoring at 15 minutes interval over first 24 hours. Maximum and minimum BP, maximum BP increase and drop from baseline, and BP variability values from systolic BP (SBP), diastolic BP, and mean arterial pressure (MAP) were calculated. We defined SBP and MAP loads as the proportion of readings >180 and >130 mmHg, respectively. HG (>33% or >6 mL), early neurological deterioration (END), and 3-month mortality were recorded.

Results: Baseline BP variables were unrelated to either HG or clinical outcome. Conversely, SBP 180-load independently predicted HG (OR 1.05, 95% CI 1.010–1.097, P = 0.016), while both SBP 180-load (OR 1.04, 95% CI 1.001–1.076, P = 0.042) and SBP variability (OR 1.2, 95% CI 1.047–1.380, P = 0.009) independently predicted END. Although none of BP monitoring variables were associated with HG in the spot sign-positive group, higher maximum BP increases from baseline and higher SBP and MAP loads were significantly related to HG in the spot sign-negative group.

Conclusions: In patients with acute supratentorial ICH, SBP 180-load independently predicts HG, while both SBP 180-load and SBP variability predict END. In patients with acute ICH, those who experience HG present higher SBP load from 140 to 200 mmHg thresholds. More intensive SBP-lowering treatment may be needed, at least <170 mmHg, to minimize the deleterious effect of high SBP on HG.

Keynote 5 – Friday, 2 August 2013 13:30–14:30

  1. Top of page
  2. Keynote 1 – Wednesday, 31 July 2013 09:00–10:00
  3. Keynote 2 – Wednesday, 31 July 2013 16:00–17:00
  4. Keynote 3 – Thursday, 1 August 2013 09:00–10:00
  5. Keynote 4 – Friday, 2 August 2013 09:00–10:00
  6. Keynote 5 – Friday, 2 August 2013 13:30–14:30

Telerehabilitation: a service delivery strategy for stroke

T. Russell

University of Queensland

Primarily developed to provide equitable access to individuals who are geographically remote and to those who are physically and economically disadvantaged, telerehabilitation also has the capacity to improve the quality of rehabilitation health care. Online delivery of rehabilitation enables the rehabilitation therapist to optimize the timing, intensity and duration of therapy that is often not possible within the constraints of face-to-face treatment protocols in current health systems.

This presentation will outline recent advances in telerehabilitation applications within the fields of physiotherapy, speech-language pathology, occupational therapy, and biomedical engineering and provide evidence for the success and failure of these applications for stroke survivors. Applications to date encompass systems ranging from low-bandwidth low-cost videophones, to highly expensive, fully immersive virtual reality systems with haptic interfaces.

The challenges, barriers and opportunities that these technologies present for the rehabilitation of stroke survivors will be discussed and the possible future directions of telerehabilitation will be presented.