By Francesco Corea, Stroke and Neurology Units, Ospedale San Giovanni Battista Foligno, Italy
The session at the ESO 2021 virtual conference, Acute Stroke Treatment in Difficult Clinical Situations: In-Hospital Strokes and Other Challenges was one of several sessions that addressed stroke in COVID-19 patients. Francesco Corea, Chair of ESO`s Social Media Committee and an Acute Stroke Specialist, summarises the session below.
The session took place on Thursday 2nd September at 08.30 in Hall A and will be avaliable to watch on demand via the ESOC platform until 3 December 2021 in case you missed it.
Introduction of the Speakers and Session Overview
Introduction of the Speakers and Session Overview
Thrombolysis in Patients With Recent Surgery or Trauma
Gordian Hubert presented the talk on Thrombolysis in Patients with Recent Surgery or Trauma. A relevant topic, as he points out, but with little evidence to support our decisions. The experiences of the telestroke network TEMPiS may be encouraging, showing a low rate of surgical site hemorrhages. Recent surgery and major surgery and especially the combination of both seem to have the highest risk of surgical site hemorrhage. But given the retrospective design and general low evidence, decisions have to be made case by case. In post-traumatic patients evidence is even more scarce. He proposed an approach on how to find decisions in these cases: a) define the risk of surgical site hemorrhage, b) know the damage a bleeding could cause and c) know about possible interventions. Further research is encouraged in this area.
The Older Patient With Extensive Medical History: What to Do?
The speaker Senior neurologist working in Stroke Unit and Emergengy Medical services at Helsinki University Hospital addressed the topic of stroke in older and complex patients. In these cases comorbiity index may be useful. Thus we can define the concept of frailty with specific related scales. Together with scoring scales to select the patients also an appropriate evaluation of the premorbid functional performance of the patient may be vital for the decision making process. The pre-notification and accessibility of electronic medical charts may simplify the management of stroke admissions. Functional performance may be relevant for the decision making process to speed up treatment. Not living alone and having impaired mobility with limited functionality may need to better select candidates to IVT EVT.
Stroke in the Cath Lab and Related Situations
The third speaker Rajiv Advani depicted how the diffusion of endovascular procedures in many hospitals is increasing all over the world. The complications of cardiac procedures is low but in absolute numbers can be relevant in daily practice. Both ischemic and hemorrhagic event may complicate the hospitalization and need for an urgent neurological evaluation. These patients are often in advanced age thereby are selected for endovascular procedures instead of undergo to traditional open heart surgery. The detection of stroke during the procedure can be challenging for various reasons such as the setting of the patients in a ICU and multi-morbidity. An appropriate balance of risks and benefits is need. Main risks are due to GE tract bleedings. The use of iv salicylates or abciximab seem not safe for higher risk of bleedings after IVT. The recent use of heparins needs monitoring of aPTT. TWhile in general thrombolysis using reduced doses or rTPA have no sufficient data available to state a reduced bleeding risks. Direct EVT may be indicated in selected cases with large vessels occlusion.
Thrombus Composition in Diverse Stroke Aetiologies: Imaging, Histology and Treatment.
Dr Bacigaluppi continued the session with a presentation from Stroke Unit and Neuroimmunology lab of San Raffaele Hospital in Milan. His data demonstrated relevant informations from the analysis of thrombi retrieved after EVT. Thrombus analysis, can be made by many pathologists, and may offer relevant data but only in a small amount of subjects (3% of all stroke cases, because limited to those with large vessels pathology undergoing EVT). The analysis of the sample may offer interesting informations on: etiology, imaging correlations, new therapeutic targets/devices and blood biomarkers.
The point is to unravel stroke etiology looking in the sample for a “signature” on the origin: colesterol, structure, calcification, prostethic tissues, bacteria.
Management of Acute Ischemic Stroke in Patients Suspected of COVID-19 Infection
The last speaker from Padua University Hospital Claudio Baracchini reported interesting data on the incidence of stroke in COVID pandemic series, which was initially reported up to 5 % but later in lower but not negligible figures.
Potential mechanisms underlying are various: coagulopathy, inflammation, cardiopathy, platelet abnormalities. Stroke patients are more prone to develop COVID in a severe way.
As well as many COVID 19 related strokes seems crypto-genetic and occurring in abnormal age with higher mortality rates and poorer outcome. During pandemic times a protected stroke code was recommended to keep a fast safe lane together with temporary stroke buffer areas and mobile CT unit. No general contraindication to stroke specific treatments in acute a secondary prevention in COVID stroke cases. The use of tenecteplase may reduce staff exposure.