Looking back at ESOC 2021: infection and inflammation in stroke

By Dr. Inna Lutsenko, neurologist, specialist at the Center of Distance and Advanced Training, Kyrgyz State Medical Academy.

Several weeks have passed since the ESOC 2021 and we are now reflecting on some important topics. In the light of the COVID-19 pandemic, several study groups have addressed the relationship between stroke and infection. The ESOC provided a special session entitled Infection and Inflammation in Stroke, moderated by dr. Andreas Meisel, from the Charité Universitätsmedizin of Berlin and Laura McCulloch from the University of Edinburgh.

In her presentation COVID-19 and Stroke: Aetiologies, Short and Potential Long-Term Effects,  Dr. Elena Moro, discussed that stroke is among the most severe complications of the coronavirus infection. COVID-19 infections may lead to systemic changes including a cytokine storm, systemic inflammatory response, neuroinflammation, ACE2 receptors downregulation, multifactorial activation of coagulation, and thrombotic microangiopathy.(1)

Besides, COVID-19 infections can have a direct influence on the endothelium and choroid plexus.(2) It can also damage the brain-blood barrier and the coagulation cascade.(3) However, in contrast to what we would expect, COVID-19 is associated with large vessel strokes and affects multiple vascular territories. Nevertheless, the treatment of the COVID-19 related stroke does not differ from the standard stroke treatment.(3) Intravenous thrombolysis and mechanical thrombectomy might be accompanied with anti-inflammatory agents (e.g. eculizumab, secukinumab, and tocilizumab).

Dr. Angel Chamorro in his presentation Inflammation as a Target in Stroke Prevention discussed the available evidence for neuroprotection targets in the inflammation process in the prevention of stroke. He emphasized that inflammation plays an a major role in the development of atherosclerotic related diseases. Several anti-inflammatory drugs have been studied and the ones that are effective require a rather large number-needed to treat. To understand neuroprotection and inflammation, dr. Chamorro emphasized the impact of oxidative stress, reperfusion injury, and hyperglycemia. He also discussed the URICO-ICTUS Trial that studied uric acid, a strong antioxidant in the human plasma. The results showed that the mean outcome of the trial did not reach statistical significance. However, there seemed to be a benefit for several subgroups.(3)

Dr. Craig Smith, in his presentation entitled Infection Preceding Stroke and Complicating Stroke – Epidemiological Evidence underlined that all systemic infections (i.e. urinary, skin, respiratory, and abdominal) are associated with the increased risk of ischemic stroke. He discussed a Chinese registry study in which the authors showed that pre-stroke infections are associated with a higher risk of recurrent stroke (adjusted OR 1,73 95% CI 1.02-2.94).(4). Besides, poststroke infections were also associated with a higher risk of recurrent stroke (adjusted OR 1,40 95% CI 1.05-1.86). Dr. Smith pointed out that the causality between stroke and infections remains, however, unclear and needs more research to allow modification of this risk by preventive interventions.