Period of visit: 28^th June – 9^th July 2021

I am happy to bring you back some of my educational experience at Inselspital Bern, Switzerland, and to report here about the many inspirations received. My visit lasted two weeks, and together with Dr Mirjam Heldner, on the first day we designed the program that best suited my interests.

In the Emergency Department, I had the opportunity to follow the care pathway of stroke patients since the very beginning. I am truly grateful to the neurologists and the residents for their warm welcome and their availability to illustrate me the whole process and discuss every single case, even in emergency conditions. An efficient system of pre-notification allows the early activation of neurologists, nurse staff, and neuroradiologists before patient arrival. Moreover, helicopter transportation grants the access to urgent care for patients living in remote areas of Switzerland, such as mountains and valleys. In most cases, the initial imaging of choice is represented by a comprehensive MRI protocol (including parenchymal imaging, MR angiography, and MR perfusion), and an efficient organisation defined in every detail allows to greatly reduce the time of intervention. Within a few days, I had the opportunity to assist to a large spectrum of different cases, including wake up strokes, microbleeds on baseline imaging, distal occlusion strokes, mild strokes with proximal occlusions, and intracerebral haemorrhages on anticoagulation. I could also assist to several procedures of endovascular thrombectomy: in the angiographic suite, the neurointerventionalists illustrated me the entire procedures, and we discussed about dealing with complex anatomy and complications, as well as pharmacological protocols and device details for stenting procedures.

I attended the morning ward round in the Stroke Unit: each single case was discussed in a helpful and cooperative environment together with all the professional figures implied in patient care, including neurologists, residents, specialized nurses, physiotherapists, occupational and logotherapists, and other specialists. The open discussion of each case was also an occasion for me to ask about the practical approaches to unanswered questions and controversies in stroke medicine. I really admire the implementation of the latest scientific findings in the day-to-day care routine and the decision-making process based on a careful evidence-based basis. More, I have learned about the ongoing internal clinical trials, which will give relevant answers to all our stroke community in the next future. I was also curious about observational protocols and clinical research: lots of studies covering the wide spectrum of stroke research fields are ongoing and a dedicated staff is always active to bring research to the best standards.

Last but not least, I would like to express my gratitude for the whole experience. Thanks to the European Stroke Organisation and Prof Urs Fischer for giving me the opportunity to visit the Stroke Centre at Inselspital, to Dr Mirjam Heldner for the careful organisation of the visit, to Prof Marcel Arnold and Dr David Seiffge for the stimulating ideas and discussions, to Dr Pasquale Mordasini, Dr Tomas Dobrocky, Dr Eike Piechowiak for the neurointerventional tips, and importantly to the entire team for the warm welcome and the inclusive environment. Hope to meet you all again in the next ESO conferences!

Time of fellowship: 16.7 – 30.08.2021

Supervisor Prof. em. Maja Steinlin, together with Dr.Phil.nat Leonie Steiner (Neuropsychologist) and PD dr. Arsany Hakim (Neuroradiologist)

I would like to express my gratitude to the European Stroke Organization (ESO) for an opportunity of two weeks to research at the Department of Neuropaediatrics, Development, and Rehabilitation, University Children’s Hospital, Inselspital (Bern, Switzerland), chaired till the end of July 21 by Prof. Maja Steinlin (who is still working there as a Senior Consultant and being PI of the PASTA study).

It was a great pleasure to work under the supervision of Prof. Steinlin,

During my fellowship, I was introduced to the Swiss Pediatric Stroke Database SNPSR, founded by Prof. Steinlin, which is a population-based registry from the Swiss Society of Neuropediatrics with the study center in Bern. The register is running since January 2000 and up to date, more than 800 children are registered. Every child living in Switzerland from birth to 16 years who suffered an acute stroke is registered. Data on manifestation, risk factors, neuroimaging, treatment, and outcome are collected and analyzed on different aspects.

I observed the recent and ongoing studies from SNPSR, and was involved in the research of the outcome of pediatric stroke. I was also integrated into the research group of the department.

During these two weeks, I had the opportunity to finalize the design of a project including Swiss and Georgian children after stroke. I was introduced to some modern techniques for analyzing neuroimaging, which will not only be the base for the ongoing study but will also help me back home in Georgia to improve care for children with stroke.

With some further funding from the EAN, I have now the opportunity to stay for another 6 months in Switzerland and finalize the project. Our study aims to evaluate the predictive value for prognosis (outcome by PSOM and occurrence of epilepsy) in children after stroke by different methods for analyzing neuroimaging. We will analyze images from Georgian and Swiss children – all together from about 200 children.

In neuroimaging from the acute phase (first diagnostic imaging), several techniques were applied: 1. Segmentation: The DWI sequence for the determination of infarct volume and the T2 weighted sequence for the determination of supratentorial brain volume (SBV) (because of superior resolution). Segmentation of the acute/subacute infarct and determination of SBV performed using 3D Slicer volumetric software program. Infarct volume was expressed continuously as a percentage of SBV, and categorically as ≥ 5% of the SBV (Wiedemann et al.). 2. Alberta Stroke Program Early CT Score using acute MRI (modASPECTS): The DWI images from clinically acquired MRIs were reviewed, cross-checked with the ADC maps, and scored, using the pedASPECTS. 3. The Diffusion-Weighted Imaging (DWI) infarct volume measurement using the ABC/2 method, calculated by two maximal orthogonal diameters multiplied by slice thickness.

The main part of the time, I spent (and will spend) at the neuroradiology department, where we worked on the MRI images of AIS patients (Supervision from Arsany Hakim). We will continue analyzing images from Georgia and CH and will get out the clinical data of the both systems.

With the support of the ESO fellowship, I got an insight into one of the best university hospitals in the field of pediatric stroke. The collaboration was established with Prof. Maja Steinlin, who is the leading expert in the field of pediatric stroke. Our common research will go on.

Working under the supervision of Prof. Steinlin, was valuable for my professional development.

I first had the idea to apply for the ESO Department to Department Visit programme after attending the very inspiring ESO-ESMINT-ESNR Stroke Winter School in Bern in the beginning of 2020. It made me curious about stroke management in clinical practice in the largest Stroke Centre in Switzerland, providing endovascular therapy for a population bigger than the entire Estonia. The COVID-19 pandemic did however pose several obstacles, so more than a year later the stars finally aligned and I was able to visit Inselspital in Bern.

The team in Inselspital was very welcoming and this is just one of the reasons why it has become a popular host for awardees of the ESO grant. With Dr. Mirjam Heldner we decided on a programme that aligned best with my interests. I spent the mornings joining rounds in the Stroke Unit with Dr. David Seiffge and the residents. I was fascinated by the well organized secondary prevention programme in the clinic. We had many interesting patients in the stroke unit during my visit, including patients who were eligible for PFO closure, left atrial appendage closure and event recorder implantation. Several questions about antithrombotic therapy in complex scenarios came up. I was especially impressed with the evaluation and management of atherosclerotic carotid artery disease. All patients with atherosclerotic changes or stroke with suspicion of artery-to-artery embolism received at least two modalities of imaging of the extra- and intracranial vessels. I was also able to attend the weekly neurovascular meeting, where treatment strategies for eligible patients were discussed with an interdisciplinary team.

In the afternoons I divided my time between the emergency room, the neurovascular lab and the stroke follow-up outpatient clinic. In the emergency room I was able to observe the pathways for patients who came in with a stroke alarm. Inselspital uses MRI as the main imaging modality for acute stroke patients so it was interesting to note the advantages but also difficulties this poses. Having a neuroradiologist on call around the clock certainly was alluring! In the neurovascular sonography unit the team was hard at work investigating the vessels of stroke patients. As my experience with neurovascular ultrasound is limited, I learned about the possibilities of the  investigation and the benefit of using this modality for following up stroke patients. In the outpatient clinic I was able to appreciate the wellstructured follow-up programme of stroke patients to ensure the continuity of secondary prevention strategies.

I would like to thank the European Stroke Organization and the team in Inselspital for this excellent educational opportunity and for being so accommodating through the obstacles that the global pandemic posed. Many  thanks to the wonderful team who welcomed me so warmly in Inselspital! I returned to Tallinn with many fond memories of the week and numerous ideas to discuss with my colleagues.

Period of Visit: 18th October – 5th November 2021

Firstly, I would thank the European Stroke Organization for allowing me to live this wonderful experience and the Neurology Department of Inselspital for accepting my application.

What an experience!

During the external rotation of my residency, which finished in 2019, I could get the first contact with vascular neurology, not having an emergency department at my Academic Hospital. Then I continued my training on my own, trying to improve my skills as a vascular neurologist and as a neurosonologist in my Department and during short working experiences in non-academic hospitals in my Region.

During the weeks at Inselspital, my main goal was to capture the decision-making process of the Stroke Team, and to steal some tips to apply to my daily routine once came back. Furthermore, to put my new knowledge in the development of a Stroke Unit at my Academic Hospital and to hand it over to residents of my School of Neurology.

I expect that this period of internship in Bern will be crucial in my professional path. During time spent there I had the privilege to assist and discuss a great variety of clinical scenarios and a large number of stroke patients.

Inselspital is the place that each vascular neurologist imagines in his dreams: my daily routine was made of early morning hours spent in the emergency department waiting for a wake-up stroke; then to the ward round in the Stroke Unit, discussing and visiting each patient admitted (and mostly yet known, because welcomed at the emergency department in the day before) and then to the ultrasound lab where despite I routinely perform ultrasound examinations in my Hospital, I could learn new techniques and the correct setting of each neurovascular doppler examination. Surely this will help me improve the quality of my exams and give me the possibility to guarantee better care to my vascular patients.

Every step of this path had its peculiarity: the emergency department, which welcomes patients directly from emergency territorial services or from peripheral stroke units able to perform only intravenous treatments, is the place where I had the chance to learn what was the process to decide whether and how to treat acute stroke patients; conversely, the visit round in Stroke Unit is the moment in which, by re-discussing the imaging (mainly MRI) and the peculiar features of each patient, we tried to state the exact mechanism of the stroke to provide the best secondary prevention therapy. Furthermore, in Stroke unit skilled paramedical team guide patients through the very early phase of rehabilitation; lastly the ultrasound lab represents a key place in the
process of discovering the possible causes of strokes and in patients’ long-term follow up. Moreover, during these three weeks, I was able to assist directly in the angio-suite four thrombectomies. It was surprising how interventional neuroradiologists were so engaged in explaining to me each part of the procedure!

Concluding, it was impressive the importance given to theoric education granted to residents: each week took place the neurovascular board in which each resident can discuss a case of particular interests; moreover, on Tuesday afternoon neurologists of peripheral stroke units could ask the neurology team of Bern how to manage challenging cases. Lastly, once a week, residents could follow in-site seminars about various neurological diseases.

The richness of this experience, nevertheless, was not made up of only neurovascular concepts. What I witnessed was a highly organized staff, not only regarding supervisors or residents but also concerning the entire system of stroke care. From nurses to physiotherapists, from neuropsychologists to logopedics, everyone knows what to do and did it in the best way possible, resulting in a higher chance of a good outcome for patients.

But I had not only professional enrichment; from a personal point of view, I found a team with a great willingness to teach, available to translate any discussion in English, and with always an answer to my thousands of doubts. My welcome was very warm: I had never been left alone in my time at the hospital because in every moment I found someone available to answer my doubts and to discuss challenging cases.

My main aim, once at home, will be to export the model of stroke assistance seen at Inselspital in my Hospital, where the project is to create a Stroke Unit of the second level deeply involved in stroke treatment in my Region. Not of less importance will be the process of handing over to the residents of my School of Neurology, that must become skilled to train properly acute stroke patients in our territory.

I am grateful to the Stroke Team of Inselspital, Bern, for sharing with me their knowledge on vascular neurology, hoping to take advantage of it to serve my country the best as possible!

Naples, 8th November 2021

Time of visit: 09 August – 03 September 2021

First, I would like to thank the European Stroke Organization and Prof. José M. Valdueza for this excellent educational opportunity at Segeberger Kliniken. I would also like to express my gratitude for the warm welcome I received from the team at the Departments of Neurology and Neurorehabilitation.

During the four weeks internship, I spent most of my time in the Neurosonology Laboratory, where we performed around 100 extracranial and transcranial doppler ultrasounds, as well as bubble tests for right-to-left shunt detection. With the guidance and supervision of Professor Valdueza, I had the opportunity to see the whole spectrum of vascular pathologies in stroke patients, such as arterial dissections, AV malformations, ICA origin or intracranial stenoses, and Halo sign in vasculitis.

I acquired new techniques which are not part of the daily practice in my home country, for example midbrain ultrasound for patients with movement disorders or contrast-enhanced transcranial dopplers for patients with no temporal bone window. The training provided detailed knowledge on vascular anatomy and advanced protocol for transcranial doppler ultrasound. This hands-on experience supported my theoretical knowledge to be used in practice and increased my confidence in diagnostics.

I was most fascinated by the complex way of thinking about ischaemic stroke subtypes and the thorough protocol of stroke etiology investigation. The different modalities of investigation, especially vascular imaging (CTA, MRA, DSA, ultrasound) findings were always integrated to reach the final diagnosis of each patient.

To further support the colleagues’ development, Professor Valdueza led case presentations and neuroradiology sessions every week. These lectures gave an opportunity to learn about other central nervous system disorders besides stroke and further supported my knowledge and shaped my thinking as a professional.

After completing this internship, I could revise and develop the protocols of neurosonography examinations and bring the diagnostic workup of stroke patients to a higher standard in my home Institution.