Aristeidis Katsanos

Welcome, everyone, and thank you for joining this roundtable discussion on the initial assessment of patients after a stroke. Today, we’ll explore how early evaluation shapes long-term outcomes, including the risk of stroke recurrence. I’m joined by three distinguished experts, Drs. Gisele Sampaio Silva, Diana Aguiar de Sousa, and Jesper Petersson. Could I ask each of you to briefly introduce yourselves to the audience and describe your main clinical research focus in stroke care?

Gisele Sampaio Silva

Yeah, I can start. So my name is Gisele Sampaio Silva. I’m a stroke and neurocritical care physician, a neurologist based in Brazil, São Paulo. And for me, it’s a great pleasure to be here and to contribute to this podcast.

Diana Aguiar de Sousa

Thank you, Aris. I think I can follow. So it is also a pleasure to be here. I’m Diana Aguiar de Sousa, a neurologist based in Lisbon, specialized in vascular diseases. I’m also professor at the University of Lisbon School of Medicine and investigator at the Gulbenkian Institute for Molecular Medicine. My research focus is on stroke in the young, with a particular focus on cerebral venous thrombosis. But I have been involved also in trials and studies on acute stroke care and stroke prevention and stroke care implementation. So I’m, as I said, very pleased to join this discussion today. And I hope we will go through all the key points in this topic. Thank you.

Jesper Petersson

So thank you again for the invitation for this really interesting discussion. So my name is Jesper Petersson. I’m based in Malmö, Sweden. I’m a stroke neurologist trained here and also a professor in neurology at Lund University. I have a long-standing interest in acute stroke treatment, especially taking part in organizing RCTs, but also in the last years a lot of epidemiological studies to find hopefully new associations and ways to treat and prevent stroke. So that would be my background.

Aristeidis Katsanos

Thank you all for being here and sharing your expertise. And starting with the basics, Gisele, how many patients do actually experience a recurrent stroke in the first month after the initial stroke? And if they do, what is the impact of stroke recurrence on patient outcomes?

Gisele Sampaio Silva

Yeah, so that’s a very important question because having a stroke is something so impactful in a patient’s life and having a recurrent stroke, it’s really, really something that we have to avoid. Yeah, there are some surveys that say that after a stroke, what patients fear the most is having a a second one so approximately three to five percent of patients experience a recurrent stroke within the first month and the highest rate is concentrated in the first two weeks after the index event so importantly it’s not just another event so as we just discussed is this is also associated with worse outcomes including higher mortality and greater disability and loss of independence. So in generally recurrent strokes tend to be more severe and significantly related to long-term health care burden, so this is something that we have to think about and to try to avoid the more that we can.

Aristeidis Katsanos

Thank you so much, Gisele, for nicely outlining the impact of stroke recurrence. Diana, if I may ask, are there any patient groups that clinicians should be very concerned about their risk of stroke recurrence? What is your experience about it?

Diana Aguiar de Sousa

Yes, absolutely. You know, although every patient with stroke and TIA really requires urgent evaluation and secondary prevention, the same, but some groups really should immediately raise our level of concern because their risk of recurrence is especially high, and especially, as Gisele was mentioning, especially in the early phase. I think the first group I would like to highlight is patients with large artery atherosclerosis, either extracranial or intracranial. These patients often have some of the highest early recurrence risks. For example, symptomatic carotid disease, symptomatic intracranial stenosis, or evidence of other unstable atherosclerotic sores are one of the reasons why we really need early vascular imaging and rapid treatment decisions according to the findings. This is very important.

Second, I think one of the important groups we all think about when we think of recurrence risk is cardioembolic stroke. Of course, especially patients with atrial fibrillation or other cardiac embolic sources, these patients, the risk is high, especially if we don’t identify promptly this mechanism and then do the appropriate preventive treatment in time. This is also why having cardiac evaluation and when needed prolonged monitoring are very important parts of the workup. And we all know now that we have all these trials, the ELAN, the OPTIMAS, the individual patient data meta-analysis from all these trials, the catalyst collaboration. In these patients with atrial fibrillation, this early diagnosis is very important also because we should really timely initiate anticoagulation, usually with DOAC when appropriate, of course, and this early initiation will reduce the risk of recurrence and this is something also to consider and very well supported now.

Third, I think another important group to consider is patients with TIA or minor stroke that have a high-risk underlying mechanism. Of course, this is a heterogeneous group but it is important to have in mind that a mild deficit or a transient deficit does not necessarily mean a low-risk situation. And sometimes I think this is misunderstood. So some of these patients will be in a very unstable phase. They have a substantial recurrent risk, especially if we don’t identify and treat the underlying mechanism. And so this is also why it is so important to really have a good assessment very early on of patients, also with TIA and minor stroke.

And then I think overall, patients with multiple uncontrolled risk factors, for example, high blood pressure, uncontrolled diabetes, smoking, high lipids, history of cerebrovascular events, these are all patients that we know also have a higher risk of recurrence. And finally, this is a less common group, more rare, but there are these patients with active cancer or prothrombotic states in general that often have an unusual clinical picture. They have these recurrent events without an obvious explanation, or they have this infarct pattern with several lesions, or very high D-dimers. So these patients, we should think more broadly if there’s an underlying prothrombotic mechanism, and we know these patients have also a high risk of recurrence.

So I think overall, and then in practical terms we should be worrying about these patients that have an underlying cause that the risk is still active so it’s still not treated. So large artery disease that is not treated, cardioembolism that is not identified and treated, high-risk TIA or minor stroke without the proper assessment, uncontrolled risk factors, possible cancer or other prothrombotic mechanisms. So the important really is that it doesn’t matter really how the patient looks clinically. What is important is to identify the mechanism. And to do that, we do need a very good assessment.

Aristeidis Katsanos

Thank you so much, Diana, for highlighting those high-risk subgroups that they have a high risk of stroke recurrence. But actually, what are the key steps in identifying those patients in routine clinical practice? And Jesper I’m coming to you, and I would like to ask, what is your approach in your everyday clinical practice in terms of investigation and subtyping the group of patients that Diana mentioned about that you are very much worried about stroke recurrence early on.

Jesper Petersson

Yes and indeed Diana mentioned many important facts that you need to gather when you have a stroke patient and I will try to allude to some of them in the true time order when things happen. So some things we really need to establish very early. I mean, obviously, we need to see if the patient’s symptoms, if it’s really a stroke. But I will not go too deep into that. Let’s just assume that clinically we suspect a stroke. There is a high degree of suspicion. And then the clock starts ticking because everything is very, very time sensitive. And that will also guide us as what we can actually do and in what order we should do things. Because if we do it in the wrong order or if we do too much we might actually lose time and actually the patient could be worse off. So that’s trying to be very complete but also trying to target what you do is important in the acute phase.

The first most obvious step is, of course, thinking about if it’s a hemorrhagic or an ischemic stroke. And to know that, we obviously need imaging. There is no way around. I mean, in the textbooks, there are still some texts about that the clinical pictures can be a bit different. But in my experience, that’s very, very difficult. I’m usually wrong about it when I try to make a guess. It could be ischemic. It could be hemorrhagic. The symptoms are really very, very similar. I’m not talking, obviously, here about subarachnoid hemorrhage. I think that’s quite a different chapter, and those patients are usually, at least clinically, very different. So we start, obviously, with imaging as fast as possible. And in our department, we would start with a CT, usually combined with perfusion and angiography, which then makes subtyping a bit easier. The first thing I think we need to think about is a large versus small vessel. Why is that important? Well obviously because of the treatment. Small vessel stroke will probably not be a case for thrombectomy. Could still be a case for thrombolysis as we’ve learned in many trials that thrombolysis can have an effect also in small vessel stroke. And to our help here, we have, okay, we have the clinical picture, which could point us if we have a very high NIHSS score, it’s probably a large vessel stroke. But if it’s, let’s say, an NIHSS score between 5 and 10, it can be quite tricky. And that’s, I think, especially our younger clinicians I find always like to add the perfusion imaging and then you can often get an idea if it’s a large vessel territory and that way you can differ. MR we don’t usually do in the acute phase, but we would do the MR perhaps within 24 hours if we want to deepen the investigation. So that would not be, at our institution, we would not usually use MR to guide the very acute phase.

So, back again to the therapy, we need to make this very fast decision about re-canalization therapy, thrombolysis with or without thrombectomy. And we need to move really fast because it could involve further investigations. It could also involve transportation to a comprehensive stroke center if you are working at a smaller hospital. And all this is highly time-critical.

I would also, obviously, as everyone, we add the laboratory investigations, but my advice would be not to wait too much for them. In fact, don’t wait at all. Do the next steps. Because the laboratory investigations, they will show up while you are handling the patient. And why are they still important? Because we need to rule out these negative factors. Diana mentioned some of them like high glucose, anemia, thrombocytopenia, kidney failure, maybe the electrolyte balance is wrong. And why is that important to have these facts early? Because they may impact on preservation of critically at-risk brain tissue. So actually you can help the patient with quite a few of those.

Going on about the subtyping and finding out about the cause for the stroke, obviously the embolic versus non-embolic, as we have already discussed a bit, is very relevant, but could be postponed for maybe for a few hours at least if you are still in the process of treating the very acute stroke. But you should obviously start with the investigation, for example, having a recording of the heart rhythm. That could start immediately, I guess, even in the pre-hospital phase in many cases. If we start to think about things other than atrial fibrillation. We should also think about other cardiac diseases like valvular disease or maybe a shunt, a right-left shunt in the heart. But those are investigations which usually you could perform maybe also a little bit later, maybe during the first 24 or 48 hours, adding ultrasound to your investigation. Carotid stenosis now is often diagnosed already with the acute CT if you add the angiography so that you often have at a very early stage when you don’t even have to treat the carotid stenosis but you just get it in the acute phase.

And then thinking about these more rare causes which were also mentioned earlier because the most likely is obviously that the patient will have an atherosclerotic cause. But there are some rare causes like vasculitis, antiphospholipid syndrome, other prothrombotic states like mentioned by Diana with like if the patient has a cancer or something. You have to think about those but don’t delay things or doing too much advanced diagnosis in the very early phase. So that can usually be done again the first 24 to 48 hours.

And then I would like to add something which I think is really important, and it’s to ask for the patient’s views on any treatment or investigation. A lot of our stroke patients are elderly people, and that’s obvious because of the epidemiology of stroke. And if you have a very frail person in front of you, it may be a person with a high risk of complications. And again, is there a serious underlying condition like cancer which will affect prognosis? And again, what is the patient’s own view on all this? I’ve had patients who have actually told me, well, you know what, Dr Petersson, I’m not interested in this thrombolysis. I’ve had a great life and this might be the end of it, actually. It’s not very common but it does happen and I think that truly personalized medicine you need to take these aspects into account and it may point you in a certain direction quite early. I think I will stop there. Thank you.

Aristeidis Katsanos

Thank you so much, Jesper, for sharing your experience and also commenting on this individualized approach, bringing patients into the decision-making, both in terms of diagnostics and also therapeutics. So thanks also for providing this overview, this stepwise approach, how we deal with those patients in the emergency. The question comes down to the fact of what we can do about those patients. So we have phenotyped them using, you know, your recommendations and also Diana’s suggestions. So what we can actually do to reduce the risk of stroke recurrence. And Gisele, I would like to ask you, what are the most important risk factors you try to address immediately after a stroke, after the patient arrives in the emergency and gets admitted into a stroke unit?

Gisele Sampaio Silva

So I think it will be easier for me to speak after what was said. And it’s very important for us to understand that stroke is definitely a preventable disease, even the first event. So there’s some data from the INTERSTROKE studies showing that if we treat some specific risk factors, we would avoid at least 80 to 90% of strokes happening. So it’s very important for us to be aware of it and to know that we can modify the risk of another stroke. As we just discussed, this can be a very, very important event for a family and for the patient as well.

So I think that the cornerstone of preventing stroke, first of all, is treating blood pressure. So blood pressure control is the single most important modified risk factor for ischemic and for hemorrhagic stroke. And we have very robust data from trials like the PROGRESS that showed that when we put blood pressure down you can reduce recurrent stroke by around 25 to 28%, even in patients without severe hypertension. So we know that literature is getting modified for the ideal blood pressure levels. So just like my colleagues, I’m also involved in many trials for secondary prevention. And then one of the trials that we are actually running in Brazil is checking if the blood pressure level of less than 120 would be better than one that’s recommended by guidelines. So it might have to be more aggressive, just what the SPRINT trial showed in patients with high-risk cardiovascular events that didn’t include the patients with stroke. So we might have to be even more aggressive than what we are. We also have the SPS3 data suggesting that more intensive targets might further reduce recurrence, particularly in patients with small vessel disease. So I think that we should do it early. We should, you know, be aware that the patient, when the patient is admitted to the hospital and when we have access actually to starting blood pressure medications and to be aggressively enough, you know, to make sure that 140 is not good for a patient after stroke.

So second of all, I mean, we think a lot about antithrombotic therapy. So this is very important as well. And as discussed here, the antithrombotic therapy is fundamental, but it has to be etiology-driven. So we have data from the CHANCE and the POINT trial showing that early dual antiplatelet therapy with aspirin and clopidogrel in selected patients, especially in patients with minor stroke, can reduce recurrence in about 30 to 40% in the early phase. And it’s also very important to have the data from the examination of the heart to make sure that we are able to diagnose cardiobolic stroke early on and to start anticoagulants in most of the patients because this can lead to a relative risk reduction to about 60 to 70%. So we cannot lose this opportunity to find out atrial fibrillation when the patient is at the hospital and to start those medications. And now, as Diana said, based on data from ELAN and from OPTIMAS, early on. We have this opportunity. And we do know that atrial fibrillation is one of the most underdiagnosed and undertreated causes of stroke recurrence. We know that we have some data from the CRYSTAL AF showing that if you monitor a little bit more, you increase the chances of finding the atrial fibrillation. So I think that after the patient is being discharged, you have to continue to look for atrial fibrillation, especially in patients who have embolic partners in the neuroimaging.

Lipid control is another key pillar of stroke prevention. We know that the SPARCL trial showed that high-intensity statin therapy reduced recurrent stroke by about 16 to 18% and also reduced the risk of major cardiovascular events. So we have to be aware that our patient is not only prone to having a recurrent stroke, which is very bad, but also other cardiovascular events like MIs and cardiovascular death. And more recently, we have the Treat Stroke to Target trial that demonstrated that targeting LDL to less than 70 milligrams per deciliter led to a further reduction in vascular events compared to more lenient targets. So just like the cardiologists are doing, we have to look at the drug that we are doing. So using high potency statins, especially in patients with atherosclerotic disease, and also looking at the levels of LDL. So less than 70 is the good target for patients with stroke.

Diabetes also significantly increases both the first and recurrent stroke risk. Close control has a modest direct effect on stroke recurrence, but now we have the newer agents such as the GLP-1 receptor agonists that have shown cardiovascular benefits in patients with high-risk cardiovascular disease. So I guess that training neurologists to use them might add recurrence in patients with high risk, especially in patients with diabetes. And we have to have the trials in stroke patients as well showing how much this drug can help us as it’s helping patients with high cardiovascular risk.

And one very important thing also is lifestyle factors. So that’s often underestimated. So we have to discuss with our patient smoking cessation, which can reduce recurrence risk substantially, physical activity. So it’s always easier to ask our patients to take a pill and to go home, but convincing them that they have to do physical activity regularly, it’s not that easy. And we also have some data from diet, especially the Mediterranean diet with the PREDIMED study, showing that it reduced major cardiovascular events by about 20 to 30%. So these interventions are low cost. They need time, you know, because you have to talk to patients, but they can be very high impact.

And just to finalize, I think it was very important to hear a little bit the perspective of the patient. I completely agree that the real challenge of managing risk factor after stroke is adherence. Adherence remains one of the biggest barriers to effective secondary prevention, not only stroke, but also in cardiovascular disease. A significant proportion of patients just discontinue or don’t consistently take their medication. So we’ve got to think how we can improve this. So as neurologists who are seeing patients for stroke prevention, we have to think about simple regimens. So prefer once a day dosing, fixed combination when it’s possible. There is a lot of data for this in hypertension control. Patient education is very, very important. So they have to know what their risks are and the importance of preventing a next stroke or a new stroke. And early follow-up after the patient is discharged. So it’s when the patient is more sensible to our information.

We also have to think about multidisciplinary care. So involving nurses, pharmacists, the rehab team that sometimes the patients do see like every single day after they are discharged might have more impact than us physicians talking to the patient. We are living in a brave new world of the digital tools, so why not to use apps, reminders, to use telemedicine, especially teaching this population on how to use it because they are generally older people. So we have to be aware and to use family to help us. And finally, to involve family and caregivers because they are decisive on long-term adherence.

Aristeidis Katsanos

Thank you so much, Gisele, for very nicely summarizing the most important interventions, pharmacological, non-pharmacological, and also providing us with the evidence backing up those interventions. You did raise again the important thing, which is the individual. We all know that there is this ongoing discussion about personalized approach in patient diagnosis, diagnostics, management, and therapeutic decisions. So Diana, I would like to ask you if there is any age, sex, or ethnicity factors, or even personal factors, as Jesper mentioned, that would change your approach in the management of risk factors or patient treatment?

Diana Aguiar de Sousa

Yes, absolutely. This is a very important question. But I think it is important to be precise about what we mean by personalization, because the core principles of secondary prevention are the same for most patients. So, as mentioned, we need to identify the stroke mechanism, we need to control blood pressure, we need to treat lipids, support smoking cessation, optimize diabetes management, physical activity, healthy diet and so on. So what changes according to age, sex or ethnicity is not if we address these risk factors, it is really how to prioritize them, how to communicate and really how to tailor treatment to the individual patient.

So starting with age, because I agree this is particularly important and has been mentioned before, because we do distinguish older and younger patients in many ways. And it is an important part of personalization, I think. So in older patients, we have strong evidence supporting secondary prevention, no doubt about it, but the management often needs to be individualized. For example, patients with frailty, as mentioned before as well, comorbidities, polypharmacy interactions, patients with cognitive impairments, with problems with walking, with many falls, or short life expectancy for other diseases, for example. All this will influence how aggressively and how safely also we can intervene. For example blood pressure control is critical but we may require slower titration or closer monitoring in older patients to avoid hypotension and other adverse events. Also, many of the procedural decisions, and this was also mentioned by Jesper, we should not reduce our ambition for prevention, but we do have to refine our judgment in several of these interventions. In contrast, in younger patients, the challenge is often more on how to have a more aggressive diagnostic and prevention approach. So traditional risk factors indeed are present quite often, but they may not explain the event, so we do need to actively look for less common mechanisms, for example, arterial dissection, acquired pro-thrombotic states or genetic conditions, less common types of heart conditions. So this is part of this young stroke workup, which is different in many ways. At the same time, when we consider the lifestyle-related risk factors, smoking, obesity, the hormonal factors, of course, this has a particularly strong impact because we know there’s a long lifetime risk ahead. So in this group, it’s not only about reducing the recurrence in the shorter term, it is really about how to minimize this cumulative risk that will develop over decades if the patient survives for a long time. So this also requires a different type of communication, really a strong emphasis on adherence, long-term adherence, behavioral change that will last for a long time.

Then concerning sex, of course, this matters, perhaps not always in the way people assume. So it’s not that we have a different approach to risk factor control. It should be aggressive in both male and female patients, but also because we know the risk is not so different. So if we control for the other conventional risk factors, the risk of recurrence is not really very different across men and women, for example, and minor stroke and high-risk TIA. But we know that sex is clinically relevant for certain exposures and also certain care gaps. Women, for example, of course, we have the pregnancy-related risk, we have the postpartum risk, all the hormonal therapies. Women also have more autoimmune disease and there are reports of possible delayed recognition and even undertreatment and less awareness about the risk of vascular disease in women.

More or less the same, I think, about ethnicity, because it also influences the biological profile and the context in which the prevention is delivered. Some patients, some populations have a higher burden of hypertension, for example, Asian patients, intracranial atherosclerosis as well, or diabetes. And we know also that certain populations have structural barriers with limited access to care, also differences in affordability of medications on literacy about health and even the access to the healthcare system. So this means that for an effective prevention, we have to also sometimes adapt to the cultural and context of the patient.

So I think in conclusion, indeed, I agree, age, sex, ethnicity, all these specific factors should influence our approach, not by changing the fundamental goals, but by refining it. Because if we have a more personalized prevention, applying the same principles, but adapting to the risk profile, to the lived reality of patients, we will be more precise and more equitable as well in providing this care.

Aristeidis Katsanos

Thank you so much, Diana. Both you, Diana and Gisele, you did bring up the need for lifestyle changes in terms of diet and exercise. My main question and something that I always think about is when is the right time to start initiating that discussion. So stroke is a life-changing event somebody comes into the hospital, maybe it’s their first time that they ever come, and they come some of them with significant deficits. Is it the right time to start talking about diet and exercise? So Jesper, what is your approach? When is the timing and the frequency of this discussion?

Jesper Petersson

Yes, thank you. Thank you for this rather tricky question, I would say. But I will try just to answer maybe the way I would usually go about. There is obviously, there is some evidence on the influence of physicians. How can we influence patients? Is it even worthwhile? I think sometimes one has to ask oneself these questions. But it’s been shown quite reliably that, for example, smoking cessation does happen after physician advice. This was something which was published in the 80s, actually. Before that, it was not really known if physician’s advice did make a big difference. The problem was perhaps that many physicians were smokers at that time. So obviously there was a difficulty in explaining to other people that they should not smoke. I think that that is a very small problem nowadays.

So again, coming back to how do you approach it? Well, I find that very early discussion is a good approach. But what you have to keep in mind when you start such a very early discussion is you have to keep it very simple. Don’t do the whole package. I mean, both Gisele and Diana here presented all those important things where you can give advice. But I would advise against giving the whole package in the first maybe 24 hours or so. But you could choose some very important points. For example, if I catch that the patient is a smoker, that’s typically something I would bring up immediately, actually, because usually the patient will ask, oh, if there is no aphasia or communication problem, they will usually ask, oh, doctor, what will happen now? What is my prognosis? And if it’s a minor stroke, a small stroke, they will often ask, well, will I get another one? That’s a typical question, actually. And in that moment, I would always approach the smoking, and usually I even ask them, and that’s maybe a language thing in Sweden or so. I ask them, are you a smoker? And then they answer yes. And then I answer actually not, because you just stopped. And that’s a very maybe patronizing way of putting it. But that usually works quite well because it’s very clear that the patient should not leave the hospital as a smoker. That’s really my goal. If they came with a stroke as a smoker, they shouldn’t leave the hospital as a smoker. That’s just not an option, I usually tell them, because they will ask about, you know, how can we prevent this? How is my prognosis? And then I will say, well, you know what? You can do this. You can do much more than all the pills I will give you. You can stop smoking. So that’s really something I put a lot of work in.

Then, going on, I will, of course, discuss the importance of medication and other advice, but I will not go into specifics during the first 24 hours, usually, because I find often people tend to forget. They forget sometimes, I think, like 90% of what I tell them. And the first, because they are in shock. Also, they get a lot of medical information. Most patients are not used to take in complex medical information. And for several reasons, they will probably forget a lot of what you told them. And so I would bring it up maybe the next day and then try to repeat it every day during the rather short hospital stays we have nowadays. We usually keep the patients around four days on average and then they are transferred either to rehab or to home. And that really makes it important then to follow up. But in that case, I find it really important to give the whole package when they leave us. And then that really needs to be repeated again. I think Gisele mentioned it, that you have to like when you have the target for hypertension that also you need to again and again you have to come back to those things.

Diet and alcohol consumption I also mention, and those are often quite tricky. Some people, of course, will just say that no problem, I can drink less alcohol. Other people who drink high amounts of alcohol, as you know, they will need a special. That’s not something you can do on a stroke unit. You need to refer them to specialized physicians or facilities if there is a heavy alcohol consumption. And I guess it’s not only in Sweden that people are very discreet about describing the amount of alcohol they drink. In Sweden, they often say, well, you know, maybe Christmas or something like that, I drink a little bit. But you need to ask more, penetrate the history there. Diet is complex. You all mentioned the diet, the importance of diet. And we know from studies that the association with stroke, first-time stroke especially, is quite strong actually. So you can find these strong associations and also with exercise. I do still find that the evidence for intervention on diets is much weaker. Also, exercise recommendations is also weaker than, much weaker than the primary association found with stroke. That doesn’t mean that I don’t give those advices because, as I think Diana or Gisele or both mentioned, that for younger patients, we’re talking about decades. And obviously, even a small effect of a diet change could make quite a big, if you shave off a few percent every year of your stroke risk, it will make a difference. And actually, we have done research here at our department looking at trends in stroke. We didn’t look at diet, unfortunately. We weren’t able to gather that on a national basis. But we do see quite a strong trend. We see a reduction in stroke, but we also see a reduction in major strokes, which is hopeful. But it also means that we now have a bigger population of stroke survivors who are actually out there in society. And they really would benefit a lot, I think, from these lifestyle changes and also exercise, although again the evidence is not very strong on sustained exercise changes for stroke patients. And it obviously can also be a physical issue if you have you know paresis or something it’s not easy to exercise. So again, you need to have a really personalized approach for that. Yeah, I could go on talking for ages, I think, on this, Aris. So please stop me.

Aristeidis Katsanos

Oh, we don’t want to stop you. All those things that you said are very, very and all those you know examples from daily practice that we do encounter frequently like at a daily basis and as you said you know personalization is the key timing is also key and also having these open conversations and sticking with the individual to make sure that they follow the advice and I’ll come to the later point. And this was already touched upon by Gisele. We prescribe interventions. We ask patients to follow diet and exercise. But the key to the success is patient adherence. And I do remember, Gisele, that you didn’t bring up that there are some tools available that they can help us. I would like to ask you, what is your approach, you know, to help a patient being more adherent to their medications and also to monitor adherence in your clinical practice?

Gisele Sampaio Silva

So I guess that one of the most important things nowadays in science is implementation science because we have the opportunity to see like trials like the SPRING trial of blood pressure control while the patients were in the trial. So they had like a 10 millimeters gradient of blood pressure when compared the interventional group to the control group. But after the trial is finished these curves come together. So that means that if you’re not looking at our patients, there is a really high risk that the patient is going back to what he was doing before. Just because, as Jesper and Diana said, stroke is a chronic disease. So we’ve got to think of a patient of a really, really high risk patient that went through that acute phase. Fortunately, we found out the etiology with all the investigation. But, you know, it’s important to continue monitoring this patient actually forever. Yeah. So and this is not easy. That’s a real challenge, especially in systems of care like low- and middle-income countries like Brazil. So I guess that we live, as I just discussed, in the era of technology. So what we try to do here at our public hospital in Brazil is we try to bring the patient early on to a visit because I think although the technology is good, you know, talking to the patient and actually being able to touch the patient, it makes a difference. So if it’s possible, especially for elderly people who are not very useful to technology, does not use it very well. So I think that the first contact is really important.

So one thing that we try to do is to make a big bond with family because whenever this patient is going to use technology for something, we’ve got to have someone, you know, some younger people trying to help such patients to use it. We’ve been discussing a lot, you know, the problem of technology exclusion and the bias of elderly people and people from low- and middle-income countries not being represented in those new algorithms. So we want more and more to have data from our patients to help us guide the treatment. So we have actually some trials using implementation and some APPs for blood pressure control and as well for cholesterol control in Brazil.

But this is not the only solution. I think that education, having some time to talk to the patient is crucial. I also agree with Jesper that when a patient is being discharged from the hospital, it’s a lot of information. So sometimes you just have a patient who has, you know, had a completely normal life that’s going home with hemiparesis, changing completely their life. So if you keep, you know, putting a lot of information like diet information and it’s there is the risk that the patient is not going to take their basic pill. So we can’t escalate it so start by what you think it’s more important and then check at the patient you know absorb it and go to the further steps so this might be the way to go with some patients some young patients might be very eager to take all the information early on. So you’ve got to use a little bit of personalized medicine and find out which patients are going to be prone to receive everything at the discharge and which patients need this stepwise approach.

So a little making sure that this patient comes back. It doesn’t have to be a neurologist. So in Brazil, we have a real gap of neurologists in the country, especially in the north and central part of Brazil. And this is the reality for rural areas in many countries as well. So telemedicine can be very important using all the rehab services. So where the patients go more frequently to make sure that this patient is going to be followed for at least once or twice a year to make sure that blood pressure levels glucose control and cholesterol is going to be checked so you don’t need you don’t need a specialist for that. So a primary care physician can do this very well, so training primary care physician on this important basis and making sure they are aware that the stroke patient is the highest risk patient. It’s also important to keep up following our patients after stroke.

Aristeidis Katsanos

Thank you so much, Gisele. And thanks for bringing up this complexity in patient adherence and how important it is to actually consider the individual and using technology or personal communication and tailor to their needs. And now I would like to move to another challenge from the challenge of the adherence of the individual patient to the system-level challenges. So we all have come across some challenges at the national level, on the institutional level, when we try to implement changes in the early management of stroke patients. So I would like to ask Diana your experience around it. And if you encounter some of them, how would you be able to address them? So how were you addressing them to advocate for your patients?

Diana Aguiar de Sousa

And this is a very important question indeed, because even the best clinical knowledge, and we all put a lot of effort in creating new knowledge, but all of this will have very limited impact if the system cannot deliver the timely and coordinated care we need. And in my view, really the biggest system level changes in this topic of early management fall into three broad categories. Let’s say time, resources, and coordination. And many of these questions have been mentioned already by Jesper and Gisele.

But really, I think the first challenge is time, so stroke care we know we all know it’s extremely time sensitive, right? But it’s not only for reperfusion therapies, but also for this diagnostic workup that will guide recurrence prevention. And we mentioned this delays in brain imaging, in vascular imaging, in the heart assessment, even in the specialist review of these patients can mean missed opportunities. For example, if we have a delay in identifying the large artery disease or a delay in identifying atrial fibrillation, we may have recurrent events because we are delaying the initiation of the right preventive strategy. So really, I think one key priority will be to create a streamlined pathway for all patients in all hospitals for a rapid triage, access to imaging, really clear protocols, and I think predefined timelines for these investigations are also critical.

Then there’s the issue, of course, of resources. And I think this is where inequality between centers is really very visible. Not all hospitals have the same access to stroke neurologists, to advanced imaging, even to echocardiography, especially transesophageal, to the prolonged read monitoring, to rehabilitation, even to stroke units. For example, in Portugal, only half of the patients are managed in stroke units. So in many settings, clinicians do their best, but they are under significant resource constraints. And we do need practical solutions. So increase and strengthen the stroke unit models. As mentioned by Gisele, telemedicine. I think it’s a good way also to improve this and have these minimum standards for early assessment, as mentioned before, and really ensuring that the referral pathways to the more specialized centers for exams that are not available in primary centers are efficient and realistic and well-established.

And then I think the third challenge, and this has been touched upon before, is the coordination across disciplines and these transitions of care. So stroke patients, very typically, they move rapidly, as mentioned by Jesper, from the emergency department to the stroke unit, from the stroke unit to rehabilitation, then to the outpatient follow-up, then to primary care. And in these steps, important information can be often lost. So the mechanism, the exams that are still pending, the blood pressure targets, the lipid targets, the anticoagulation and other antithrombotics plan, even the smoke cessation support and follow-up, for example, for cardiac carotid disease or heart problems. So if the handovers are weak, the prevention will also be fragmented. So I do think we also need to invest a lot on this on this process.

And also we need to look into the patients that are more vulnerable because they are especially prone to be affected by these types of problems. So those with communication barriers with cognitive impairment with less literacy with social disadvantage in general or with difficulty in access medication or follow-up. In these patients all these failures will be really magnified.

So I think in summary to improve this early management at the system level we need pathways that are well established, standardized, fast, multidisciplinary and really accessible for all patients. Because if the system works well, we clinicians will be able to make decisions faster, and the patients will be also more likely to receive the correct prevention they need.

Aristeidis Katsanos

Thank you, Diana. This is very important. Thanks for sharing. So we discussed many complex issues. We discussed the individual level, the systems level. And Jesper, I’m going to ask you for the most difficult and challenging thing to do is to summarize the three takeaway messages for the clinician and whoever is attending this webinar. What they should never forget and they should always do in their early assessment of stroke patients, you should select only three and discuss those three key takeaway messages.

Jesper Petersson

Yeah, thank you for that challenge. Well, I think the first key step is really this general assessment of your patient in the very early phase. Don’t only focus on the neurology, the neurological examination is of course essential, but also look at the whole patient including this very early level of consciousness, blood pressure all that stuff you need to stabilize the patient. And that will also guide you a lot about what you’ve heard about the important assessments which you will then take with you for planning for the secondary prevention. So actually that first contact with your patient, maybe the first 30 minutes, you can really cover a lot of what has been said here. So think more than the stroke, think the whole patient. That would be my first key step.

The second one is obviously still imaging. I mean, imaging is such a huge game changer for neurology. I’m of the age that as a student, I still remember when they showed us the first CT pictures at our department, a bit fuzzy, and we were not allowed to order them because that was such a valuable thing. Anyway, but it’s a huge game-changer. So the imaging and combine it preferably with angiography and perfusion, it will give you a lot of help to guide the next steps.

As a third key thing, I think this discussion with the patient, start discussing with the patient, get the connection with your patient, with the relatives, and that will help you because if the patient is so lucky to have a family and everything, they will help them remember all these things that they will probably forget otherwise. And I think making this connection with the patient and the relatives, that is something which will save you a lot of time during the next days and also for the follow-up of the patient. So I think if I need to limit myself to three key points, then those are the three I would choose.

Aristeidis Katsanos

Thank you so much, Jesper. Thank you, Gisele. Thank you, Diana, for sharing your experience and your expertise and highlighting that early and thorough assessment after a stroke is essential. It’s not only essential to understand what happened, but also to identify those patients at highest risk and lay the groundwork and foundations for effective long-term management.

In our next webinar, we’re going to build on this discussion we have today, and we’re going to discuss about how we can explore current pharmacologic and non-pharmacologic interventions for secondary stroke prevention. I would like to thank you all for your valuable insights and of course the audience for joining us and see you next time and stay tuned.

Aristeidis Katsanos: Research Grants from HSFC, CIHR, Brain Canada, HHS, HAHSO; Consulting fees for Diamedica Therapeutic Inc and Bayer Inc.

Diana Aguiar de Sousa: Personal fees from Bayer and Daiichi-Sankyo for advisory board participation; speaker fees from AstraZeneca and Bial; and DSMB participation for the SECRET trial (University of British Columbia).

Gisele Sampaio Silva: Ministério da Saúde: Resilient trial, Optimal Trial; Boehringer Ingelheim: speaker, consultant; NIH: National PI SPARE.