Published: Wednesday 17 May 2017

The European Stroke Organisation Conference (ESOC) 2017 is currently on from 16-18 May in Prague, Czech Republic.

The second day of ESOC included a focus on the global perspectives on stroke, including:

  • the link between poverty and stroke
  • understanding cerebral small vessel diseases (SVDs), which can lead to vascular dementia
  • stroke in young people.

The GAINS collaborators (Global Alliance of Independent Networks for Stroke Research) also discussed approaches to improve stroke research globally. The GAINS collaborators are a network of colleagues from Stroke Research Networks from Europe, USA, Canada, Japan, China, South Korea, and Australia.

Global perspective on stroke

A joint session between the European Stroke Organisation (ESO) and the World Stroke Organisation (WSO) provided a ‘Global Perspective on Stroke’, from the effect of poverty to current approaches aimed at reducing the impact of stroke on a global scale. Jon Barrick, SAFE President and WSO Chair of the World Stroke Campaign Committee, co-chaired the session with WSO President Prof Werner Hacke.

“It was clear from the presentations that stroke is related to poverty,” said Mr Barrick. “As such, stroke is not just a health issue but requires economic and government action.

"The message to governments from advocacy groups like SAFE and WSO is that their decisions have consequences in health terms.” He added that one of the most striking points of the session is that air pollution was ranked fifth on the list of stroke risk factors. “Risk factors one to four can all be managed by changes in lifestyle or with the assistance of medication,” he said. “Poverty and air pollution are, in most cases, beyond the individual’s control.”

The session also highlighted that there's a greater proportion of haemorrhagic stroke compared to ischaemic stroke amongst the poorest people in the poorest regions of the world. “Poverty and air pollution are, in most cases, beyond the individual’s control,” commented Mr Barrick. “We need to address these issues at a national and global level.”

ESO and the Chinese Stroke Association (CSA) compared the differences in stroke care and research between the different healthcare systems. A number of clinical trials in China have informed practice in recent years, eg the CHANCE study (Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack). The ESO-CSA collaboration aims to build on this already successful partnership.

The ESO EAN ESMINT SAFE collaboration presented their survey of the current provision of stroke care in Europe and what needs to be done in the next decade to meet the challenges ahead. The survey highlighted the need to adopt common standards and ensure better access to stroke treatments across Europe.

Cerebral small vessel diseases (SVD)

Cerebral small vessel diseases (SVDs) involve the damage of the small blood vessels of the brain. SVDs can cause vascular cognitive impairment, which can develop into vascular dementia.

Eric Jouvent summarised imaging findings in SVD and addressed questions that frequently come up in clinical routines, such as differential diagnosis. He emphasised the importance to integrate information from different MRI brain imaging techniques. While very small acute lesions can be difficult to detect, follow-up imaging might provide additional information.

Joanna Wardlaw and Marco Duering discussed the role that dysfunction of the blood-brain-barrier (BBB) plays in SVD. Human studies in vivo (in alive people) and post-mortem histopathological analyses (looking at the brain after death) suggest increased BBB leakage with ageing and in association with SVD. However, some studies are conflicting. Animal models also support a role of BBB failure in SVD.  Both in CADASIL transgenic mice (mice genetically modified with a hereditary gene for stroke in humans), and BBB leakage has also been found in Foxf2-knockout mice, with the FOXF2 gene recently linked to SVD in a genome-wide association study.

Hugh Markus summarised the treatment of SVD patients. He emphasized that we have limited knowledge from clinical trials and therefore a great demand for new trials. In addition, there's a need for better stroke subtyping in large stroke trials as many classification systems cannot discriminate between SVD-related infarcts and small infarcts of other origins. Recent data from an Austrian registry suggest that thrombolysis is equally beneficial in SVD-related stroke compared with other stroke subtypes. Antihypertensive treatment is very important, also in SVD patients without stroke. But blood pressure lowering might be harmful in late disease stages. Ultimately, a better understanding of SVD pathomechanisms is needed in order to develop new therapies.

Stroke in young people

This interesting session covered the most relevant areas of stroke in young age, pointing out well-calibrated updates on selected topics and take-home messages oriented to clinical practice.

Dr. Annette Fromm showed a complete overview of diagnostic pathways in young stroke patients, following literature proposals and the experience of the ongoing NOR-SYS study, addressing in particular this item, with a special focus on under evaluated role of “classical” vascular risk factors in young people and sub-clinical atherosclerosis (narrowing of the arteries) with a systemic screening approach.

L. Rutten-Jacobs, pointed out the consequences of this underestimation of traditional vascular risk factors in young people with stroke, using the results of FUTURE study and showing us the complex but non-favourable long-term outcome of TIA/stroke in young people mostly regarding stroke recurrence, cognitive consequences, loss of quality of life, unemployment rate and so on.

The other speakers, D.d.A.D. de Sousa, A. Singhal, and F. Heinen, gave significant updates about new evidence and active research fields.

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