Updates in Acute Stroke and post-stroke rehab

Question 1

New studies in thrombolysis

Answer 1

Argatroban + alteplase - infusion
- no increased bleeding risk
- no new benefit

Glenzocimab - infusion
- good recannulisation
- no new benefit

Tenecteplase - single bolus
- easier to use
- safe and effective
- no new benefit

Question 2

BP control in RTPA

Answer 2

No difference in bleeding risk between controlled vs uncontrolled BP - Netherlands study
–> BP control may not be necessary?

Worse outcomes for active BP management in ischaemic stroke based on mRS - China study

Better outcomes for active BP management in haemorrhagic stroke

Question 3

ZODIAC trial on head positioning

Answer 3

Head down to 0 degree has improved perfusion, improved NIHSS score in 7 days
No difference in mRS for 3 month outcome though

Question 4

Mechanism of stroke recovery

Answer 4

Resolution of oedema, metabolic injury and restoration of circulation
Reversal of diaschisis

Use dependent plasticity
- Changes in synaptic efficacy
- Collaterals
- Cortical map re-organisation

Question 5

Influencing cortical excitability/plasticity

Answer 5

Non-invasive brain stimulation
- Transcranial magnetic stimulation (TMS)
> 1Hz suppresses cortical excitability (over unaffected site)
> 10Hz or more increases cortical excitability (over affected site)
- Xiang et al 2019, Zhang et al 2017 - 5 sessions better for acute stroke, no difference in low vs high frequency
- Level A for M1 hand motor recovery
- Level B for M1 morotrecovery, aphasia

• Transcranial direct current stimulation (TCDS)
• Effects lasted after stimulation
• 20 minutes of stimulation results in up to 2 hours of effect
• Cochrane review: does no improve function, strength, cognition, neglect
• Meta analysis: moderate improvement in chronic patient, mild to moderate severity, higher charge and increased duration 30 minutes led to greater improvement but not increased session