The Calgary Stroke Program
Program Lead: Dr. Andrew Demchuk
The Calgary Stroke Program (CSP), a collaboration between the University of Calgary (DCNS and Hotchkiss Brain Institute) and Alberta Health Services (AHS), continues to lead and contribute to the field of stroke care. Our program figured prominently nationally and internationally on a number of fronts. We continue to strive to meet our vision of “Creating the Future of Stroke Care.”
The program: New members and impact
Dr. Aravind Ganesh joined our program as new faculty. He is a clinician scientist in both Vascular and Cognitive Neurology. He completed his MD degree at the University of Calgary, followed by a DPhil in Clinical Neurosciences at the University of Oxford’s Centre for Prevention of Stroke and Dementia as a Rhodes scholar. He earned an Associate Fellowship from the United Kingdom’s Higher Education Academy through his teaching contributions at St John’s College (Oxford). He completed his neurology residency in Calgary, He recently completed a one year combined fellowship in stroke and cognitive neurology in Calgary funded by Alberta Innovates and the Canadian Institutes of Health Research. Dr. Ganesh is actively involved in the development of best-practice guidelines for stroke and dementia care. His clinical research is focused on the natural history, prevention, and treatment of stroke and cognitive impairment. He is passionate about medical education, and serves on the editorial boards of Neurology, Neurology: Clinical Practice, and Stroke.
Dr. Katie Lin also joined our program as faculty and take acute stroke call with us as an attending. Katie provides a crucial linkage between stroke neurology and emergency medicine that will be essential to achieving widespread improvements of emergency management of acute stroke nationally given the importance of both specialities in such care. She is an emergency medicine physician who completed stroke fellowship training with us and passed her C-CSC certification. She joined the Calgary Stroke Program and will She is also cross-appointed in DCNS. She is the first Emergency Medicine physician to pass the C-CSC exams and become certified by the Canadian Stroke Consortium.
Members of the Calgary Stroke Program continue to progress up the rankings of the leading Canadian researchers based on individual H-indices. Our clinician scientists represent 3 out of the top 10 highest ranking at the University of Calgary. Dr. Hill is ranked 88th; Demchuk 105th; Smith 161st in Canada over career.
Using Expertscape.com our clinical scientists and institution are ranked very high globally in all major stroke topic areas (ranging from 2nd to 7th):
Transient Ischemic Attack: Univ of Calgary ranked 7th S. Coutts 5th.
Ischemic stroke: Univ of Calgary ranked 5th M Goyal 5th; M Hill 7th; A Demchuk 9th; B Menon 12th.
Cerebral hemorrhage: Univ of Calgary ranked 6th A Demchuk 25th; E Smith 29th and M Hill 30th
Brain infarction: Univ of Calgary ranked 7th. E Smith 1st; M Goyal 8th; A Demchuk 10th
Brain ischemia: Univ of Calgary ranked 5thM Hill 2nd; M Goyal 6th; E Smith 7th; A Demchuk 14th; B Menon 16th. Cerebral angiography: Univ of Calgary ranked 2ndA Demchuk 1st; M Goyal 3rd; B Menon 5th, M Hill 10th
Thrombolysis: Univ of Calgary ranked 6th M Hill 12th; E Smith 17th; A Demchuk 21st; M Goyal 27th.
Mechanical thrombolysis: Univ of Calgary ranked 5th M Goyal 1st; M Almekhlafi 16th and B Menon 20th.
We are also making great progress in Stroke Rehabilitation with Univ of Calgary ranked 47th and S Dukelow 43rd.
Highlights/Key Publications
As the major CSP practicing changing achievement of the year. Dr. Bijoy Menon (PI) and colleagues presented the main results of the ACT trial entitled: “Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial” at the European Stroke Organization Conference. This trial has resulted in a global shift to Tenecteplase that includes Alberta. The trial main paper has been since published in the Lancet journal (first among all general and internal medicine journals globally).
An ongoing achievement of the program continues to be a leadership role in the HERMES Collaboration, led by Dr. Mayank Goyal. The collaboration successfully brought together all seven predominantly stent retriever based randomized clinical trials of mechanical thrombectomy in stroke (five published in NEJM 2015). This HERMES collaboration continues to roll out many publications (20 as of June 2022)—Lancet (1), JAMA (1), Lancet Neurology (3), JAMA Neurology (1), Stroke (9), Neurology (1), JNIS (3), Neuroradiology (1)—that are influencing guidelines for EVT care throughout the world by clarifying when and how endovascular treatment is effective. Several of these manuscripts have been first or senior authored by CSP members, including Dr. Goyal, Dr. Michael Hill, Dr. Bijoy Menon and Dr. Mohammed Almekhlafi.
Dr. Jessalyn Holodinsky (post-doctoral fellow) presented her work on the relationship between routine influenza vaccination and reduction in subsequent stroke using data from the province of Alberta. There was a clear reduction in stroke occurrence and evidence of dose-response effect (greater reduction in stroke with serial, annual vaccination). The data were published in the Lancet Public Health.
Dr. Aravind Ganesh and Dr. Mayank Goyal published a scientific statement for the American Heart Association on considerations for endovascular treatment and thrombolysis for acute ischemic stroke patients with pre-morbid disability or dementia in Stroke. Dr. Ganesh, Dr. Michael Hill, and Dr. Eric Smith used population data from Alberta to show that the first year of the COVID-19 pandemic was associated with persistently reduced rates of patients presenting with ischemic stroke, recurrent treatment delays, and higher risk of in-hospital death after stroke in later waves. These findings, published in CMAJ, helped support public health messaging that encourages care-seeking for medical emergencies during pandemic periods, and demonstrated the need for stroke systems to re-evaluate protocols to mitigate inefficiencies.
Clinical Trials
Dr. Coutts (PI) is leading the CIHR funded, multicentre TEMPO-2 trial examining Tenecteplase (2nd generation tPA) for patients with mild stroke with a proven intracranial occlusion. Sites are active in Canada, UK, Ireland, Austria, Spain, Finland, New Zealand, Singapore, Brazil and Australia. 782 subjects have been enrolled.
Dr. Hill and Dr. Goyal (PIs) are making terrific progress with the second pivotal trial of the NA-1 neuroprotectant focused on patients undergoing endovascular treatment but ineligible for IV TPA. The ESCAPE-NEXT trial Is collaboration between The Calgary Stroke Program and NoNO Inc (Toronto). This trial has enrolled 736 subjects at over 50 sites in multiple countries. The ESCAPE-NA-1 trial was previously published in Lancet in early 2021.
Dr. Hill and Goyal (PIs) are also leading the ESCAPE-MeVO trial evaluating mechanical thrombectomy in patients with occlusions in more distal locations (M2/M3 MCA; P1/P2 PCA; A1/A2 ACA) known as medium vessel occlusions (MeVOs). A total of 12 subjects have now been enrolled.
Dr. Demchuk (co-PI) continues progress for a phase 2/3 randomized trial of endovascular treatment in mild stroke entitled ENDOLOW in conjunction with co-PIs at Emory University (Atlanta), University of Cincinnati (Ohio) and Heidelberg University (Germany). This is a planned 200 patient study at 40 centres. 61 subjects are now enrolled with additional sites coming on-line in the next few months Including Canada, US and Germany.
Dr. Almekhlafi and Dr. Goyal (PIs) have Initiated the CIHR funded “Evaluating oral peri-operative acetylsalicylic acid in patients undergoing endovascular coiling-only of unruptured brain aneurysms. A Phase 3 Multicenter Randomized Placebo-Controlled Trial”.
Dr. Hill, Goyal and Lin are running the pre-hospital Surface EEG Evaluation of Prehospital Stroke (SEGUE-PS) trial across Alberta. So far 120 subjects have been enrolled.
Dr. Phil Barber continues to lead the “Predementia Neuroimaging of Transient Ischemic Attack (TIA) – PREVENT Study”.
Dr. Sean Dukelow is leading several multicenter studies. The new addition is the CAMAROS trial evaluating Maraviroc at several centers across Canada. Maraviroc is a CCR5 receptor antagonist shown in animal models to enhance brain plasticity after stroke. This is the first phase 2 randomized trial evaluating the agent in stroke recovery. This clinical trial aims to recruit up to 120 stroke patients across multiple (7-12) sites in Canada. Participants will be recruited within six weeks of stroke onset. This study is funded by The Dr. Miriam and Sheldon G. Adelson Medical Research Foundation
Dr. Eric Smith and Dr. Aravind Ganesh are co-leading the Trial of Remote Ischemic Conditioning in Vascular Cogntive Impairment (TRIC-VCI), a pilot trial of the tolerability of remote ischemic conditioning for vascular mild cognitive impairment, funded by the Canadian Institutes of Health Research.
Dr. Phil Barber leads the longitudinal cohort “Predementia Neuroimaging of Transient Ischemic Attack (TIA) – PREVENT Study” investigating MRI and blood biomarkers in cognitive decline. Dr Barber also leads the Simple Perfusion Reconstruction Algorithm (SPIRAL) Clinical Research Study
Team Grant/Core Lab Progress
The Stroke Imaging Core Lab coordinates brain MRI and CT imaging for observational studies and clinical trials, with more than 15,000 brain scans analyzed. Imaging endpoints include strokes, hemorrhages, vascular occlusions, brain perfusion, and others. These endpoints are critical for understanding the natural history of stroke and the effectiveness of new treatments. The most significant accomplishment from the imaging core lab was the analysis of…
The acute stroke imaging research program has expanded to now have research fellows from countries as diverse as The Netherlands, South Korea, UK, Switzerland, Saudi Arabia, Japan and China. The program has a full time imaging scientist, post docs and graduate students along with stroke fellows, neurology and radiology residents and summer students.
Leadership of National/International Organizations
Dr. Sean Dukelow and Dr. Demchuk continued as co-Scientific Directors of the Leadership Council for Canadian Partnership for Stroke Recovery. Efforts have been focused on transitioning stroke recovery in Canada to a new reality once the CPSR sunsets in March 2023.
Dr. Andrew Demchuk was re-elected Chair of the Board of Directors of the Canadian Stroke Consortium in Nov 2021. During his first 2 year term, numerous changes have been accomplished in the organization to fulfill the new mandate of being Canada’s professional organization for stroke physicians. Full membership has grown substantially with new membership categories now in place. A sponsored webinar series and National Fellowship Rounds have been initiated. The organization has quickly returned to profitability despite the pandemic. CSC joined the Canadian Neurological Sciences Federation as the 6th society. CSC participated in the CNSF Congress in Montreal and awarded the first Sandra Black plenary lecture on behalf of the CSC. The F-CSC certification program for fellowship training has now graduated ~40 fellows since starting in 2020. A 4 person CSC Executive has been formed and additional committees developed. Several of the committees have expanded scope and influence through much greater engagement and distributed leadership. Dr. Coutts and Hill also serve as members of the board of directors. Dr. Coutts is also Deputy Chair, Research Committee and co-Chair CAN-WIN Committee.
Dr. Andrew Demchuk co-leads the Global Alliance of Independent Networks in Stroke (GAINS). In which GAINS co-led a virtual global early career investigator workshop in December 2021. GAINS continues to host Global Trials Forums every four months and provides support/communication between national and regional stroke clinical trial networks globally.
Dr. Michael Hill continues as President of the Canadian Neurological Sciences Federation. During his tenure progress has been made on several fronts. A sponsored webinar series has been implemented. Cross society activities have increased to leveraging different societies as one voice for neurological conditions.
Dr. Eric Smith co-Chairs the Heart and Stroke Foundation of Canada Stroke Best Practice Advisory Committee, which oversees the development of Canadian guidelines for stroke care.
Dr. Aravind Ganesh was appointed to the American Academy of Neurology’s Geriatric Neurology Standing Measure Development Work Group, and to the Heart and Stroke Foundation of Canada’s Health Systems Quality Committee.
Personal Achievements/Appointments/Awards
Dr. Hill was one of 8 scientists at University of Calgary named as a “Web of Science highly cited researcher (top 1%) 2021.”
Dr. Aravind Ganesh has been extremely successful with obtaining peer reviewed grants. In this academic year he obtained the following funding: Alberta Innovates for “Automated Remote Image-guided Diagnosis and Risk Stratification of Carotid Disease for Stroke prevention” for $600,000; the Government of Canada’s INOVAIT Strategic Innovation Fund for “StrokeSENS: Rapid image-guided remote decision-making for patients with acute ischemic stroke” for $125,000; The Government of Canada’s New Frontiers in Research Fund (NFRF) for “Using Artificial Intelligence Based Solutions to Facilitate Clinical Trial Enrolment” for $237,970 (all mentored by Dr. Menon); the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Canada for “EVOLVE-Cog: A prospective cohort study of the cognitive and neuropsychiatric effects of iatrogenic brain infarcts and their prevention by acetylsalicylic acid” ($100,000 and $172,500 respectively, building on the EVOLVE trial by Dr. Goyal and Dr. Almekhlafi); Alzheimer Society of Canada for “Perspectives, Quality of Care, and Outcomes of People Living with Dementia who Experience Ischemic Stroke: A Mixed-Methods Research Program” for $200,000 (mentored by Dr. Smith). He was also awarded the Heart and Stroke Foundation of Canada’s New Investigator Award and the Henry J.M. Barnett Scholarship for his contributions as a new investigator in the field of cardiovascular disease ($190,000).
Dr Phil Barber received peer reviewed grant funding from the Heart and Stroke Foundation of Canada. “Predementia Neuroimaging of Transient Ischemic Attack (TIA) – PREVENT Study” $235,000 over 3 years, a Mitacs Accelerate Grant and Cumming School of Medicine to continue the Simple Perfusion Reconstruction Algorithm (SPIRAL) Clinical Research Study
Clinical Care Achievements
Initial planning of a new integrated stroke unit at Foothills Medical Centre has been completed. Architectural firm Group 2 and AHS (Nora Smith, lead) have led the planning sessions. A functional plan document has been received by Alberta Innovates and is being prioritized that describes the critical elements needed for a new unit and architectural renderings of how it might look. This is a critical step toward a future capital fundraising campaign and ultimate build of a new world-class integrated stroke unit which will likely be housed on two wings of the Foothills Medical Centre.
Dr. Michael Hill took on role of Co-Senior Medical Director, Stroke for the Cardiovascular Health and Stroke Strategic Clinical Network at AHS.
Mr. MacNeil Cornez took over the role of Calgary Stroke Program manager from Samantha Arnott.
Education
As of June this year, our program reached a major milestone having trained/graduated 100 stroke fellows, from 23 countries including Canada. We graduated 5 fellows in 2021-22 academic year who have taken positions at comprehensive stroke centres throughout Canada including Vancouver; Kelowna; London; Toronto/Mississauga and Halifax. All five passed their F-CSC certification exams.
As a result of the terrific support from our philanthropic community and Hotchkiss Brain Institute. Dr. Sherry Hu became the first fellow to receive a Carolyn Barham Family fellowship award.
The Calgary Stroke Program in collaboration with the Indian Stroke Association and several former stroke fellows, developed and successful completed the CASTLE virtual stroke education program for neurologists in India. This was 14 module course every second Saturday for 6 months with lectures from current CSP and former CSP fellow faculty covering all major topic areas of stroke that was attended by over 300 neurologists across India.
CSP stroke faculty participated in over 50 international speaking engagements around the world virtually given the limitations of travel during the pandemic. In some instances, 3 or more CSP faculty spoke at the same virtual conference for a far away region that speaks to the global outreach our program is achieving.
Commercialization
Recently Circle CVI was bought by venture capital firm Thoma Bravo. As a result Circle NVI (Circle CVI spinoff) was integrated into Circle CVI as part of that buyout. Drs. Menon, Goyal, Hill and Demchuk were minor shareholders in Circle NVI. StrokeSens is the main commercial product of Circle NVI that is a stroke imaging software tool to assist in acute stroke decision making. StrokeSens has now received FDA, CE Mark and Health Canada approvals for ASPECTS and LVO detection. Access to StrokeSens version 4.0.1.2 at Foothills Medical Centre is expected in 2023.
Andromeda Medical Imaging Inc.is a stroke imaging software startup. Dr. Phil Barber is the Chief Medical Officer. A patent for mCTA perfusion mapping has been granted.
Dr. Mayank Goyal continues to develop Collavidence Inc as a disruptive way to fund stroke research through crowd source funding.Collavidence believe in the wisdom of the many by leveraging the power of PrecisionFunding™ and Dynamic Review™ to catalyze innovation and incentivize radical ideas from people all over the world. Several CSP members are assisting Dr. Goyal in supporting this venture.
Dr. John Wong (CEO) and Alim Mitha continue to develop the startup company called FluidBioMed. FluidBioMed is developing a bioresorbable stent to cure aneurysms. They recently obtained several million in seed funding through fundraising.
Stroke.ai, a startup co-founded by Dr Mohammed Almekhlafi and Mr Craig Doram (Business Operations – Calgary Stroke Program), aims to advance movement technology to improve stroke outcomes. The startup has support from Innovate Calgary through the Life Sciences Fellowship and the Hotchkiss Brain Institute at the University of Calgary for developing and validating its wearable sensor technology.
Dr. Aravind Ganesh is developing a system for remote ischemic conditioning and patient monitoring through the startup SnapDx. This work has been funded by a seed grant from Campus Alberta Neuroscience.
Dr. Peter Stys co-founded a biotech startup (Amira Medical Technologies) focused on developing blood-based biomarkers for early diagnosis of Alzheimer's and other neurodegenerative diseases.
Members
Stroke Neurology: Dr. Mohammed Almekhlafi, Dr. Simer Bal, Dr. Phil Barber, Dr. Philippe Couillard, Dr. Shelagh Coutts, Dr. Andrew Demchuk, Dr. Aravind Ganesh, Dr. Michael Hill, Dr. Adam Kirton (Pediatrics), Dr. Gary Klein, Dr. Julie Kromm , Dr. Katie Lin, Dr. Bijoy Menon, Dr. Alekys Mineyko (Pediatrics), Dr. Steve Peters, Dr. Eric Smith, Dr. Peter Stys, Dr. Suresh Subramaniam
Stroke Physical Medicine and Rehabilitation:
Dr. Sean Dukelow, Dr. Gentson Leung
Physician Assistant: Allen Szabon
Vascular Neurosurgery: Dr. Alim Mitha,
Dr. Garnette Sutherland, Dr. John Wong
Interventional Neuroradiology: Dr. Muneer Eesa,
Dr. Mayank Goyal, Dr. Will Morrish
Nurse Practitioner: Nancy Newcommon
Stroke Program Manager: MacNeil Cornez
Stroke Fellowship Program Administrator:
Emily Collins
Stroke Observership/Sabbatical Program Administrator: Lori Herard