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.”

Highlights/Key Publications

As the major CSP led publication of the year. Dr. Shelagh Coutts (PI) and colleagues published the main results of the five-year CIHR-funded DOUBT study entitled: Rate and Prognosis of Brain Ischemia in Patients With Lower-Risk Transient or Persistent Minor Neurologic Events. JAMA Neurology  2019 Sep 23. doi: 10.1001/jamaneurol.2019.3063. https://calgary.ctvnews.ca/research-removes-doubt-on-importance-of-mris-in-diagnosing-strokes-1.4606175

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—Lancet (1), JAMA (1), Lancet Neurology (3), JAMA Neurology (1), Stroke (6), Int J Stroke (1) and JNIS (2)—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. Coutts was also senior author of the SpecTRA study publication entitled: Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event. JAMA Neurology 2019 May 22. doi: 10.1001/jamaneurol.2019.1305. https://www.cbc.ca/news/canada/calgary/minor-stroke-diagnosis-men-women-1.5145552

Dr. Hill and Dr. Andrew Demchuk each co-authored commissioned review articles in Lancet on the topic of acute ischemic stroke (Lancet. 2018 Oct 6;392(10154):1247-1256.) and intracerebral hemorrhage (Lancet. 2018 Oct 6;392(10154):1257-1268).

The collective H-index of the clinician scientists within the program now exceeds 150, with over 105,000 citations and 1,000 publications cited at least 10 times. https://scholar.google.ca/citations?user=AhoG3gMAAAAJ&hl=en&authuser=1

Clinical Trials

Dr. Coutts (PI) is leading the 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 and Australia with further sites soon active in Brazil and Israel. 414 subjects have been enrolled.

Dr. Hill and Dr. Goyal (PIs) continue to lead the ESCAPE NA-1 trial which is a collaboration between The Calgary Stroke Program and NoNO Inc (Toronto) to study a novel neuroprotectant (NA-1) in patients undergoing endovascular treatment for acute stroke. This trial has now completed enrollment of 1,105 subjects with a rapid ramp up to twice daily enrollment achieved from over 50 sites in multiple countries. Results will be presented in early 2020.

Main results of two major randomized clinical trials supported at steering committee level by members of the Calgary Stroke Program were published. STOP-IT/SPOTLIGHT trials (JAMA Neurol. 2019 Aug 19) and CLOTBUST-ER trial (Lancet Neurol. 2019 Apr;18(4):338-347.)

Dr. Menon, Dr. Hill, Dr. Goyal, Dr. Brian Buck and Dr. Rick Swartz received funding for “Alteplase Compared to Tenecteplase in patients with Acute Ischemic Stroke: QuICR & OPTIMISE Registry based Pragmatic Randomized Controlled Trial”. The award for the grant was $1,277,550 over three years. It ranked second out of 37 applications to the Randomized Controlled Trials 2 committee.  Recruitment to the ACT-QuICR trial is expected to begin before year end.

Dr. Demchuk (co-PI) will soon initiate recruitment of 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 200 patient study at 30 centres in four countries.  

Dr. Almekhlafi and Dr. Goyal (PIs) received funding for “Evaluating oral peri-operative acetylsalicylic acid in patients undergoing endovascular coiling-only of unruptured brain aneurysms. A Phase 3 Multicenter Randomized Placebo-Controlled Trial”. The award for the grant was $569,926 over three years. Ranking 2nd out of 40 applications in Clinical Investigation D committee. Recruitment to the EVOLVE trial is expected to begin shortly. 

Dr. Phil Barber received a Grant-in-Aid from Heart and Stroke Foundation of Canada: “Predementia Neuroimaging of Transient Ischemic Attack (TIA) – PREVENT Study” for $300,000 over three years.

Team Grant/Core Lab Progress

The QuICR Alberta Stroke Program is an Alberta Innovates CRIO grant that has just completed its funding cycle supporting a number of quality improvement and clinical trial activities.  

Dr. Demchuk continues to lead the implementation of the “CaSTOR Canadian Stroke Trials for Optimized Results” national stroke clinical trials network funding by CIHR/ Institute of Circulatory and Respiratory Health. This $1.5 million emerging networks grant (2015-2020) is a collaboration with the Canadian Stroke Consortium and Canadian Partners for Stroke Recovery. A second early career workshop is planned for WSC/ESOC 2020 in Vienna to followup from the first one led by GAINS.

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 recent accomplishment from the imaging core lab was the volumetric analysis of intracranial hemorrhages for a new antidote to direct Factor Xa inhibitors published in NEJM 2019 and two recent presentations of MRI substudies for the NAVIGATE and COMPASS trials.

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. 

The program also recruited the first intern from the Bio-Medical Imaging Department to do a one-year internship on stroke image processing. New research focuses on using deep learning and machine learning tools for analysis of large imaging datasets, automating image interpretation and understanding neuro-cognitive aspects of image interpretation.

Personal Achievements/Appointments

Dr. Goyal successfully defended his PhD thesis at Erasmus University in Rotterdam, Netherlands.

Dr. Demchuk was one of seven scientists at University of Calgary named as a “Web of Science highly cited researcher (top 1%).”

Dr. Sean Dukelow and Dr. Demchuk were named co-leads of the Leadership Council for Canadian Partnership for Stroke Recovery which replaces the role of Chief Scientific Officer with CPSR.

Dr. Julie Kromm joined the Department of Critical Care as a neurointensivist. She will also partake in stroke service care as an attending stroke physician after completing one year of combined fellowship in stroke and neurocritical care at Columbia University.

Clinical Care Achievements 

Initial planning of a new integrated stroke unit at Foothills Medical Centre has begun. Architectural firm Group 2 and AHS (Nora Smith, lead) have led the planning sessions. The goal remains to complete a functional plan document within six months that describes the critical elements needed for a new unit and architectural renderings of how it might look. This is a critical first step toward a future capital fundraising campaign and ultimate build of a new world-class integrated stroke unit.

The Stroke Program has once again completed another cycle of Stroke Accreditation and received full accreditation for acute, prevention and rehabilitation activities for four years.

The acute stroke endovascular program continues to grow with a further increase in thrombectomy rates in fiscal year 2018-2019. We now also have admin data measurement of outcomes after thrombectomy, called “home time” (number of days in first 90 that patient is back home from stroke admission). This data reveals a remarkable 37 per cent rate of 85-90 day home time amongst severe strokes treated with this intervention performed at FMC. This means that more than one in three endovascular treatment patients are returning home with little or no disability within five days of stroke admission.

Conference Leadership

The program successfully hosted our fourth 5T Stroke Conference in Kananaskis in June 2019 with over 200 participants in attendance. 

The CSP has taken a leadership role, bringing together global collective expertise in selective hypothermia treatment. The first ever selective hypothermia symposium was organized by
Dr. Almekhlafi and hosted in Calgary on March 1, 2019. This academic and commercial consortium plans to continue to collaborate in hopes to accelerate foundational science knowledge and technological development so that a human clinical trial protocol to cool the ischemic hemisphere can be safely implemented and tested in large efficacy trials. Two foundational science grants on the topic of selective hypothermia were recently successfully funded by CIHR (Dr. Fred Colbourne) and HSF
(Dr. Ting Lee) with Drs. Almekhlafi and Demchuk as co-investigators.

Education

As of June this year, our program is training and/or has graduated 86 stroke fellows, from 21 countries including Canada. Last year we trained eight fellows, including three Canadians. In addition, we have seen a major increase in applications to our fellowship program, with on average three applicants per month. 

Our research fellow/sabbatical and observership program has expanded substantially with 14 individuals from nine countries spending at least a week or much longer with the CSP in 2018-2019.

Members 

Stroke Neurology: Dr. Mohammed Almekhlafi, Dr. Simer Bal, Dr. Phil Barber, Dr. Philippe Couillard, Dr. Shelagh Coutts, Dr. Andrew Demchuk, Dr. Michael Hill, Dr. Adam Kirton (Pediatrics), Dr. Gary Klein, Dr. Bijoy Menon, Dr. Alekys Mineyko (Pediatrics), Dr. Steve Peters, Dr. Eric Smith, Dr. Peter Stys, Dr. Suresh Subramaniam, Dr. Julie Kromm

Stroke Physical Medicine and Rehabilitation: Dr. Sean Dukelow, Dr. Ken Lam, Dr. Gentson Leung, Dr. Steve McNeil 

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: Samantha Arnott

Stroke Fellowship Program Administrator: Emily Collins

Stroke Observership/Sabbatical Program Administrator: Lori Herard

(Updated December 2019)