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, 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”.

Key Publications

An extraordinary achievement of the program this year 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 major publications — Lancet (1), JAMA (1), Lancet Neurology (3) and JNIS (2) — that are influencing/changing guidelines for EVT care throughout the world by clarifying when and how endovascular treatment is effective. The most recent publication in Lancet Neurology clarified the ASPECTS cutoff for benefit of EVT (ASPECTS 3 and above). Several of these publications list CSP faculty as first or senior authors.

The AURORA collaboration has also been created of which Drs. Goyal, Hill and Demchuk are on the executive committee. This brings together the five mechanical thrombectomy trials that enrolled patients in the late time window. The first two initial analyses have now been presented at major conferences.

Drs. Bijoy Menon and Andrew Demchuk completed and published in JAMA the INTERRSeCT study main result. This prospective cohort study was funded by a three-year CIHR operating grant. 575 subjects from 12 centres in five countries were recruited to the study. The study has provided unique insights into when, how often and how fast IV TPA successfully recanalizes an intracranial occlusion.

The UNMASK-EVT study has now been completed. It is a large survey led by Dr. Saposnik and the CSP on physician decision making in acute stroke with 603 respondents from 38 countries.

A number of additional significant original contributions were published in the past year. The collective H-index of the clinician scientists within the program now exceeds 140 with over 90,000 citations from over 800 publications cited at least 10 times.

Clinical Trials

Dr. Shelagh Coutts (PI) is leading the multicentre TEMPO-2 trial examining Tenecteplase (second generation tPA) for patients with mild stroke with a proven intracranial occlusion. Sites are active in Canada, the United Kingdom, Ireland, Austria, Spain and Australia, with further sites being considered in Chile, Brazil and Israel. So far, 257 subjects have been enrolled with a major step up in enrollment of late.

Drs. Michael Hill and Mayank Goyal (PIs) continue to lead the ESCAPE NA-1 trial which is a collaboration between the University of Calgary/Calgary Stroke Program and NoNO Inc to study a novel neuroprotectant (NA-1) in patients undergoing endovascular treatment for acute stroke. This trial has now enrolled 644 subjects with a rapid ramp up to twice daily enrollment achieved from over 50 sites in multiple countries. It is expected to complete enrollment of 1,120 subjects by summer 2019, with final results available in early 2020.

New trials to be launched: Dr. Andrew Demchuk (co-PI) will soon launch 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 (Cincinnati) and Heidelberg University (Germany). This is a 200-patient study at 30 centres in four countries. Dr. Bijoy Menon (co-PI) will soon begin the ACT-QuICR trial using the infrastructure of the QuICR registry to test Tenecteplase as a new thrombolytic stroke drug. Dr. Mohammed Almekhlafi (co-PI) will soon begin the EVOLVE trial to examine antiplatlet therapy in the peri-operative management of unruptured aneurysms.

Team Grant/Core Lab Progress

The QuICR Alberta Stroke Program is an Alberta Innovates CRIO grant. It is a provincial program led by Drs. Hill, Demchuk and from Edmonton, Drs. Jeerakathil and Shuaib. The quality improvement section of the program, led by Dr. Noreen Kamal, has focused on acute stroke treatment. Over the past year we have remained very close to achieving our goal of a 30 minute median door-to-needle time for all stroke patients treated in the province. 

Dr. Demchuk continues to lead the implementation of the “CaSTOR Canadian Stroke Trials for Optimized Results” national stroke clinical trials network in Canada, with funding by the 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 global high impact accomplishment this year as part of the grant was the first ever Global Alliance of Independent Networks in Stroke (GAINS) WSO Early Career Investigator Workshop held just prior to the World Stroke Congress 2018 in Montreal in which 102 very promising early career clinician researchers attended from 23 countries. This workshop provided a truly unique opportunity for these individuals to be inspired and build connections with peers across the world with similar interests.

The CaSTOR grant also held a capacity building competition throughout Canada with eight successful applications receiving funding. The competition aimed to create new stroke trial recruitment capacity at Canadian stroke centres previously inactive or without prior experience in trial recruitment.

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 acute stroke imaging research program has expanded to now have research fellows from countries as diverse as the Netherlands, South Korea, the United Kingdom, Switzerland, Saudi Arabia, Japan and China. The program now 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 on understanding neuro-cognitive aspects of image interpretation.

Personal Achievements

Dr. Mayank Goyal received the 2018 CAR Distinguished Career Achievement Award from the Canadian Association of Radiologists for his outstanding contributions to clinical research in acute stroke triage, diagnosis and endovascular therapy. Dr. Goyal also became a fellow of the Canadian Academy of Health Sciences.

Dr. Bijoy Menon first authored papers this year in JAMA, Lancet Neurology and Circulation. Three students of his (Lexi Wilson, Moiz Hafeez and Moe Najm) successfully entered medical school. His HSF Professorship in stroke imaging was also renewed. 

Dr. Eric Smith chaired an Evidence Review Committee for the American Heart Association that synthesized evidence in two areas of uncertainty in clinical stroke care: the accuracy of pre-hospital stroke severity scales for identifying ischemic stroke patients with large vessel occlusion for transport to endovascular thrombectomy-capable hospitals and the efficacy of screening stroke patients for dysphagia. One of the stroke severity scales identified in the review, the Los Angeles Motor Scale, has been implemented by ambulance services across Alberta as part of the ERA project to increase access to endovascular thrombectomy for acute ischemic stroke. 

Dr. Sean Dukelow and colleagues received CIHR funding for the RESTORE trial which will investigate the role of early robotic rehabilitation in upper extremity stroke recovery in 132 patients at two centres in Canada. The trial will also evaluate the utility of neuroimaging and transcranial magnetic stimulation in predicting recovery after stroke. 

Dr. Mohammed Almekhlafi joined our program after relocating from Jeddah, Saudi Arabia. Dr. Almekhlafi is well known to the program having completed his neurology residency and three years of stroke and interventional training in Calgary. Dr. Almekhlafi is the first interventional neurologist in Canada with an academic appointment. 

Dr. Philip Barber is leading the multisite REPERFUSE NA-1 which is a longitudinal MRI study of acute stroke patients participating in the ESCAPE NA-1 study. Sites are currently active in Canada and USA, and other sites coming on board are from Korea and Germany. The study has recruited 30 stroke patients to date. 

Dr. Barber is leading the PREVENT Dementia study, a prospective longitudinal cohort study of age-matched TIA patients and healthy controls which aims to address the crucially important population health question, “Can we reliably identify dementia risk in TIA patients by using valid biological markers of disease thereby optimizing vascular risk management to reduce the risk of dementia?” The study has recruited 331 TIA patients and controls to date, of which 150 have completed followup visits. 

Clinical Care Achievements 

The Endovascular Reperfusion Alberta (ERA) project led by CSP and Edmonton Stroke Program through the Stroke and Cardiovascular Health Strategic Clinical Network continues to result in improvements in access to endovascular treatment for rural patients with large geographic barriers. The three zones of transport are now fully functional throughout the province. Patient outcomes are being monitored and mirror results obtained in clinical trials of EVT despite the added distances and more liberal criteria for treatment. 

Samantha Arnott and the clinical management team has successfully launched a patient flow/care improvement project entitled CARROT (Carotid Artery Rapid Revascularization Optimization Team) aimed at achieving carotid revascularization within 72 hours of admission to hospital for symptomatic carotid stenosis patients.

The Calgary Health Trust provided a significant donation to support the initial planning of a new integrated stroke unit at Foothills Medical Centre. Architectural firm Group 2 has been secured to lead the FMC Stroke Unit Development Study. A committee of multiple stakeholders has been struck and first meetings have taken place. The goal is completion of a functional plan within six to nine 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 ultimately build a new world class integrated stroke unit.

The Stroke Program has once again completed a cycle of Stroke Accreditation and is expected to receive full accreditation for acute, prevention and rehabilitation activities in December 2019.

Conference Leadership

The program successfully hosted our third 5T Stroke Conference in Banff in May 2018 with over 200 participants in attendance. 

The program also hosted two delegations from several thrombectomy centres in Canada and China/Korea/Australia in a training course on all things mechanical thrombectomy related.

Education

As of June this year, our program is training and/or has graduated 86 stroke fellows from 19 countries, including Canada. Last year we trained eight fellows, including three Canadians. In addition, we have seen a major increase in applications to our fellowships with on average three applicants per month. 

Our research fellow/sabbatical and observership programs has expanded substantially with 17 individuals from 12 countries spending at least a week or much longer with the CSP in 2017-2018.

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

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 Managers: Lara Osterreicher, Samantha Arnott

(Updated Dec. 2018)