ANNUAL REPORT

ANNUAL REPORT 2009 2010

With renewed funding, a clear vision and a plan of action, the Canadian Stroke Network is prepared to work harder than ever to have an impact on the Big P icture of stroke and to improve the lives of stroke patients and their families.

CSN MISSION To reduce the impact of stroke on Canadians through collaborations that create valuable new knowledge; to ensure the best knowledge is applied; and to build Canadian capacity in stroke. www.canadianstrokenetwork.ca High-school student Mackenzie Shaheen accompanies her father, who had a stroke in 2007, to rehabilitation therapy.

Contents Message from Management....2 Prevention....7 Treatment....10 Training....13 Canadian Stroke Strategy....17 Knowledge Translation and Outreach....20 Seeing the Big Picture.... 28 29 Financials....30 CANADIAN STROKE NETWORK 1 SEEING THE BIG PICTURE

Message from Management Cutting-edge research. Focused clinical trials. The National Stroke Nursing Council. Training programs. International partnerships. Resources and support for patients and families. Prevention tools. The Canadian Stroke Strategy. Best practices. Evaluation and measurement of health systems. Hospital accreditation. The Canadian Stroke Congress. Our efforts are coordinated and interconnected. From research to training to clinical care to improved health systems to outreach to families and caregivers, WE SEE THE BIG PICTURE. In late 2009, an international panel of stroke experts recognized the Canadian Stroke Network s big-picture thinking when it assigned high praise after a rigorous research review. The result was an additional four years of funding from the Networks of Centres of Excellence program. The panel s final report declared that: The Network has positioned Canada as a world leader in stroke research. It said that the CSN is bringing significant social, health and economic benefits to Canada and that it has achieved the highest excellence. Michael Cloutier Chair, Board of Directors Dr. Antoine Hakim CEO and Scientific Director Katie Lafferty Executive Director CANADIAN STROKE NETWORK 2 ANNUAL REPORT 2009 2010

The credit, of course, goes to our dedicated researchers in all parts of Canada who work together to tackle the challenges of stroke whether they are treating patients in hospital, studying cells in a laboratory, conducting clinical trials, working in prevention or rehabilitation clinics or writing policy briefs. Our researchers see THE BIG PICTURE. Renewed funding for the Canadian Stroke Network will support many promising initiatives, including: large clinical trials focused on prevention and rehabilitation; a 12-centre research project probing ways to protect the brain after stroke; four new projects studying the link between stroke and vascular cognitive impairment; a major global project to identify emerging risk factors for stroke; the Registry of the Canadian Stroke Network, which is monitoring and evaluating care; the Canadian Stroke Strategy, which is working to improve stroke services in every province; a national audit of stroke care in every province, which culminates in a National Stroke Report this fall; training programs for researchers, health professionals and students; and the National Stroke Nursing Council, which is bringing the latest research knowledge to frontline care providers. The Network has developed an impressive portfolio of basic, clinical and applied research. Bringing together basic scientists and clinicians, supporting trainees and allied health professionals, the Network has facilitated new multi-disciplinary and high quality research that improves patient care. Expert panel review of the CSN, October 2009 CANADIAN STROKE NETWORK 3 SEEING THE BIG PICTURE

We are extremely pleased that Canada has been recognized as an international leader in the field of stroke and that the federal government is making a strong commitment to support this important research. CEO and Scientific Director Dr. Antoine Hakim Among the many highlights of the past year was the first Canadian Stroke Congress, held in early June in Quebec City. More than 1,000 dedicated stroke clinicians and researchers came from all parts of Canada and beyond. This threeday event provided an opportunity to exchange views, collaborate and learn about innovative approaches to stroke research and clinical care. Response to the landmark Congress was overwhelming and plans are already under way for the next one, to be held in late 2011. With renewed funding, a clear vision and a plan of action, the Canadian Stroke Network is prepared to work harder than ever to have an impact on the Big Picture of stroke and to improve the lives of stroke patients and their families. Canadian Stroke Congress delegates CANADIAN STROKE NETWORK 4 ANNUAL REPORT 2009 2010

The Canadian Stroke Network wishes to thank the members of the Board of Directors for their service to the Network. The following individuals retired from the Board in 2010: Michael Cloutier, Chair; Diane Campbell of Halifax; Dr. Dale Corbett, Memorial University of Newfoundland; Dr. Tom Jacobs, U.S. National Institutes of Health; Senator Dr. Wilbert Keon; Dr. Carol Richards of Université Laval. New members to the Board of Directors in 2010 are: Dr. John F. MacDonald, Robarts Research Institute; Dr. Marilyn MacKay-Lyons, Dalhousie University; Dr. Paul Morley of Ottawa; and Dr. Remi Quirion, Douglas Hospital Research Centre. Incoming Chair appointed by the Board of Directors: Dr. Pierre Boyle, Université de Montréal. Thanks are also extended to members of the CSN s Planning and Priorities Committee (PPC). Retiring from the PPC in 2010 is Dr. Nicol Korner-Bitensky of McGill University. The PPC welcomes Dr. Mark Bayley of Toronto Rehabilitation Institute. The CSN research program has been extraordinarily productive, producing more than 600 peer reviewed manuscripts since 2000, many of them in high impact journals. The range and quality of research is laudable. Expert panel review of the CSN, October 2009 CANADIAN STROKE NETWORK 5 SEEING THE BIG PICTURE

WHO WE ARE The Canadian Stroke Network is an independent, not-for-profit corporation. It was established in 1999 to reduce the burden of stroke through leadership in research innovation. It is made up of the country s best and brightest clinicians, rehabilitation specialists and knowledge-translation experts from universities and hospitals across the country. Headquartered at the University of Ottawa, the Canadian Stroke Network brings together partners from government, industry and the non-profit sector. The Canadian Stroke Network is one of Canada s Networks of Centres of Excellence: www.nce.gc.ca

Prevention U n d e r s ta n d i n g Risk Factors The CSN-funded INTERSTROKE study published Phase 1 results in Lancet in June 2010 that identified the major risk factors for stroke. The report, which received widespread media coverage, was the result of a study of 6,000 people in 22 countries in Asia, North and South America and Europe. The study found that the five most important risk factors for stroke are high blood pressure, smoking, poor diet, abdominal obesity and lack of regular exercise, which together predicted over three-quarters of the global risk of stroke. Hypertension alone was responsible for half of that risk. The results of the study were presented in Beijing at the World Congress of Cardiology. Our study highlights the particular importance of blood pressure, which was the strongest risk factor for all stroke. To reduce the global burden of stroke, health systems must invest in populationbased programs that screen for hypertension, and provide effective and inexpensive treatments. Dr. Martin O Donnell CSN researcher, Dr. Martin O Donnell, Hamilton Health Sciences Centre CANADIAN STROKE NETWORK 7 SEEING THE BIG PICTURE

The Network has recognized the importance of demographic changes for stroke services by jointly funding with the Heart and Stroke Foundation of Canada four new projects into vascular cognitive impairment. CSN researchers are probing the link between covert strokes, small vessel disease and dementia. In an award-winning paper published in the journal Stroke in 2009, CSN Scientific Director Dr. Antoine Hakim and Dr. Charlie Thompson of the University of Ottawa write that the health-care system needs to gear itself toward better prevention strategies, particularly as the population ages. CSN-funded basic research published in Nature Neuroscience (October 2009) demonstrates for the first time in animal models that suppressing TRPM7, a relatively unstudied channel protein found in neurons, confers resistance to the death of neurons in the brain caused by stroke. Reducing the levels of this protein does not appear to disrupt the ability of the neurons or the brain to function normally. This opens the exciting possibility that new drugs can be designed to target TRPM7 that would have applications in minimizing damage to the brain occurring as a result of stroke and cardiac arrest, and from neurodegenerative diseases such as Alzheimer s, Huntington s and Parkinson s. The Network has made important progress in the support of vascular health clinics as a model to deliver stroke secondary and primary prevention more effectively. Expert panel review of the CSN, October 2009 CANADIAN STROKE NETWORK 8 ANNUAL REPORT 2009 2010

Dr. Kaczorowski won the Impact Award at the Canadian Stroke Congress for his work on the CHAP research program, which has been shown to have significant benefits to population health and stroke prevention. Dr. Janusz Kaczorowski CSN s research has made important contributions to our understanding of the basic molecular and cellular mechanisms of neuronal injury in stroke, and to understanding and improving secondary and tertiary stroke prevention and care. With significant financial support to conduct rigorous evaluation of the Cardiovascular Health Awareness Program, CSN re-affirmed its leadership in population-based primary prevention of stroke. The resulting research demonstrated that a collaborative, multipronged community-based health promotion and prevention program targeted at older adults can significantly reduce cardiovascular morbidity at the population level. Janusz Kaczorowski PhD Professor & Research Director Department of Family Practice University of British Columbia CANADIAN STROKE NETWORK 9 SEEING THE BIG PICTURE

Treatment L i n k i n g Heart and Stroke Atrial fibrillation (AF), an abnormal heart rhythm, is the most common heart-related cause of ischemic stroke but it can be a very elusive diagnosis. Improved ways to detect the condition in patients who have a stroke or TIA are needed in order to prevent a second or more major stroke. The problem is that atrial fibrillation often has no symptoms and existing technologies usually only monitor the heart for 24 or 48 hours. A new Canadian-made electrode belt was produced with the support of the Canadian Stroke Network for testing in a 17-centre clinicial trial, called EMBRACE (Event Monitor Belt for Recording Atrial fibrillation after a Cerebral ischemic Event.) Supported by the Network, the EMBRACE trial tracks heart rhythms over a 30-day period in an effort to better diagnose atrial fibrillation. This is the largest study and first randomized trial of ambulatory cardiac monitoring in the stroke/tia population. Dr. David Gladstone EMBRACE and its sub-studies will have immediate impact. We expect the study results to contribute to the first evidencebased practice guidelines for cardiac monitoring after stroke and TIA. Dr. David Gladstone, University of Toronto CANADIAN STROKE NETWORK 10 ANNUAL REPORT 2009 2010

Telestroke, which started as a pilot project with seed funding from the CSN, has become an important part of stroke treatment in Canada. In June 2009, Ontario s Telestroke program reached a milestone with the treatment of its 1,000 th patient. We are pleased to see how Telestroke has grown, says CSN Executive Director Katie Lafferty. It is vital for people in rural communities. A National Stroke Audit is under way in all provinces in an effort to gather data on stroke services across the country and to measure the impact of the Canadian Stroke Strategy and provincial initiatives. It will culminate with a major report, to be released in late 2010. The audit will provide new benchmarks for stroke care in all parts of the country. The Registry of the Canadian Stroke Network has collected data on more than 100,000 patients with acute stroke or TIA. This information is being used by health service researchers to measure and monitor stroke care in order to improve quality. Stroke researchers are also using the data to answer important research questions. Ten CSN-funded research studies, based on Registry data, were published in high-impact journals in 2009-10. They included topics such as gender differences in stroke, quality of inpatient care and the prevalence of post-stroke depression. CANADIAN STROKE NETWORK 11 SEEING THE BIG PICTURE

Taking part in Getting On with the Rest of Your Life After Stroke has shown me that I am still able to contribute even though I suffered a major stroke. This has meant a great deal to me. sherman Elliott, Winnipeg, Manitoba Sherman Elliott The Canadian Stroke Network s Getting On With the Rest of Your Life After Stroke, the largest national clinical trial into stroke recovery, continues in centres across Canada. The four-year project is the first study of its kind to develop and evaluate a model for community participation post-stroke. Activities include exercise, art, goal-setting and more. For example, participants in Getting On With the Rest of Your Life After Stroke in Winnipeg have produced a brochure for stroke patients with information that they wish they had known on discharge from hospital, says Ruth Barclay-Goddard, PhD., Assistant Professor at the University of Manitoba. They have also written a letter to federal Health Minister Leona Aglukkaq asking Health Canada to regulate sodium content in food and beverages in order to reduce hypertension. This effort was initiated after members of the group participated in an activity on reading food labels, using the CSN s Sodium101.ca information as a guide. In 2010, the Canadian Stroke Network s Burden of Ischemic Stroke (BURST) study found that the direct and indirect health-care costs for new stroke patients tally an average $50,000 in the six-month period following a new stroke. There are about 50,000 new strokes in Canada each year. CANADIAN STROKE NETWORK 12 ANNUAL REPORT 2009 2010

Training B u i l d i n g Canadian Expertise in Stroke Canadian Stroke Network Trainee Association (CSNTA) held workshops in October 2009 and June 2010, which included panel discussions, trainee presentations and opportunities for networking. CSNTA is growing and reaching out to students across Canada. National Stroke Nursing Council, governed by an independent leadership team, produces a newsletter for Canadian stroke nurses, pushes out the latest information on stroke best practices to frontline care providers, disseminates information about new research initiatives, and organizes workshops. The response to the Stroke Nursing Workshops at the first Canadian Stroke Congress was incredibly positive. More than 100 nurses from across Canada took part. Participants said the sessions provided great information, an opportunity to collaborate with other nurses in stroke care and a great way The objectives of the CSNTA include encouraging and initiating collaboration between trainees and researchers and strengthening visibility of trainees within the CSN. Sandeep Subramanian, Chair, CSNTA PhD. candidate, McGill University Sandeep Subramanian CANADIAN STROKE NETWORK 13 SEEING THE BIG PICTURE

to find out what is done across Canada. The Canadian Stroke Network s support of the National Stroke Nursing Council and its sponsorship of the Nursing Workshops is having an impact on the delivery of frontline stroke care by providing tools for knowledge translation of stroke best practices to the clinical areas. Linda Kelloway linda Kelloway, RN, MN, CNN(c) Best Practices Leader Ontario Stroke Network In addition to nursing workshops, the Canadian Stroke Network organized workshops this year in Stroke Imaging, Rehabilitation and Recovery and Basic Research. The Focus on Stroke training program supports researchers across Canada working in the field of stroke. Focus on Stroke is organized in partnership with the Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research. Dr. D.J. Cook D.J. Cook (above) won the Innovation Award at the first Canadian Stroke Congress for work on development of a neuroprotective agent for the treatment of ischemic stroke. This agent is now in human clinical trials. The CSN Focus on Stroke fellowship has not only provided me with the means to pursue a research career in a strong laboratory, but has plugged me into a network of researchers in basic and clinical science from across the country. The CSN makes an effort to involve Focus on Stroke Fellows in network events providing frequent opportunities for mentorship, feedback on ongoing projects and career planning. These aspects of the CSN Focus on Stroke Fellowship have vastly improved my research projects and have placed me in the best possible position to pursue a career in basic stroke research in Canada. D.J. Cook, University of Toronto Division of Neurosurgery CANADIAN STROKE NETWORK 14 ANNUAL REPORT 2009 2010

The Canadian Stroke Network provides funding for undergraduate and graduate students to work in stroke research centres every summer. Funded by a CSN 2009 Summer Fellowship, My Tram Van, a research fellow supervised by McGill University s Nicol Korner-Bitensky, successfully created a new screening tool called the Self Medication Safety post-stroke Scale (S-5). This scale will enable clinicians to identify readiness for self-medication considering the multiple impairments that may impact safety post-stroke. My Tram Van I would like to note what a wonderful opportunity the CSN summer fellowships have been in enabling students to work in the area of stroke research. I have found that each of my students has come out of their contacts with the CSN with a greater understanding of the issues related to stroke rehabilitation and with a commitment to working in the area of stroke. Dr. Nicol Korner-Bitensky, School of physical and occupational therapy, McGill University Dr. Vladimir Hachinski delivering lecture at McGill University CSN research leader Dr. Vladimir Hachinski, outgoing editor of the international journal Stroke, delivered the first Canadian Stroke Network Lecture for Medical Students at McGill University on April 26, 2010. The lecture, Better Brains for a Better World: Careers in Neurology, was webcast and it is posted on YouTube and in the training section of the Canadian Stroke Network website, and available to medical students everywhere. www.canadianstrokenetwork.ca/index.php/training/ trainee-lectures CANADIAN STROKE NETWORK 15 SEEING THE BIG PICTURE

Dr. Andrew Demchuk Dr. Andrew Demchuk, head of the Calgary Stroke Program, was the 2009 winner of the Canadian Stroke Network s Paul Morley Mentorship Award. The prize recognizes an individual who has provided exceptional mentorship to the next generation of stroke specialists. Dr. Demchuk was applauded for his work in recruiting and training stroke fellows from within and outside of Canada. Dr. Demchuk is one of the main reasons I chose to become a stroke neurologist, said Dr. Albert Jin, assistant professor in the division of neurology at Queen s University and former clinical research fellow in the Calgary Stroke Program. He is an excellent role model as a scientist, physician and teacher. Through its partnership with the Canadian Stroke Consortium, the Canadian Stroke Network supports the popular National Stroke Course for emergency-room physicians and family doctors It also supports an annual Stroke Review Course for Neurology Residents. CANADIAN STROKE NETWORK 16 ANNUAL REPORT 2009 2010

Canadian Stroke Strategy Launched in 2006, the Canadian Stroke Strategy (www.canadianstrokestrategy.ca) is a joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada. The Canadian Stroke Strategy is working to improve stroke care across the country by ensuring that the best research knowledge is put into practice. The Strategy provides the latest research evidence about effective stroke care; tools to evaluate and monitor how well hospitals are doing; and it promotes public education and awareness. The Canadian Stroke Strategy released in January 2010 the Stroke Unit Guide, a new resource that helps direct the establishment of new stroke units and the enhancement of existing stroke units in Canada. The Stroke Unit Guide has been designed for regional health authorities and hospital administrative and clinical leaders as well as frontline health-care professionals. Benefits to stroke patients and their families from the activities of the Network are evident in hospitals and health regions across the country. Expert panel review of the CSN, October 2009 CANADIAN STROKE NETWORK 17 SEEING THE BIG PICTURE

The Canadian Stroke Strategy provides an exemplary model for the management of other chronic diseases. Expert panel review of the CSN, October 2009 The Canadian Stroke Strategy s Information and Evaluation Working Group released an updated set of Core Performance Indicators to measure key aspects of stroke care. The 2010 Core Indicators will be used as part of Accreditation Canada s Stroke Services Distinction program, which recognizes hospitals that provide top quality stroke care. The 2010 CSS Core Indicators document is posted at www.canadianstrokestrategy.ca. A guide was produced in April 2010 for Emergency Medical Services (EMS) on the Management of Suspected Stroke Patients. The guide, available at www.canadianstrokestrategy.ca, provides guidelines for EMS ambulance and dispatch personnel as well as hospital Emergency Room staff to ensure effective treatment of stroke patients. The Stroke Prevention Best Practice Tool Kit was developed in 2010 to support the implementation of the Canadian Best Practice Recommendations for Stroke Care for prevention. The Tool Kit provides members of the interprofessional health care team with the knowledge required to care for patients who have recently had a stroke or TIA or have been identified as being at high risk. CANADIAN STROKE NETWORK 18 ANNUAL REPORT 2009 2010

A symposium was held in June 2010 for Community-based Stroke Recovery Groups. The meeting brought together people from across the country to help develop tools for setting up the governance structure for recovery groups and to develop strategies for community reintegration. Some Additional Canadian Stroke Strategy highlights this year: The 2010 Ontario Stroke Evaluation Report showed organized care is leading to decreasing rates of death and disability from stroke. At the Canadian Stroke Congress in June, the Quebec Health Minister announced the formation of four new regional stroke centres as part of a broader effort to improve stroke care in the province. PEI s first-ever stroke unit opened and the premier announced the establishment of secondary stroke prevention services as part of a provincial plan for organized care. A TIA hotline was launched in Alberta to help physicians identify patients at highest risk of a major stroke and ensure that they get the treatment they need. The Network has created productive partnerships with the Heart and Stroke Foundation of Canada, researchers, provincial government agencies and industry to bridge the gap between stroke research and clinical practice across the country to launch the national stroke strategy. The Expert Panel noted that this was an impressive achievement. Great value has been added by integrating stroke multidisciplinary knowledge capacity in Canada that would not have happened without the work of the Network. Expert panel review of the CSN, October 2009 CANADIAN STROKE NETWORK 19 SEEING THE BIG PICTURE

Knowledge Translation and Outreach I m p r o v i n g Hospita l Care From the inception of the Canadian Stroke Strategy, the Canadian Stroke Network s goal has been to work with Accreditation Canada on a program that would integrate stroke best practices and stroke system monitoring into current accreditation programs. The CSN is pleased that the first disease-specific accreditation effort in Canada Stroke Services Distinction was introduced in 2010. At the Canadian Stroke Congress in June, it was announced that Toronto Rehabilitation Institute and the Calgary Stroke Program are the first in Canada to earn Stroke Services Distinction from Accreditation Canada. Qmentum Article by Katie Lafferty CANADIAN STROKE NETWORK 20 ANNUAL REPORT 2009 2010

Stroke Services Distinction gives health-care centres an opportunity to look at areas of strength and areas where they can improve stroke services. It makes institutions accountable for the stroke care they provide. Dr. Patrice Lindsay, Director, Performance and Standards, Canadian Stroke Network This award recognizes leadership, clinical excellence, and innovation in stroke care. The highly specialized standards, developed in consultation with stakeholders from across the continuum of care, are based on the Canadian Stroke Strategy s Canadian Best Practice Recommendations for Stroke Care. As part of the process, health-care centres undergo an on-site review conducted by experts who have extensive practical experience in the field of stroke. The Distinction program is available to accredited clients of Accreditation Canada. The Calgary Stroke Team after winning their award CANADIAN STROKE NETWORK 21 SEEING THE BIG PICTURE

Evidence-Based Review of Stroke Rehabilitation www.ebrsr.com With the support of the CSN, the EBRSR has become the most comprehensive synthesis of evidence in the field of stroke rehabilitation available today. Successful dissemination of EBRSR content has been accomplished through an active, current and free website and a prolific publication record including more than 70 peer-reviewed articles and over 300 presentations. It has become an unparalleled resource for the development of stroke rehabilitation guidelines, recommendations and models of care. It has formed the basis for a number of clinical studies and economic reviews designed to facilitate the application of best evidence as determined by the EBRSR. Moreover, the impact of the EBRSR extends well beyond the borders of Canada. The fact that other funding agencies have invested in and continue to support evidence-based research syntheses modeled directly off the EBRSR, whether for spinal cord injury or acquired brain injury, speaks to its impact and popularity. CANADIAN STROKE NETWORK 22 ANNUAL REPORT 2009 2010

StrokEngine www.strokengine.ca Over the past five years, the CSN has funded a com - mitted interdisciplinary team of stroke rehabilitation experts who have come together to develop StrokEngine, StrokEngine-Assess and an interactive e-learning module (all viewable at www.strokengine.ca). The StrokEngine team continues to grow: more than 75 researchers, clinicians and decision-makers have put their expertise into creating, evaluating, and disseminating StrokEngine s content. StrokEngine has received international recognition from stakeholders, including students, clinicians, academics who use the resource for teaching, researchers, policymakers, those with stroke and their families. The team receives ongoing feedback, requests and queries from stakeholders at all levels. StrokEngine is recognized by the Canadian Cochrane Center for its scientific rigor and is directly linked to this and other key sites that focus on stroke and best practices in stroke rehabilitation. CANADIAN STROKE NETWORK 23 SEEING THE BIG PICTURE

Sodium 101 www.sodium101.ca The Canadian Stroke Network continues to raise awareness of the health risks of excessive sodium in the food supply. In the past year, the Network has done dozens of media interviews about sodium health risks, published an article on the topic in the Canadian Medical Association Journal and participated in Health Canada s Sodium Working Group. The CSN continues to respond to public inquiries for information about sodium. More than 100,000 refrigerator magnets with food-label guides have been sent out this year in response to requests. In early October, CSN appeared as a witness before the House of Commons Standing Committee on Health as it examined ways to move the issue forward, and later briefed the Health Minister and opposition health critics. In February 2010, the Network announced its third annual Salt Lick Award this time, highlighting food marketed for toddlers. CANADIAN STROKE NETWORK 24 ANNUAL REPORT 2009 2010

On the Web: CSN launched a newly designed website (www.canadianstrokenetwork.ca) to make information more accessible. There were more than two million hits on the Canadian Stroke Network website from mid-2009 to mid-2010, and about 180,000 visitors. More than 800 people visit the CSN website every day. From mid-2009 to mid-2010, the sodium101.ca website received 2.3 million hits, with about 97,000 individual visitors. More than 500 visitors come to the site each day. The Network is also on Facebook and Twitter. CANADIAN STROKE NETWORK 25 SEEING THE BIG PICTURE

International connections: The Canadian Stroke Network s Dr. Antoine Hakim chaired the World Stroke Organization committee that created the Clinical Practice Guideline Development Handbook for Stroke Care. The committee also included the CSN s Dr. Patrice Lindsay. The handbook provides a basic guide for healthcare professionals who wish to develop or adapt clinical guidelines across the continuum of stroke care. This has been an opportunity to share all the lessons we have learned from our own experience in the development of the Canadian Best Practice Recommendations for Stroke Care, says Dr. Lindsay. CSN Scientific Director Dr. Hakim is advisor to STROKAVENIR, a collaborative national stroke program in France and serves as chair of the International Scientific Advisory Committee for EUSTROKE, the European Stroke Network. Dr. Antoine Hakim Dr. Patrice Lindsay Clinical Practice Guideline Development Handbook for Stroke Care 230 abstracts from the Canadian Stroke Congress were published in Stroke: Journal of the American Heart Association in June 2010. CANADIAN STROKE NETWORK 26 ANNUAL REPORT 2009 2010

Patient Perspective: Hector Mackenzie My own experience is eloquent testimony to the importance of prompt action, including calling 911 and getting the victim quickly to a hospital, as well as effective treatment. Administering tpa so soon well within the limit of three hours after the stroke not only saved my life but also minimized the impact of the stroke. I would like to underline how important every aspect of the work involved has been in my case from the research on identification, treatment and procedure to the analysis of impacts of diet on medication all of these matter and make a difference. Quite simply, without your work, I would not be here. stroke survivor Hector Mackenzie addressing Canadian Stroke Network researchers at their October 2009 annual meeting High-school student Mackenzie Shaheen accompanies her father, who had a stroke in 2007, to rehabilitation therapy. CANADIAN STROKE NETWORK 27 SEEING THE BIG PICTURE

The paths we take today will lead to success and renewed opportunity in the future. Research Prevention Treatment Rehabilitation CANADIAN STROKE NETWORK 28 ANNUAL REPORT 2009 2010

Awareness Training Canadian Stroke Strategy International Ties Knowledge The CSN is bringing significant social, health and economic benefits to Canada. CANADIAN STROKE NETWORK 29 SEEING THE BIG PICTURE

CANADIAN STROKE NETWORK 30 ANNUAL REPORT 2009 2010

CANADIAN STROKE NETWORK 31 SEEING THE BIG PICTURE

STATEMENT OF OPERATIONS For the year ended March 31, 2010 REVENUE 2010 2009 Networks of Centres of Excellence grant $ 7,238,744 $ 5,473,650 Other grants 1,509,013 1,515,886 Cost sharing contributions 73,335 55,000 Services and other in-kind contributions (note 7) 47,568 47,568 Interest 249 37,798 8,868,909 7,129,902 EXPENSES Research grants (notes 6 and 7) 6,560,287 4,988,811 Salaries and benefits 996,664 916,908 Canadian Stroke Strategy 861,451 873,033 Conferences, seminars and meetings 265,039 310,304 General and administration 246,645 260,108 Professional and consulting fees 43,918 34,251 Amortization of capital assets 23,010 11,927 8,997,014 7,395,342 Excess of expenses over revenue $ (128,105) $ (265,440) See accompanying notes to the financial statements CANADIAN STROKE NETWORK 32 ANNUAL REPORT 2009 2010

STATEMENT OF CHANGES IN NET ASSETS For the year ended March 31, 2010 INVESTED IN CAPITAL TOTAL TOTAL ASSETS UNRESTRICTED 2010 2009 Balance, beginning of year $ 22,990 $ 1,046,059 $ 1,069,049 $ 1,784,489 Excess of expenses over revenue (17,646) (110,459) (128,105) (265,440) Acquisition of capital assets 35,274 (35,274) Unrealized loss on investment (450,000) Balance, end of year $ 40,618 $ 900,326 $ 940,944 $ 1,069,049 See accompanying notes to the financial statements CANADIAN STROKE NETWORK 33 SEEING THE BIG PICTURE

STATEMENT OF FINANCIAL POSITION For the year ended March 31, 2010 ASSETS 2010 2009 Current Cash and cash equivalents $ 2,310,891 $ 2,890,395 Other receivables (note 7) 55,205 68,336 Prepaid expenses 64,652 43,394 Short-term investment (note 3 (f)) 50,000 50,000 Contributions receivable 7,227,809 1,146,299 Total current assets 9,708,557 4,198,424 Capital assets (note 4) 56,709 44,445 LIABILITIES $ 9,765,266 $ 4,242,869 Current Accounts payable and accrued liabilities (note 7) $ 671,902 $ 452,776 Contributions received in advance (note 5) 8,152,420 2,721,044 Total liabilities 8,824,322 3,173,820 NET ASSETS Invested in capital assets 40,618 22,990 Unrestricted 900,326 1,046,059 Total net assets 940,944 1,069,049 Commitments (note 8) $ 9,765,266 $ 4,242,869 Approved by the board: members members See accompanying notes to the financial statements CANADIAN STROKE NETWORK 34 ANNUAL REPORT 2009 2010

STATEMENT OF CASH FLOWS For the year ended March 31, 2010 OPERATING ACTIVITIES 2010 2009 Excess of expenses over revenue $ (128,105) $ (265,440) Items not affecting cash Amortization 23,010 11,927 Contribution of capital assets (26,818) Loss on disposal of capital assets 3,105 (105,095) (277,226) Change in non-cash working capital items Other receivables 13,131 145,514 Prepaid expenses (21,258) 95,271 Contributions receivable (6,081,510) Accounts payable and accrued liabilities 219,126 103,945 Contributions received in advance 5,431,376 1,031,281 (544,230) 1,098,785 INVESTING ACTIVITY Acquisition of capital assets (35,274) (26,889) Increase (decrease) in cash (579,504) 1,071,896 Cash and cash equivalents, beginning of year 2,890,395 1,818,499 Cash and cash equivalents, end of year $ 2,310,891 $ 2,890,395 See accompanying notes to the financial statements CANADIAN STROKE NETWORK 35 SEEING THE BIG PICTURE

NOTES TO THE FINANCIAL STATEMENTS For the year ended March 31, 2010 1. NATURE OF OPERATIONS Canadian Stroke Network (CSN or the Network) was incorporated on May 23, 2001, as an independent not-for-profit corporation in accordance with the provisions of the Canada Corporations Act. CSN is part of the Canadian Networks of Centres of Excellence (NCE) program. CSN s mission is to reduce the effects of stroke on the lives of Canadians and Canadian society. The Network will place Canada at the forefront of stroke research through its multidisciplinary research program, high-quality training for Canadian scientists, and national as well as global partnerships. The new knowledge generated by the Network s research activities will help launch a competitive Canadian commercial presence. CSN consists of research experts across Canada in basic sciences, clinical sciences, social sciences, epidemiology, health economics and policy, and rehabilitation. CSN aims to break the barriers of treatment of stroke by developing innovative prevention and recovery strategies through multidisciplinary and multi-sectorial research. Specifically, CSN focuses on five research themes: preventing stroke, treating stroke, reducing cell death and minimizing stroke damage, brain repair and functional recovery post-stroke, and knowledge translation. CSN has been approved for NCE funding of $6,400,000, $3,438,865 and $3,200,000 for the years ending March 2011 to March 2013 respectively. 2. Adoption of new accounting policies The Network has adopted the following accounting and disclosure standards issued by the Canadian Institute of Chartered Accountants as of April 1, 2009: Section 4400 Financial statement presentation : This amended standard clarifies how revenues and expenses should be recognized and presented on a gross basis when a not-for-profit organization is acting as a principal in transactions and makes standard 1540 Cash flow statements applicable to not-for-profit organizations. Section 4470 Disclosure of allocated expenses by not-for-profit organizations : This new standard establishes disclosure standards for not-for-profit organizations that choose to classify their expenses by function and allocate expenses from one function to another. The adoption of the above standards is for presentation purposes only and has no impact on the Network s financial position. CANADIAN STROKE NETWORK 36 ANNUAL REPORT 2009 2010

NOTES TO THE FINANCIAL STATEMENTS For the year ended March 31, 2010 3. Significant accounting policies The following is a summary of the significant accounting policies used by management in the preparation of these financial statements. a. Revenue recognition CSN follows the deferral method of accounting for contributions, which includes government grants. Funds are received from the Canadian federal government as well as private and public sector partners. Grants and other contributions which have external restrictive covenants governing the types of activities that they can be used for funding are deferred until such time as the actual spending is incurred. Consequently, unspent grants having restrictions will be recognized as revenue in future periods when the spending occurs. Grants approved, but not received at the end of the accounting period, are accrued. Investment revenue and unrestricted contributions are recognized as revenue when received or receivable if the amount to be received can be reasonably estimated and collection is reasonably assured. b. Contributions and services in-kind Many organizations and individuals contribute a significant amount of volunteer effort in each year. The fair value of these services is often difficult to determine. Contributed services are not recognized in the financial statements unless a fair value can be reasonably estimated, such services are used in the normal course of operations and the provider of the services has explicitly defined the value of the services to CSN. CSN is dependent on such contributors to appropriately report the value of all contributions and services in-kind to its administrative centre. c. Cash and cash equivalents All highly liquid investments with original maturities of three months or less are classified as cash and cash equivalents. The fair value of cash equivalents approximates the amounts shown in the financial statements. Cash and cash equivalents were held with one institution. CANADIAN STROKE NETWORK 37 SEEING THE BIG PICTURE

NOTES TO THE FINANCIAL STATEMENTS For the year ended March 31, 2010 d. Capital assets Purchased capital assets are recorded at cost. Contributed capital assets are recorded on the statement of financial position at their estimated fair value, and recognized in the statement of operations based on their related amortization policy. Capital assets are amortized on a straight-line basis using the following annual rates: Furniture and fixtures 20% Leasehold improvements 20% Computer equipment 33% Software 100% Tradeshow booth 20% e. Research grant expenses Research grant expenses are recorded as expenses when they become payable. Research grants that will be payable in future periods are summarized and disclosed as commitments in the notes to the financial statements. If, at the end of the funding period, unspent research grants are returned, they are accounted for in the year returned. f. Financial instruments Investments have been classified as available-for-sale and are carried at fair value. Changes in fair value are recorded directly to the unrestricted net assets account. Fair value was determined to be the listed share price as at March 31, 2010. A cumulative loss of $50,000 has been recorded directly to the unrestricted net assets account (2009: cumulative loss of $50,000). The Network s other financial instruments consist of cash and cash equivalents, other receivables, contributions receivable and accounts payable and accrued liabilities. Unless otherwise noted it is management s opinion that the Network is not exposed to significant interest, currency or credit risks arising from these financial instruments. The fair values of these financial instruments approximate their carrying values, unless otherwise noted. The Network has previously adopted Section 3861 Financial Instruments Disclosure and Presentation. The Network has chosen not to adopt the new sections Section 3862 Financial Instruments Disclosures and Section 3863 Financial Instruments Presentation. Not-for-profit organizations are permitted to adopt these new sections but are not required to do so. g. Income taxes The Network is not subject to income taxes. CANADIAN STROKE NETWORK 38 ANNUAL REPORT 2009 2010

NOTES TO THE FINANCIAL STATEMENTS For the year ended March 31, 2010 h. Use of estimates The preparation of financial statements in conformity with Canadian generally accepted accounting principles requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the balance sheet date and the reported amounts of revenues and expenses during the year. Actual results could differ from those estimates. 4. CAPITAL ASSETS 2010 ACCUMULATED NET BOOK COST AMORTIZATION VALUE Furniture and fixtures $ 33,621 $ 16,289 $ 17,332 Computer equipment 194,755 160,329 34,426 Software 150,280 150,280 Tradeshow booth 17,831 12,880 4,951 $ 396,487 $ 339,778 $ 56,709 2009 ACCUMULATED NET BOOK COST AMORTIZATION VALUE Furniture and fixtures $ 33,621 $ 6,936 $ 26,685 Leasehold improvements 79,000 79,000 Computer equipment 159,803 148,644 11,159 Software 150,280 150,280 Tradeshow booth 17,831 11,230 6,601 $ 400,535 $ 396,090 $ 44,445 Furniture and fixtures includes contributed assets at a cost of $26,818 with accumulated amortization of $10,727 (2009: $5,364). 5. CONTRIBUTIONS RECEIVED IN ADVANCE Contributions received in advance represent grants and other restricted contributions for which the related spending has yet to occur. Contributions received in advance are comprised of the following: continued on next page CANADIAN STROKE NETWORK 39 SEEING THE BIG PICTURE

NOTES TO THE FINANCIAL STATEMENTS For the year ended March 31, 2010 NETWORKS OF HEART AND CENTRES OF STROKE EXCELLENCE FOUNDATION GRANTS FUNDING OTHER Balance, beginning of year $ 2,281,098 $ 55,680 $ 362,811 Add: contributions received during the year 12,561,135 428,571 1,194,791 Less: amounts recognized as revenue in the year (7,238,744) (401,407) (1,107,606) 7,603,489 82,844 449,996 DEFERRED CONTRIBUTION CAPITAL ASSETS TOTAL Balance, beginning of year $ 21,455 $ 2,721,044 Add: contributions received during the year 14,184,497 Less: amounts recognized as revenue in the year (5,364) (8,753,121) 16,091 8,152,420 Networks of Centres of Excellence grants are restricted as specified by the Federal government s Network Centres of Excellence program. Heart and Stroke Foundation funds are used to support training and Canadian Stroke Strategy initiatives. Other contributions received in advance are subject to restrictions and will be used accordingly in various on-going projects which include the Evaluation of the Ontario Stroke Care System, and various training courses. CANADIAN STROKE NETWORK 40 ANNUAL REPORT 2009 2010

NOTES TO THE FINANCIAL STATEMENTS For the year ended March 31, 2010 6. Research Grants Research grant expenses are allocated as follows: 2010 2009 Theme I Preventing Stroke $ 531,006 $ 598,598 Theme II Optimizing Acute Stroke Care 1,495,722 1,532,556 Theme III Reducing Cell Death and Minimizing Stroke Damage 736,003 750,003 Theme IV Brain Repair and Functional 974,822 831,207 Recovery Post-stroke Research training (studentships, fellowships, frontiers and libraries) 205,154 421,843 Discretionary initiatives 2,631,946 869,367 Recovery of unused research funds (14,366) (14,763) $ 6,560,287 $ 4,988,811 7. Related party transactions Under an agreement with the University of Ottawa (the University ), the University provides administrative support services as well as office space without charge to CSN. The value of the in-kind contribution received for services in fiscal year 2010 is estimated to be $42,204 (2009 $42,204). CSN has expensed $163,667 during fiscal year 2010 (2009 $78,334) in research grants to its host institution, the University. Included in accounts payable and accrued liabilities is $1,571 (other receivables in 2009 $54,342) due to (from) the University. 8. Commitments CSN commits annually to funding a number of research projects. It reserves a portion of its annual research budget to additionally fund promising projects that are presented during the fiscal year and also commits to funding several training programs. continued on next page CANADIAN STROKE NETWORK 41 SEEING THE BIG PICTURE

NOTES TO THE FINANCIAL STATEMENTS For the year ended March 31, 2010 CSN is committed to the following future expenses totaling $9,579,272 as follows: 2011 2012 2013 NCE funds: Research grants $ 2,765,176 $ 2,766,532 $ 1,878,704 Summer Studentships 105,000 105,000 105,000 2,870,176 2,871,532 1,983,704 Ministry of Health funds: CSN Registry Project 955,500 Heart and Stroke funds: Focus on Stroke MOU 298,360 300,000 300,000 9. Capital Management $ 4,124,036 $ 3,171,532 $ 2,283,704 CSN s capital is comprised of restricted contributions received in advance and unrestricted net assets. 2010 2009 Contributions received in advance $ 8,152,420 $ 2,721,044 Unrestricted net assets 900,326 1,046,059 $ 9,052,746 $ 3,767,103 Contributions received in advance are derived from the Network Centres of Excellence, the Ontario Ministry of Health, the Heart & Stroke Foundation of Canada and various other sources. CSN s objectives when managing contributions received in advance are to comply with externally imposed spending guidelines and budgets and to safeguard CSN s ability to continue as a going concern so that it can effectively continue to meet its mission as described in note 1. There are no restrictions on the use of CSN s unrestricted net assets. CSN invests a portion of its unrestricted capital in Guaranteed Cashable GIC s that are prime-linked, thus income is subject to interest rate risk. CSN s objective is to use its unrestricted capital primarily for business development activities that are not permitted through other sources of funding. 10. Comparative amounts The financial statements have been reclassified, where applicable, to conform to the presentation used in the current year. The changes do not affect prior year earnings. CANADIAN STROKE NETWORK 42 ANNUAL REPORT 2009 2010