Organisation of inhospital acute stroke care and minimum criteria for stroke care units. Recommendations of the Belgian Stroke Council

There is ample evidence from randomized trials that for patients with stroke, stroke unit care is superior to care in general medical or neurological wards. This evidence, which has been adopted by international guidelines has to be implemented into daily stroke care. This consensus document prepared by the Belgian Stroke Council provides a set of minimum criteria to meet international standards for stroke care. It is intended to provide help in the creation of stroke units in centers who do not currently have one and to provide a benchmark for centres already having organised stroke care.

Is there a decline in the vascular event rate after transient ischemic attack or stroke in antiplatelet trials?

BACKGROUND

We examined the baseline characteristics and the rates of serious vascular events in randomized clinical trials after cerebral ischemia of presumed arterial origin to identify study features that predict vascular event incidence and to identify whether event rates have declined over time.

METHODS

We performed a systematic review to identify all published randomized controlled trials of patients with stroke or transient ischemic attack of presumed arterial origin that included an aspirin arm. We performed metaregression to analyze whether baseline features of included patients, design features and the year of study start and publication influenced vascular event rates under aspirin treatment.

RESULTS

Included studies comprised 23,247 patients who had 3,615 serious vascular events. Baseline characteristics of patients included in the different trials varied substantially over time. In multivariate metaregression analysis a shorter maximum allowed delay from symptom onset to randomization (p = 0.012) and a double-blind design were associated with higher annual event rates (p = 0.014). Event rates did not significantly decrease over time (p = 0.242).

CONCLUSION

The baseline characteristics of patients included in trials that study antiplatelet agents have changed over time. The strongest predictors for higher event rates are a double-blind design and a short delay between symptom onset and randomization. An important reduction in event rates over time could not be demonstrated.

Reducing prehospital delay in acute stroke

Despite the proven benefits of thrombolysis for patients presenting with acute ischemic stroke, only a limited number of patients receive thrombolytic therapy. The reason for the low treatment rate is that thrombolysis is only effective a few hours after the onset of ischemic stroke, so delays in patients being admitted to hospital and being diagnosed mean that the therapeutic window is often missed. Major factors that lead to prehospital delay include the general public's lack of knowledge of stroke symptoms and their poor understanding of the appropriate course of action following a stroke. Indeed, the patients who arrive early in hospital tend to be those who recognize the symptoms of stroke and take them seriously. Deficiencies in the identification of stroke by emergency medical services and general practitioners also contribute to prehospital delay. Aggressive, combined educational programs aimed at the general public, general practitioners, and medical and paramedical hospital staff can lead to increased stroke treatment rates. In this Review, we explore the extent of prehospital delay in stroke, identify the factors that affect the time taken for patients to reach hospital, and describe strategies designed to reduce the delay.

Discriminant ability of the Trunk Impairment Scale: A comparison between stroke patients and healthy individuals

PURPOSE

The Trunk Impairment Scale (TIS) is a standardized scale to evaluate the trunk function in stroke patients. It was the aim of this study to determine the discriminant ability of the TIS by comparing stroke patients with healthy individuals. Further, the variables that had an influence on obtaining a high score on the TIS in healthy subjects were examined.

METHOD

Forty stroke patients and 40 age- and sex-matched healthy individuals were included in the study. TIS scores from the stroke patients and healthy individuals were compared using the Wilcoxon ranked sum test.

RESULTS

Sub-scale and total TIS scores showed significant differences between stroke patients and healthy individuals (P < 0.0001). Univariate analysis and logistic regression analysis further revealed that younger persons, women and people who are more active in daily life have a higher chance of obtaining a high score on the TIS.

CONCLUSIONS

The TIS discriminates between stroke patients and healthy individuals. A submaximal score on the TIS was found in 45% of the healthy subjects suggesting that a lower score on the TIS still indicates normal trunk function and full participation in daily life.

Patients with acute stroke treated with intravenous tPA 3-6 hours after stroke onset: correlations between MR angiography findings and perfusion- and diffusion-weighted imaging in the DEFUSE study

PURPOSE

To study magnetic resonance (MR) angiography findings in patients with acute stroke treated with intravenous tissue plasminogen activator (tPA) in relationship to perfusion- and diffusion-weighted imaging changes and clinical outcome.

MATERIALS AND METHODS

Patients treated with intravenous tPA 3-6 hours after stroke onset (with informed consent) were evaluated in a HIPAA-compliant multicenter prospective study approved by all institutional review boards. MR imaging and MR angiography studies were performed before and 3-6 hours after treatment. MR angiography studies that were technically adequate at both time points were evaluated for occlusion, decreased flow, any early recanalization, and degree of recanalization. These results were compared with favorable clinical response (an improvement in National Institutes of Health Stroke Scale score of >or=8 points at 30 days or a modified Rankin scale score of 0 or 1 at 30 days) in patients with and those without mismatch between perfusion- and diffusion-weighted imaging at baseline.

RESULTS

Seventy-four patients were enrolled in the initial investigation; pre- and posttreatment MR angiography studies were both technically adequate in 62 patients. MR angiography demonstrated occlusion or decreased flow in 46 patients. Patients with isolated middle cerebral artery (MCA) occlusion and early recanalization at MR angiography had higher rates of favorable clinical response than those with tandem internal carotid artery-MCA occlusion and early recanalization (P = .05). Any early recanalization was not associated with favorable clinical response, but degree of recanalization did correlate with favorable clinical response (P = .048). Favorable clinical response was more frequently seen in patients with mismatch between perfusion- and diffusion-weighted imaging findings at baseline who experienced early recanalization than in those who did not have early recanalization (odds ratio = 6.2; 95% confidence interval: 1.3, 30.2; P = .021). No relationship between early recanalization and favorable clinical response was seen in patients without mismatch.

CONCLUSION

Early recanalization seen at MR angiography before and after treatment coupled with diffusion- and perfusion-weighted imaging data may predict clinical outcome in patients with stroke treated with tPA 3-6 hours after symptom onset.

Closure of a patent foramen ovale is associated with a decrease in prevalence of migraine: a prospective observational study

BACKGROUND

A causal relationship between migraine and a right-to-left shunt, due to a patent foramen ovale (PFO), has been suggested. In mainly retrospective studies, percutaneous closure of a PFO has been associated with a decrease in the prevalence of migraine.

OBJECTIVE

In this prospective observational study we evaluated whether percutaneous closure of a PFO is associated with a decrease in the prevalence of migraine.

METHODS

Between November 2003 and August 2005, we included 92 patients (age >16 years) who underwent a percutaneous closure of a symptomatic PFO, which was considered to be related to a paradoxical embolism.They received a headache questionnaire before and six months after closure.Two neurologists diagnosed migraine, according to the International Headache Criteria.

RESULTS

Eighty-nine of 92 patients (97%, mean age 51.6 +/- 12.3 years, 63 men) completed the questionnaire immediately before PFO closure.The overall prevalence of migraine was 27.0%, for migraine without aura (MA-) 15.7%, and for migraine with aura (MA+) 11.2%. After more than six months of follow-up 84 of 89 patients (94%, mean age 52.1 +/- 12.0 years, 60 men) returned the questionnaire. The overall prevalence of migraine in this group decreased from 28.6% to 10.7% (P = 0.001), for MA-from 16.7% to 8.3% (P = 0.07), and for MA+ from 11.9% to 2.4% (P = 0.02).

CONCLUSIONS

Percutaneous PFO closure is related to a decrease in the prevalence of migraine in this prospective observational study. However, randomized placebo controlled trials have to confirm these findings.

Migraine and coarctation of the aorta: prevalence and risk factors

OBJECTIVES

We previously described a potential relationship between the presence of migraine and congenital heart defects. It has been hypothesized that a genetic substrate might determine for congenital heart defects and migraine. Therefore, we wanted to study the prevalence of migraine in female patients with coarctation of the aorta (CA) and to determine predictive variables for migraine in this specific population.

METHODS

All patients with CA, previously selected for the ZAHARA trial to evaluate pregnancies and outcome, were recruited from the database of congenital heart disease of the University Hospital of Leuven. These patients were contacted by phone and asked to complete a structured headache questionnaire. Based on this questionnaire, a neurologist blinded to the patients' files, diagnosed migraine without or with aura (MA- and MA+, respectively), according to the international headache criteria. Demographic, clinical, and technical data were obtained by reviewing the patients' records.

RESULTS

Thirty-four female patients (age 32.2 +/- 6.3 y) were included in the study. The overall prevalence of migraine in female CA patients was 38%, of which 12% were MA- and 26% MA+. No significant relationship between demographic, clinical, and technical variables and migraine could be determined, except for migraine and the number of pregnancies and smoking behaviour (univariate logistic regression; B = 1.2 and 1.9, P = 0.039 and 0.027, respectively).

CONCLUSION

In this study, we found a relatively high prevalence of migraine in female adult CA patients. We could also demonstrate a positive relationship between migraine, smoking behaviour, and the number of pregnancies. Therefore, we should pay more attention to these findings in daily practice.

New-onset and persistent migraine early after percutaneous atrial septal defect closure disappear at follow-up

AIMS

Recently we reported that percutaneous atrial septal defect (ASD) closure had no influence on the prevalence of migraine during a short followup period. 12 % of patients however developed a new-onset migraine after the ASD closure. As it has been suggested that the closing device might induce or maintain migraine temporarily, we were interested in the prevalence of migraine at longer follow-up.

METHODS

All 75 patients included in the previous study, received the same structured headache questionnaire. A neurologist, blinded to previous data, diagnosed migraine with or without aura (MA+ or MA-) according to the International Headache Criteria. McNemar paired X2 test was used to evaluate changes in the occurrence of migraine.

RESULTS

Seventy-one patients (94.7%) answer the questionnaire (55 women, mean age at closure 51 +/- 18 years). Mean follow-up time was 52 +/- 13 months. The overall migraine prevalence decreased from 30.7% before to 22.5% after closure (P=0.21). A significant reduction was noted in patients with new-onset migraine early after closure (n=7), where migraine disappeared in 6 patients (P=0.031). In the group with persistent migraine early after closure (n=13), another 6 patients became migraine-free (P=0.031).

CONCLUSION

Percutaneous ASD closure was not related to a significant decrease in overall migraine prevalence. However, new-onset and persistent migraine early after closure disappeared.

Network meta-analysis: simultaneous meta-analysis of common antiplatelet regimens after transient ischaemic attack or stroke

Network meta-analysis can provide estimates of treatment efficacy of multiple treatment regimens, even when direct comparisons are unavailable. We used network meta-analysis to compare commonly used antiplatelet regimens in the prevention of serious vascular events after transient ischaemic attack (TIA) or stroke. We performed direct meta-analyses of randomized, controlled trials evaluating antiplatelet agents after TIA or stroke. We chose the endpoint stroke, myocardial infarction, and vascular death. Network meta-analysis was then used to estimate the relative efficacy of the various antiplatelet regimens. Twenty-four trials involving 42688 TIA or stroke patients who suffered 6830 serious vascular events were included. In the network meta-analysis, all antiplatelet regimens (aspirin, aspirin plus dipyridamole, thienopyridines, and combination of aspirin and thienopyridines) were significantly more effective than placebo. The combination of aspirin and dipyridamole was more effective than thienopyridines (OR, 0.84; 95% CI, 0.73-0.97) and more effective than aspirin (OR, 0.78; 95% CI, 0.70-0.87). Our analysis suggests that the most powerful antiplatelet regimen in the prevention of serious vascular events after TIA or stroke is the combination of aspirin and dipyridamole. Network meta-analysis could be used to synthesize accumulating evidence from clinical trials in a broad range of vascular disorders.

Obstacles to the use of intravenous tissue plasminogen activator for acute ischemic stroke. Is time the only barrier?

BACKGROUND AND AIMS

The short time window is frequently cited as the main reason for exclusion of intravenous tissue plasminogen activator (tPA) in acute stroke. Identifying and circumventing barriers to thrombolysis other than time could increase the frequency of treatment. The goal of this study was to identify whether the rate of treatment with tPA would increase if time window was not an obstacle to treatment.

METHODS

In four hospitals we prospectively recorded the rate of tPA use in consecutive patients admitted with acute ischemic stroke and in those admitted within 3 hours, the reasons why thrombolysis was not given, and the potential gain in the rate of tPA use if all patients had been admitted within 3 hours considering all exclusion criteria other than time.

RESULTS

We recruited 486 patients (258 men; mean age, 70.4 +/- 13.5 years), of whom 154 (31.7%) were admitted within 3 hours. The time of stroke onset was unknown in 28 (5.8%). The rate of tPA use was 11.1% in the whole study population and 35.1% in those admitted within 3 hours. In 'eligible' patients, TIA in 33 patients (21.4%), age >80 years in 27 (17.5%), mild stroke in 27 (17.5%), rapidly recovering stroke in 9 (5.8%), a too long door-to-needle time in 8 (5.2%), and severe hypertension in 5 (3.2%) were the main reasons for not to treat. Two patients were not treated despite the absence of documented reasons. If all patients had hypothetically been admitted within 3 hours, the rate of tPA use would have increased from 11.1% up to 27.9% of the whole population and up to 37.4% if aged patients and those with no documented reasons or with a rapidly recovering stroke had also been considered for treatment.

CONCLUSIONS

Delayed presentation to hospital is the main factor limiting the use of thrombolysis in acute stroke, but additional patients would be treated if those with no contraindication, advanced age or rapidly recovering stroke were considered as eligible.

Time Course of Trunk, Arm, Leg, and Functional Recovery After Ischemic Stroke

Background. Patterns of recovery provide useful information concerning the potential of physical recovery over time and therefore the setting of realistic goals for rehabilitation programs. Objective. To compare the time course of trunk recovery with the patterns of recovery of arm, leg, and functional ability. Methods . Consecutive stroke patients were recruited in 2 acute neurology wards. Participants were evaluated at 1 week, 1 month, and 3 and 6 months after stroke. Patients were assessed with the Trunk Impairment Scale, Fugl-Meyer arm and leg test, and Barthel Index. Results. Thirty-two patients were included in the study. There were no dropouts. Repeated measures analysis of the recovery patterns of motor and functional performance revealed the most striking improvement for all measures from 1 week to 1 month ( P value between .0021 and <.0001) and a significant improvement from 1 month to 3 months after stroke ( P value ranges from .0008 to <.0001). No significant improvement was found between 3 and 6 months after stroke for any of the measures. Statistical analysis revealed no significant difference between time course of trunk, arm, leg, and functional recovery ( P = .2565). No significant differences in level of motor and functional recovery were found at the different time points. Conclusions. Separate analyses of motor and functional recovery patterns after stroke confirm the importance of the first month for recovery. Contrary to common belief, the time course of recovery of the trunk is similar to the recovery of arm, leg, and functional ability.

Overexpression of mutant superoxide dismutase 1 causes a motor axonopathy in the zebrafish

The development of small animal models is of major interest to unravel the pathogenesis and treatment of neurodegenerative diseases, especially because of their potential in large-scale chemical and genetic screening. We have investigated the zebrafish as a model to study amyotrophic lateral sclerosis (ALS), a fatal neurodegenerative disorder characterized by the selective loss of motor neurons, caused by mutations in superoxide dismutase 1 (SOD1) in a subset of patients. Overexpression of mutant human SOD1 in zebrafish embryos induced a motor axonopathy that was specific, dose-dependent and found for all mutations studied. Moreover, using this newly established animal model for ALS, we investigated the role of a known modifier in the disease: vascular endothelial growth factor (VEGF). Lowering VEGF induced a more severe phenotype, whereas upregulating VEGF rescued the mutant SOD1 axonopathy. This novel zebrafish model underscores the potential of VEGF for the treatment of ALS and furthermore will permit large-scale genetic and chemical screening to facilitate the identification of new therapeutic targets in motor neuron disease.