Thrombolysis for acute ischaemic stroke

Treatment with intravenous alteplase in ischaemic stroke patients with onset time between 4.5 and 24 hours (HOPE): protocol for a randomised, controlled, multicentre study

BACKGROUND

While intravenous thrombolysis is recommended for patients who had an acute ischaemic stroke (AIS) within 4.5 hours of symptom onset, there are few randomised trials investigating the benefits of thrombolysis beyond this therapeutic window.

AIM

To determine whether patients who had an AIS selected with the presence of potentially salvageable tissue on CT perfusion at 4.5-24 hours after stroke onset (for stroke with unknown onset time, the midpoint of the time last known to be well and symptom recognition time; for wake-up stroke, the midpoint of the time last known to be well or sleep onset and wake up time) will benefit from intravenous thrombolysis.

DESIGN

HOPE is a prospective, multicentre, randomised, open-label blinded endpoint trial with the stage of phase III. The treatment allocation employs 1:1 randomisation. The treatment arm under investigation is alteplase with standard therapy, the control arm is standard therapy. Eligibility imaging criteria include ischaemic core volume ≤70 mL, penumbra ≥10 mL and mismatch ≥20%.

STUDY OUTCOMES

The primary outcome is non-disabled functional outcome (assessed as modified Rankin Scale score of 0-1 at 90 days).

DISCUSSION

HOPE is the first trial to investigate whether intravenous thrombolysis with alteplase offers benefits in patients who had an AIS presenting within 4.5-24 hours, which has the potential to extend time window and expand eligible population for thrombolysis therapy.

Mechanical thrombectomy with retrievable stents and aspiration catheters for acute ischaemic stroke: a meta-analysis of randomised controlled trials

BACKGROUND

Retrievable stents and aspiration catheters have been developed to provide more effective arterial recanalisation in acute ischaemic stroke.

AIMS

The aim of this analysis was to test the effect of mechanical thrombectomy on mortality and long-term neurological outcome in patients presenting with acute large-vessel anterior circulation ischaemic stroke.

METHODS

A structured search identified randomised controlled trials of thrombectomy (using a retrievable stent or aspiration catheter) versus control on a background of medical therapy which included intravenous thrombolysis if appropriate. The primary endpoint was disability at 90-day follow-up as assessed by the modified Rankin scale (mRS). Secondary endpoints included all-cause mortality and symptomatic intracranial haemorrhage. A Bayesian mixed-effects model was used for analysis.

RESULTS

Twelve trials met the inclusion criteria, comprising a total of 1,276 patients randomised to thrombectomy and 1,282 patients to control. Randomisation to thrombectomy significantly reduced disability at 90 days (odds ratio [OR] 0.52, 95% credible interval [CrI] 0.46 to 0.61, probability(control better)<0.0001). Furthermore, thrombectomy reduced the odds of functional dependence at 90 days, indicated by an mRS score >2 (OR 0.44, CrI 0.37 to 0.52, p<0.0001). Thrombectomy reduced all-cause mortality at 90 days (16.1% vs 19.2%, OR 0.81, 95% CrI 0.66 to 0.99, p=0.024). The frequency of symptomatic intracranial haemorrhage was similar between thrombectomy (4.2%) and control (4.0%) (OR 1.12, 95% CrI 0.76 to 1.68, p=0.72).

CONCLUSIONS

In patients with an acute anterior circulation stroke, modern device thrombectomy significantly reduces death and subsequent disability. The magnitude of these effects suggests that universal access to this treatment strategy should be the standard of care.

Oral antiplatelet therapy for acute ischaemic stroke

BACKGROUND

In people with acute ischaemic stroke, platelets become activated and can cause blood clots to form and block an artery in the brain, resulting in damage to part of the brain. Such damage gives rise to the symptoms of stroke. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and also reduce the risk of early recurrent ischaemic stroke, thereby reducing the risk of early death and improving long-term outcomes in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage.

OBJECTIVES

To assess the efficacy and safety of immediate oral antiplatelet therapy (i.e. started as soon as possible and no later than two weeks after stroke onset) in people with acute presumed ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and two trials registers, and performed forward reference/cited reference searching in August 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing oral antiplatelet therapy (started within 14 days of the stroke) with control in people with definite or presumed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria and assessed trial quality. For the included trials, they extracted and cross-checked the data. They assessed risk of bias of each study using the Risk of Bias 1 (RoB1) tool and overall certainty of the evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included 11 studies involving 42,226 participants. Three new trials have been added since the last update (743 participants). As per the previous version of this review, two trials testing aspirin 160 mg to 300 mg once daily, started within 48 hours of onset, contributed 96% of the data. The risk of bias was low. The maximum follow-up was six months. With treatment, there was a decrease in death or dependency at the end of follow-up (odds ratio (OR) 0.95, 95% confidence interval (CI) 0.91 to 0.99; 7 RCTs, 42,034 participants; moderate-certainty evidence). For every 1000 people treated with aspirin, 13 people would avoid death or dependency (number needed to treat for an additional beneficial outcome 79).

AUTHORS' CONCLUSIONS

Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in people who cannot swallow) and started within 48 hours of onset of presumed ischaemic stroke, significantly decreased death and dependency, and reduced the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications; long-term outcomes were improved.

Prunus cerasoides Extract and Its Component Compounds Upregulate Neuronal Neuroglobin Levels, Mediate Antioxidant Effects, and Ameliorate Functional Losses in the Mouse Model of Cerebral Ischemia

Prunus cerasoides (PC) has been reported to have antimicrobial and anti-inflammatory properties, but its potential as a neuroprotective agent in a mouse model of cerebral ischemia has not been explored. Considering neuroglobin (Ngb), an endogenous neuroprotective factor, as a novel approach to neuroprotection, in this study, Ngb promoter activity, Ngb expression changes, and antioxidant protection by PC extract (PCE) and PC component compounds (PCCs) were analyzed in oxygen–glucose deprivation (OGD)-treated neurons. In vivo analysis involved transient middle cerebral artery occlusion (tMCAO) in mice with pre- and post-treatment exposure to PCE. Following ischemic stroke induction, neurological behavior scores were obtained, and cellular function-related signals were evaluated in the ischemic infarct areas. In addition to PCE, certain component compounds from PCE also significantly increased Ngb levels and attenuated the intracellular ROS production and cytotoxicity seen with OGD in primary neurons. Administration of PCE reduced the infarct volume and improved neurological deficit scores in ischemic stroke mice compared with the vehicle treatment. Increased Ngb levels in infarct penumbra with PCE treatment were also accompanied by decreased markers of apoptosis (activated p38 and cleaved caspase-3). Our findings point to the benefits of Ngb-mediated neuroprotection via PCE and its antioxidant activity in an ischemic stroke model.

Endovascular thrombectomy and intra-arterial interventions for acute ischaemic stroke

BACKGROUND

Most disabling strokes are due to a blockage of a large artery in the brain by a blood clot. Prompt removal of the clot with intra-arterial thrombolytic drugs or mechanical devices, or both, can restore blood flow before major brain damage has occurred, leading to improved recovery. However, these so-called endovascular interventions can cause bleeding in the brain. This is a review of randomised controlled trials of endovascular thrombectomy or intra-arterial thrombolysis, or both, for acute ischaemic stroke.

OBJECTIVES

To assess whether endovascular thrombectomy or intra-arterial interventions, or both, plus medical treatment are superior to medical treatment alone in people with acute ischaemic stroke.

SEARCH METHODS

We searched the Trials Registers of the Cochrane Stroke Group and Cochrane Vascular Group (last searched 1 September 2020), CENTRAL (the Cochrane Library, 1 September 2020), MEDLINE (May 2010 to 1 September 2020), and Embase (May 2010 to 1 September 2020). We also searched trials registers, screened reference lists, and contacted researchers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of any endovascular intervention plus medical treatment compared with medical treatment alone in people with definite ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors (MBR and MJ) applied the inclusion criteria, extracted data, and assessed trial quality. Two review authors (MBR and HL) assessed risk of bias, and the certainty of the evidence using GRADE. We obtained both published and unpublished data if available. Our primary outcome was favourable functional outcome at the end of the scheduled follow-up period, defined as a modified Rankin Scale score of 0 to 2. Eighteen trials (i.e. all but one included trial) reported their outcome at 90 days. Secondary outcomes were death from all causes at in the acute phase and by the end of follow-up, symptomatic intracranial haemorrhage in the acute phase and by the end of follow-up, neurological status at the end of follow-up, and degree of recanalisation.

MAIN RESULTS

We included 19 studies with a total of 3793 participants. The majority of participants had large artery occlusion in the anterior circulation, and were treated within six hours of symptom onset with endovascular thrombectomy. Treatment increased the chance of achieving a good functional outcome, defined as a modified Rankin Scale score of 0 to 2: risk ratio (RR) 1.50 (95% confidence interval (CI) 1.37 to 1.63; 3715 participants, 18 RCTs; high-certainty evidence). Treatment also reduced the risk of death at end of follow-up: RR 0.85 (95% CI 0.75 to 0.97; 3793 participants, 19 RCTs; high-certainty evidence) without increasing the risk of symptomatic intracranial haemorrhage in the acute phase: RR 1.46 (95% CI 0.91 to 2.36; 1559 participants, 6 RCTs; high-certainty evidence) or by end of follow-up: RR 1.05 (95% CI 0.72 to 1.52; 1752 participants, 10 RCTs; high-certainty evidence); however, the wide confidence intervals preclude any firm conclusion. Neurological recovery to National Institutes of Health Stroke Scale (NIHSS) score 0 to 1 and degree of recanalisation rates were better in the treatment group: RR 2.03 (95% CI 1.21 to 3.40; 334 participants, 3 RCTs; high-certainty evidence) and RR 3.11 (95% CI 2.18 to 4.42; 268 participants, 3 RCTs; high-certainty evidence), respectively.

AUTHORS' CONCLUSIONS

In individuals with acute ischaemic stroke due to large artery occlusion in the anterior circulation, endovascular thrombectomy can increase the chance of survival with a good functional outcome without increasing the risk of intracerebral haemorrhage or death.

Intravenous thrombolysis for acute ischemic stroke in centenarians

PURPOSE

The benefit of intravenous alteplase is well established for patients with disabling stroke symptoms regardless of age, although data on outcomes in centenarian patients are scarce. We present our experience in patients beyond 100 years.

METHODS

Descriptive study including centenarians from our single-centre prospective registry who underwent intravenous thrombolysis with alteplase for acute ischemic stroke in our tertiary university hospital. Clinical variables and functional outcome at 3 months were collected.

RESULTS

Four patients, all women, functionally independent (mRS ≤ 2) were included. Treatment with alteplase was applied within 4.5 h of stroke onset. One patient complicated with pneumonia and died. Two patients were functionally independent (mRS ≤ 2) at discharge, while the third was partially dependent (mRS of 3 at discharge), improving after 3 months, (mRS 2). No serious hemorrhagic or systemic adverse events were registered.

CONCLUSION

In our experience, intravenous thrombolysis may be beneficial and should be considered in patients over 100 years old with no previous disability.

Silver Jubilee of Stroke Thrombolysis With Alteplase: Evolution of the Therapeutic Window

In 1995, the results of a landmark clinical trial by National Institute of Neurological Disorders and Stroke (NINDS) made a paradigm shift in managing acute cerebral ischemic stroke (AIS) patients at critical care centers. The study demonstrated the efficacy of tissue-type plasminogen activator (tPA), alteplase in improving neurological and functional outcome in AIS patients when administered within 3 h of stroke onset. After about 12 years of efforts and the results of the ECASS-III trial, it was possible to expand the therapeutic window to 4.5 h, which still represents a major logistic issue, depriving many AIS patients from the benefits of tPA therapy. Constant efforts in this regards are directed toward either speeding up the patient recruitment for tPA therapy or expanding the current tPA window. Efficient protocols to reduce the door-to-needle time and advanced technologies like telestroke services and mobile stroke units are being deployed for early management of AIS patients. Studies have demonstrated benefit of thrombolysis guided by perfusion imaging in AIS patients at up to 9 h of stroke onset, signifying “tissue window.” Several promising pharmacological and non-pharmacological approaches are being explored to mitigate the adverse effects of delayed tPA therapy, thus hoping to further expand the current tPA therapeutic window without compromising safety. With accumulation of scientific data, stroke organizations across the world are amending/updating the clinical recommendations of tPA, the only US-FDA approved drug for managing AIS patients. Alteplase has been a part of our neurocritical care and we intend to celebrate its silver jubilee by dedicating this review article discussing its journey so far and possible future evolution.

Deciding Thrombolysis in AIS Based on Automated versus on WhatsApp Interpreted ASPECTS, a Reliability and Cost-Effectiveness Analysis in Developing System of Care

Background: Automated ASPECTS has the potential of reducing interobserver variability in the determination of early ischemic changes. We aimed to assess the performance of an automated ASPECTS vs. ASPECTS interpreted for sent CT images on WhatsApp and to correlate these results with the outcome. Materials and Methods: Patients with anterior circulation stroke who had baseline NCCT and underwent successful IV-thrombolysis were included. NCCT-ASPECTS was assessed by two neuroradiologists, and discrepancies were resolved by agreement. Two groups of patients were included; group 1, where treatment was decided after an automated ASPECTS interpretation that was provided by RAPID software, and group 2, where patients received IV-tPA after an assessment of CT images sent on WhatsApp. Results: A total of 122 patients were included: 36 in group 1 and 86 in group 2. In group 2, the interobserver agreement for NCCT ASPECTS was moderate (κ = 0.36), as was the dichotomized data (κ = 0.44). IOA, however, improved (to κ = 0.57 and κ = 0.64) when the same CT images were interpreted on a workstation. In group 1, Automated ASPECTS showed excellent agreement (κ = 0.80) with agreement reads for workstation images. There were significantly (P < 0.001) increased odds of functional independence and fewer hemorrhagic complications with thrombolyzed patients in group 1. Conclusions: Automated ASPECTS provided by the RAPID@IschemaView ASPECTS performs at a level equal to the agreement read of expert neuroradiologists, and this performance was severely degraded when WhatsApp captured CT images used for ASPECTS assessment. In our study, we found that automated ASPECTS might predict outcomes after IV thrombolysis.

Scoping review of acute stroke care management and rehabilitation in low and middle-income countries

BACKGROUND

Stroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care.

METHODS

An interpretative scoping literature review based on Arksey and O'Malley's five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries.

RESULTS

A total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization.

CONCLUSIONS

There is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.

Legal medicine implications in fibrinolytic therapy of acute ischemic stroke

Background

Before the advent of fibrinolytic therapy as a gold standard method of care for cases of acute ischemic stroke in Romania, issues regarding legal medicine aspects involved in this area of medical expertise were already presented and, in the majority of cases, the doctors seem to be unprepared for these situations.

Main text

The present research illustrates some of the cases in which these aspects were involved, that adressed a clinical center having 6 years of professional experience in the application of fibrinolytic treatment for stroke. The following cases report either situations in which the afore mentioned therapy was not rightfully administrated or legal aspects regarding the obtainment of informed consent.

Conclusion

Obtaining informed consent is a mandatory procedure, which takes time, to the detriment of application of fibrinolytic treatment.

Endovascular therapy versus intravenous thrombolysis in cervical artery dissection-related ischemic stroke: a meta-analysis

BACKGROUND

The purpose of our meta-analysis is to evaluate the endovascular therapy (EVT) in patients with cervical artery dissection (CAD)-related acute ischemic stroke (AIS) by comparing its efficacy and safety with the ones of intravenous thrombolysis (IVT).

METHODS

A systematic search on EVT to CAD-related ischemic stroke is performed. The meta-analysis models are applied to calculate either the risk ratio (RR) with 95% confidence interval (CI) or pooled proportions with 95% CI of favorable functional outcome (mRS = 0-2), excellent functional outcome (mRS = 0-1), symptomatic intracranial hemorrhage (SICH), mortality and recurrent stroke between EVT and IVT in CAD-related stroke. The differences between the two treatment groups are analyzed by the pooled odds ratio value and Chi-squared test.

RESULTS

A total of 190 patients given EVT and 139 IVT-alone patients are included. By comparing EVT alone and IVT alone, patients treated with EVT alone are more likely to experience favorable outcomes than those treated with IVT alone (71.2% vs 53.4%). Besides, there is no significant difference in excellent functional outcome, SICH, mortality and recurrent stroke between the EVT-alone and IVT-alone groups (all P > 0.05). Towards general EVT (EVT with or without IVT), the outcomes are not significantly different from those of IVT alone except for a higher mortality rate (10.2% vs 3.2%).

CONCLUSION

Based on our findings, EVT is considered to be more efficacious than IVT for CAD-related AIS patients. Although EVT alone tends to be safe and promising, its safety needs to be further evaluated, particularly for EVT separating from IVT therapy.

Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack

BACKGROUND

Rapid and accurate detection of stroke by paramedics or other emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage. However, their accuracy remains uncertain and there is no agreement which of the scales perform better.

OBJECTIVES

To systematically identify and review the evidence pertaining to the test accuracy of validated stroke recognition scales, as used in a prehospital or emergency room (ER) setting to screen people suspected of having stroke.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and the Science Citation Index to 30 January 2018. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data.

SELECTION CRITERIA

We included studies evaluating the accuracy of stroke recognition scales used in a prehospital or ER setting to identify stroke and transient Ischemic attack (TIA) in people suspected of stroke. The scales had to be applied to actual people and the results compared to a final diagnosis of stroke or TIA. We excluded studies that applied scales to patient records; enrolled only screen-positive participants and without complete 2 × 2 data.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted a two-stage screening of all publications identified by the searches, extracted data and assessed the methodologic quality of the included studies using a tailored version of QUADAS-2. A third review author acted as an arbiter. We recalculated study-level sensitivity and specificity with 95% confidence intervals (CI), and presented them in forest plots and in the receiver operating characteristics (ROC) space. When a sufficient number of studies reported the accuracy of the test in the same setting (prehospital or ER) and the level of heterogeneity was relatively low, we pooled the results using the bivariate random-effects model. We plotted the results in the summary ROC (SROC) space presenting an estimate point (mean sensitivity and specificity) with 95% CI and prediction regions. Because of the small number of studies, we did not conduct meta-regression to investigate between-study heterogeneity and the relative accuracy of the scales. Instead, we summarized the results in tables and diagrams, and presented our findings narratively.

MAIN RESULTS

We selected 23 studies for inclusion (22 journal articles and one conference abstract). We evaluated the following scales: Cincinnati Prehospital Stroke Scale (CPSS; 11 studies), Recognition of Stroke in the Emergency Room (ROSIER; eight studies), Face Arm Speech Time (FAST; five studies), Los Angeles Prehospital Stroke Scale (LAPSS; five studies), Melbourne Ambulance Stroke Scale (MASS; three studies), Ontario Prehospital Stroke Screening Tool (OPSST; one study), Medic Prehospital Assessment for Code Stroke (MedPACS; one study) and PreHospital Ambulance Stroke Test (PreHAST; one study). Nine studies compared the accuracy of two or more scales. We considered 12 studies at high risk of bias and one with applicability concerns in the patient selection domain; 14 at unclear risk of bias and one with applicability concerns in the reference standard domain; and the risk of bias in the flow and timing domain was high in one study and unclear in another 16.We pooled the results from five studies evaluating ROSIER in the ER and five studies evaluating LAPSS in a prehospital setting. The studies included in the meta-analysis of ROSIER were of relatively good methodologic quality and produced a summary sensitivity of 0.88 (95% CI 0.84 to 0.91), with the prediction interval ranging from approximately 0.75 to 0.95. This means that the test will miss on average 12% of people with stroke/TIA which, depending on the circumstances, could range from 5% to 25%. We could not obtain a reliable summary estimate of specificity due to extreme heterogeneity in study-level results. The summary sensitivity of LAPSS was 0.83 (95% CI 0.75 to 0.89) and summary specificity 0.93 (95% CI 0.88 to 0.96). However, we were uncertain in the validity of these results as four of the studies were at high and one at uncertain risk of bias. We did not report summary estimates for the rest of the scales, as the number of studies per test per setting was small, the risk of bias was high or uncertain, the results were highly heterogenous, or a combination of these.Studies comparing two or more scales in the same participants reported that ROSIER and FAST had similar accuracy when used in the ER. In the field, CPSS was more sensitive than MedPACS and LAPSS, but had similar sensitivity to that of MASS; and MASS was more sensitive than LAPSS. In contrast, MASS, ROSIER and MedPACS were more specific than CPSS; and the difference in the specificities of MASS and LAPSS was not statistically significant.

AUTHORS' CONCLUSIONS

In the field, CPSS had consistently the highest sensitivity and, therefore, should be preferred to other scales. Further evidence is needed to determine its absolute accuracy and whether alternatives scales, such as MASS and ROSIER, which might have comparable sensitivity but higher specificity, should be used instead, to achieve better overall accuracy. In the ER, ROSIER should be the test of choice, as it was evaluated in more studies than FAST and showed consistently high sensitivity. In a cohort of 100 people of whom 62 have stroke/TIA, the test will miss on average seven people with stroke/TIA (ranging from three to 16). We were unable to obtain an estimate of its summary specificity. Because of the small number of studies per test per setting, high risk of bias, substantial differences in study characteristics and large between-study heterogeneity, these findings should be treated as provisional hypotheses that need further verification in better-designed studies.

A comparison of trends in stroke care and outcomes between in-hospital and community-onset stroke - The South London Stroke Register

Background

Stroke care and outcomes have improved significantly over the past decades. It is unclear if patients who had a stroke in hospital (in-hospital stroke, IHS) experienced similar improvements to those who were admitted with stroke (community-onset stroke, COS).

Methods

Data from the South London Stroke Register were analysed to estimate trends in processes of care and outcomes across three cohorts (1995–2001, 2002–2008, 2009–2015). Kaplan-Meier survival curves were calculated for each cohort. Associations between patient location at stroke onset, processes of care, and outcomes were investigated using multiple logistic regression and Cox proportional hazards models.

Results

Of 5,119 patients admitted to hospital and registered between 1995 and 2015, 552(10.8%) had IHS. Brain imaging rates increased from 92.4%(COS) and 78.3%(IHS) in 1995–2001 to 100% for COS and IHS in 2009–2015. Rates of stroke unit admission rose but remained lower for IHS (1995–2001: 32.2%(COS) vs. 12.4%(IHS), 2002–2008: 77.1%(COS) vs. 50.0%(IHS), 2009–2015: 86.3%(COS) vs. 65.4%(IHS)). After adjusting for patient characteristics and case-mix, IHS was independently associated with lower rates of stroke unit admission in each cohort (1995–2001: OR 0.49, 95%CI 0.29–0.82, 2002–2008: 0.29, 0.18–0.45, 2009–2015: 0.22, 0.11–0.43). In 2009–2015, thrombolysis rates were lower for ischaemic IHS (17.8%(COS) vs. 13.8%(IHS)). Despite a decline, in-hospital mortality remained significantly higher after IHS in 2009–2015 (13.7%(COS) vs. 26.7%(IHS)). Five-year mortality rates declined for COS from 58.9%(1995–2001) to 35.2%(2009–2015) and for IHS from 80.8%(1995–2001) to 51.1%(2009–2015). In multivariable analysis, IHS was associated with higher mortality over five years post-stroke in each cohort (1995–2001: HR 1.27, 95%CI 1.03–1.57, 2002–2008: 1.24, 0.99–1.55, 2009–2016: 1.39, 0.95–2.04).

Conclusions

Despite significant improvements for IHS patients similar to those for COS patients, rates of stroke unit admission and thrombolysis remain lower, and short- and long-term outcomes poorer after IHS. Factors preventing IHS patients from entering evidence-based stroke-specific hospital pathways in a timely fashion need further investigation.

Pericytes in Ischemic Stroke

Recent stroke research has shifted the focus to the microvasculature from neuron-centric views. It is increasingly recognized that a successful neuroprotection is not feasible without microvascular protection. On the other hand, recent studies on pericytes, long-neglected cells on microvessels have provided insight into the regulation of microcirculation. Pericytes play an essential role in matching the metabolic demand of nervous tissue with the blood flow in addition to regulating the development and maintenance of the blood-brain barrier (BBB), leukocyte trafficking across the BBB and angiogenesis. Pericytes appears to be highly vulnerable to injury. Ischemic injury to pericytes on cerebral microvasculature unfavorably impacts the stroke-induced tissue damage and brain edema by disrupting microvascular blood flow and BBB integrity. Strongly supporting this, clinical imaging studies show that tissue reperfusion is not always obtained after recanalization. Therefore, prevention of pericyte dysfunction may improve the outcome of recanalization therapies by promoting microcirculatory reperfusion and preventing hemorrhage and edema. In the peri-infarct tissue, pericytes are detached from microvessels and promote angiogenesis and neurogenesis, and hence positively effect stroke outcome. Expectedly, we will learn more about the place of pericytes in CNS pathologies including stroke and devise approaches to treat them in the next decades.

Percutaneous vascular interventions versus intravenous thrombolytic treatment for acute ischaemic stroke

BACKGROUND

Most ischaemic strokes are caused by blockage of a cerebral artery by a thrombus. Intravenous administration of recombinant tissue plasminogen activator given within 4.5 hours is now standard treatment for this condition. Percutaneous vascular interventions use an intra-arterial, mechanical approach for thrombus disruption or removal (thrombectomy). Recent randomised trials indicate that percutaneous vascular interventions are superior to usual care (usual care usually included intravenous thrombolysis). However, intravenous thrombolysis was usually given in both arms of the trial and there was a lack of direct comparison of percutaneous vascular interventions with intravenous thrombolysis.

OBJECTIVES

To assess the effectiveness and safety of percutaneous vascular interventions compared with intravenous thrombolytic treatment for acute ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last search: August 2018). In addition, in September 2017, we searched the following electronic databases: CENTRAL, MEDLINE, Embase, and Science Citation Index; and Stroke Trials Registry, and US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that directly compared a percutaneous vascular intervention with intravenous thrombolytic treatment in people with acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors applied the inclusion criteria, extracted data, and assessed risk of bias. We obtained both published and unpublished data. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included four trials with 450 participants. Data on functional outcome and death at end of follow-up were available for 443 participants from three trials. Compared with intravenous thrombolytic therapy, percutaneous vascular intervention did not improve the proportion of participants with good functional outcome (modified Rankin Scale score 0 to 2, risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.25, P = 0.92). The quality of evidence was low (outcome assessment was blinded, but not the treating physician or participants). At the end of follow-up, there was a non-significant increase in the proportion of participants who died in the percutaneous vascular intervention group (RR 1.34, 95% CI 0.84 to 2.14, P = 0.21). The quality of evidence was low (wide confidence interval). There was no difference in the proportion of participants with symptomatic intracranial haemorrhages between the intervention and control groups (RR 0.99, 95% CI 0.50 to 1.95, P = 0.97). The quality of evidence was low (wide confidence interval). Data on vascular status (recanalisation rate) were only available for seven participants from one trial; we considered this inadequate for statistical analyses.

AUTHORS' CONCLUSIONS

The present review directly compared intravenous thrombolytic treatment with percutaneous vascular interventions for ischaemic stroke. We found no evidence from RCTs that percutaneous vascular interventions are superior to intravenous thrombolytic treatment with respect to functional outcome. Quality of evidence was low (outcome assessment was blinded, but not the treating physician or participants). New trials with adequate sample sizes are warranted because of the rapid development of new techniques and devices for such interventions.

Clinical Outcome of Ischemic Stroke in Old Patients Versus Oldest-Old

BACKGROUND

It is unclear whether very old patients benefit from stroke unit. The aim of our work was to compare the clinical outcome of patients with ischemic stroke aged either 70 or 80 (G 1) versus oldest-old greater than or equal to 81 years (G 2).

METHODS

Of 1187 patients admitted with stroke during 5 years in our stroke unit, we included 252 patients with independent functional status (modified Rankin scale, [mRS] ≤ 2) before the stroke. All patients underwent clinical examination, blood test, electrocardiography, brain imaging, and cerebrovascular ultrasound. Clinical outcome was assessed with the mRS and National Institutes of Health Stroke Scale (NIHSS) at discharge. We considered favorable outcome mRS 0-2 at discharge.

RESULTS

Of 252 patients included, 55% were male, 150 (59.5%) patients belonged to G1 and 102 (40.5%) G2. We detected a significant increase of atrial fibrillation, bronchoaspiration, mortality, higher NIHSS at admission, and worse functional status at discharge in G2. No significant differences in other demographic, vascular risk factors, hospital stay, NIHSS at discharge or subtype of stroke were found. NIHSS at discharge was the only independent predictor of good functional status (odds ratio 0.4; 95% confidence interval, 0.3-0.6; P < .001).

CONCLUSIONS

Oldest-old patients showed similar NIHSS at discharge than younger patients despite having higher neurological severity at admission. Our results support the hypothesis that oldest-old patients have good recovery potential, and should not be excluded from the stroke unit. The worse functional status detected at discharge in these patients could be attributed to others factors and not to neurological severity.

Stroke Care Services in Africa: A Systematic Review

Background: Stroke is the second leading cause of death and adult-onset disability globally. Although its incidence is reducing in developed countries, low- and middle-income countries, especially African countries, are witnessing an increase in cases of stroke, leading to high morbidity and mortality. Evidently, a new paradigm is needed on the continent to tackle this growing burden of stroke in its preventative and treatment aspects.

Aims and Objectives: The aim of this study was to determine the scope of stroke care services, where they exist, and their relationship with currently existing health systems.

Methods: A detailed literature search was undertaken referring to PubMed and Google Scholar for articles from January 1960 to March 2018, using a range of search terms. Of 93 publications, 45 papers were shortlisted, and 21 reviewed articles on existing stroke services were included.

Results: The literature on models of stroke services in Africa is sparse. We identified focused systems of care delivery in the hyperacute, acute, and rehabilitative phases of stroke in a few African countries. There is a continent-wide paucity of data on the organization of prehospital stroke services. Only 3 African countries (South Africa, Egypt, and Morocco) reported experiences on thrombolysis. Also, the uptake of dedicated stroke units appears limited across the continent. Encouragingly, there are large-scale secondary prevention models on the continent, mostly within the context of experimental research projects, albeit with promising results. We found only 1 article on the interventional aspects of stroke care in our review, and this was a single-center report.

Conclusions: The literature on the organization of stroke services is sparse in Africa. Dedicated action at policy, population, community, and hospital-based levels is urgently needed toward the organization of stroke services to tame the burgeoning burden of stroke on the African continent.

A Case for Telestroke in Military Medicine: A Retrospective Analysis of Stroke Cost and Outcomes in U.S. Military Health-Care System

BACKGROUND

The development of primary stroke centers has improved outcomes for stroke patients. Telestroke networks have expanded the reach of stroke experts to underserved, geographically remote areas. This study illustrates the outcome and cost differences between neurology and primary care ischemic stroke admissions to demonstrate a need for telestroke networks within the Military Health System (MHS).

MATERIALS AND METHODS

All adult admissions with a primary diagnosis of ischemic stroke in the MHS Military Mart database from calendar years 2010 to 2015 were reviewed. Neurology, primary care, and intensive care unit (ICU) admissions were compared across primary outcomes of (1) disposition status and (2) intravenous tissue plasminogen activator administration and for secondary outcomes of (1) total cost of hospitalization and (2) length of stay (LOS).

RESULTS

A total of 3623 admissions met the study's parameters. The composition was neurology 462 (12.8%), primary care 2324 (64.1%), ICU 677 (18.7%), and other/unknown 160 (4.4%). Almost all neurology admissions (97%) were at the 3 neurology training programs, whereas a strong majority of primary care admissions (80%) were at hospitals without a neurology admitting service. Hospitals without a neurology admitting service had more discharges to rehabilitation facilities and higher rates of in-hospital mortality. LOS was also longer in primary care admissions.

CONCLUSIONS

Ischemic stroke admissions to neurology had better outcomes and decreased LOS when compared to primary care within the MHS. This demonstrates a possible gap in care. Implementation of a hub and spoke telestroke model is a potential solution.

In vivo imaging biomarkers of neuroinflammation in the development and assessment of stroke therapies - towards clinical translation

Modulation of the inflammatory microenvironment after stroke opens a new avenue for the development of novel neurorestorative therapies in stroke. Understanding the spatio-temporal profile of (neuro-)inflammatory imaging biomarkers in detail thereby represents a crucial factor in the development and application of immunomodulatory therapies. The early integration of quantitative molecular imaging biomarkers in stroke drug development may provide key information about (i) early diagnosis and follow-up, (ii) spatio-temporal drug-target engagement (pharmacodynamic biomarker), (iii) differentiation of responders and non-responders in the patient cohort (inclusion/exclusion criteria; predictive biomarkers), and (iv) the mechanism of action. The use of targeted imaging biomarkers for may thus allow clinicians to decipher the profile of patient-specific inflammatory activity and the development of patient-tailored strategies for immunomodulatory and neuro-restorative therapies in stroke. Here, we highlight the recent developments in preclinical and clinical molecular imaging biomarkers of neuroinflammation (endothelial markers, microglia, MMPs, cell labeling, future developments) in stroke and outline how imaging biomarkers can be used in overcoming current translational roadblocks and attrition in order to advance new immunomodulatory compounds within the clinical pipeline.

Decreased Lymphocyte-to-Monocyte Ratio Predicts Poor Prognosis of Acute Ischemic Stroke Treated with Thrombolysis

Background

Our previous study found that lower lymphocyte-to-monocyte ratio (LMR) is an independent risk factor of clinical outcome of acute ischemic stroke (AIS). However, whether lower LMR is independently associated with adverse prognosis of AIS treated with thrombolysis has not been determined. In this study, we explored the relationship between LMR and prognosis of AIS treated with thrombolysis.

Material/Methods

We retrospectively enrolled 108 patients treated with thrombolysis. LMR was calculated according to lymphocyte count and monocyte count on admission. Patients were classified into 3 groups according to LMR values on admission (group 1 LMR >4.34, group 2 LMR 2.79 to 4.34, group 3 LMR <2.79). Neurologic impairment was estimated by use of the National Institute of Health Stroke Scale. Clinical prognosis at 3 months was assessed by modified Rankin Scale. The relationship between LMR and neurologic impairment was analyzed by Spearman rank correlation. Receiver operating characteristic curve (ROC) was used to evaluate the ability of LMR to predict outcome.

Results

Patients in group 3 had lower lymphocyte counts and LMR values and higher monocyte counts (P<0.001). LMR value was negatively correlated with the degree of neurologic impairment (r=−0.372, P<0.001). The ROC suggested a moderate sensitivity (71.6%) and specificity (80.5%) of LMR for predicting prognosis with an optimal cut-off point at 3.48. Higher LMR value was an independent protective factor against adverse prognosis (odds ratio 0.683, 95% confidence interval 0.490−0.952, P=0.024).

Conclusions

A lower LMR value is an independent predictor of poor prognosis of AIS treated with thrombolytic therapy.

Incidental Thrombotic Thrombocytopenic Purpura during Acute Ischemic Stroke and Thrombolytic Treatment

BACKGROUND

Intravenous tissue plasminogen activator (IV tPA) was shown to be an effective treatment for acute ischemic stroke (AIS). According to stroke guidelines, there is no need to wait for the complete blood count (CBC) and coagulation test results before application of IV alteplase if there is no suspected coagulation disorder. In this study, a patient with AIS and thrombotic thrombocytopenic purpura (TTP) symptoms during thrombolytic treatment was presented.

CASE

A 33-year-old male patient was admitted at the 2.5th hour of AIS symptoms onset with right hemiparesis and sensorimotor aphasia. Cranial computed tomography (CT) and diffusion magnetic resonance imaging did not reveal any abnormality. In his medical history, the patient did not have any contraindication for thrombolytic treatment. To avoid delays to thrombolytic therapy, blood samples were taken, and after that, IV bolus alteplase treatment was applied. During maintenance treatment, agitation and vomiting developed. The result of blood samples showed less than 26,000 mm³ platelet count and maintenance therapy was stopped. In control cranial CT, there was no hemorrhage. In the laboratory examination; anemia, low platelet count; increased indirect bilirubin, lactate dehydrogenase (LDH) levels were found, and fever was 38.4°C. Schistocytes were observed in peripheral blood smear and the patient was diagnosed as TTP.

CONCLUSIONS

Stroke guidelines recommend not to wait for the results of CBC and coagulation tests before IV tPA treatment in patients who do not have any history of coagulopathy disorder. If possible, before applying IV tPA we may wait for the results of coagulation and CBC tests, keeping in mind the diseaes with high mortality such as TTP.

Efficacy and Safety of Cerebrolysin for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

Cerebrolysin was reported to be effective in the neurological improvement of patients with acute ischemic stroke (AIS) in experimental models, while data from clinical trials were inconsistent. We performed a meta-analysis to explore the efficacy and safety of cerebrolysin for AIS. PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials, which intervened within 72 hours after the stroke onset. We investigated the efficacy and safety outcomes, respectively. Risk ratios and mean differences were pooled with fixed-effects model or random-effects model. Seven studies were identified, involving 1779 patients with AIS. The summary results failed to demonstrate significant superiority of cerebrolysin in the assessment of efficacy outcomes of mRS and BI. Similarly, administration of cerebrolysin had neutral effects on safety outcomes compared with placebo, including mortality and SAE. However, the number of included studies was small, especially in the analysis of efficacy outcomes, which might cause publication bias and inaccurate between-studies variance in the meta-analysis. Conclusively, although it seemed to be safe, routine use of cerebrolysin to improve the long-term rehabilitation after stroke could not be supported by available evidence.

The golden hour of acute ischemic stroke

Background

Acute Ischemic Stroke (AIS) treatment has been revolutionised in the last two decades with the increasing use of Intravenous Thrombolysis (IVT) and with the advent of Endovascular therapy (EVT). AIS treatment and outcome are time dependant and time saving measures are being implemented at every step of the treatment chain. These changes have resulted in lower treatment times in-hospital, but it is unclear if this translates into more patients being treated within 60 min of symptom onset – the Golden Hour. The clinical outcome of IVT therapy in this patient group was our secondary outcome.

Methods

From 2009 onwards, systematic changes were made to the AIS treatment chain leading to a dramatic decrease in Door-to-Needle (DTN) time. Analyses were performed on the number of these treatments year on year and their clinical outcomes within the Golden Hour at Stavanger University Hospital (SUS).

Results

Six-hundred and thirteen patients were included; seventy-three were treated within the Golden Hour. The percentage of total IVT treatments occurring in the Golden Hour rose from 2.2% in 2009 to 14.5% in 2015 (p = 0.006) with a high of 18.3% in 2012 (p < 0.001). All of these patients had a Median NIHSS of 0 at discharge, irrespective of age and pre-existing comorbidity. There was no incidence of any ICH and in-hospital mortality was only 2.7% in this group.

Discussion

The time from AIS symptom onset to treatment is filled with delays. Despite the inherence of some delays,significant efforts on the part of the pre- and in- hospital treatment chain have made IVT therapy within 60 min a possibility. The allocation and use of resources in the setting of rapid AIS treatment is warrantedand yields unprecedented results.

Conclusions

Our study shows that improved treatment routines led to an increase in the number of patients treated within the Golden Hour. Treatment in the Golden Hour leads to excellent outcomes in all patients, irrespective of age and pre-existing comorbidity.

Relationship between functional disability and costs one and two years post stroke

BACKGROUND AND PURPOSE

Stroke affects mortality, functional ability, quality of life and incurs costs. The primary objective of this study was to estimate the costs of stroke care in Sweden by level of disability and stroke type (ischemic (IS) or hemorrhagic stroke (ICH)).

METHOD

Resource use during first and second year following a stroke was estimated based on a research database containing linked data from several registries. Costs were estimated for the acute and post-acute management of stroke, including direct (health care consumption and municipal services) and indirect (productivity losses) costs. Resources and costs were estimated per stroke type and functional disability categorised by Modified Rankin Scale (mRS).

RESULTS

The results indicated that the average costs per patient following a stroke were 350,000SEK/€37,000-480,000SEK/€50,000, dependent on stroke type and whether it was the first or second year post stroke. Large variations were identified between different subgroups of functional disability and stroke type, ranging from annual costs of 100,000SEK/€10,000-1,100,000SEK/€120,000 per patient, with higher costs for patients with ICH compared to IS and increasing costs with more severe functional disability.

CONCLUSION

Functional outcome is a major determinant on costs of stroke care. The stroke type associated with worse outcome (ICH) was also consistently associated to higher costs. Measures to improve function are not only important to individual patients and their family but may also decrease the societal burden of stroke.

Clinical Evaluation of Acupuncture as Treatment for Complications of Cerebrovascular Accidents: A Randomized, Sham-Controlled, Subject- and Assessor-Blind Trial

Background and Purpose. The effect of acupuncture as treatment for poststroke complications is questionable. We performed a randomized, sham-controlled double-blind study to investigate it. Methods. Patients with first-time acute stroke were randomized to receive 24 sessions of either real or sham acupuncture during an eight-week period. The primary outcome measure was change in National Institute of Health Stroke Scale (NIHSS) score. Secondary outcome measures included changes in Barthel Index (BI), Instrumental Activities of Daily Living (IADL), Hamilton Depression Rating Scale (HAM-D), and Visual Analogue Scale (VAS) for pain scores. Results. Of the 52 patients who were randomized to receive acupuncture (n = 28) or placebo (n = 24), 10 patients in the acupuncture group and 9 patients in the placebo group failed to complete the treatment. In total, 18 patients in the acupuncture group and 15 patients in the control group completed the treatment course. Reduction in pain was significantly greater in the acupuncture group than in the control group (p value = 0.04). There were no significant differences in the other measures between the two groups. Conclusions. Acupuncture provided more effective poststroke pain relief than sham acupuncture treatment. However, acupuncture had no better effect on neurological, functional, and psychological improvement.

Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study

Objective

To determine the comparative effectiveness of exercise versus drug interventions on mortality outcomes.

Design

Metaepidemiological study.

Eligibility criteria

Meta-analyses of randomised controlled trials with mortality outcomes comparing the effectiveness of exercise and drug interventions with each other or with control (placebo or usual care).

Data sources

Medline and Cochrane Database of Systematic Reviews, May 2013.

Main outcome measure

Mortality.

Data synthesis

We combined study level death outcomes from exercise and drug trials using random effects network meta-analysis.

Results

We included 16 (four exercise and 12 drug) meta-analyses. Incorporating an additional three recent exercise trials, our review collectively included 305 randomised controlled trials with 339 274 participants. Across all four conditions with evidence on the effectiveness of exercise on mortality outcomes (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure, prevention of diabetes), 14 716 participants were randomised to physical activity interventions in 57 trials. No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise vanticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11,1.17to 24.76). Inconsistency between direct and indirect comparisons was not significant.

Conclusions

Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

Intravenous thrombolysis with rt-PA in stroke: experience of the moroccan stroke unit

The majority of strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred. We report the case series of all patients who were treated with rt-PA at Stroke Unit of HASSAN II University hospital between 2010 and 2013. There were 52 patients treated with intravenous rtPA during the study period. The mean age was 63 years with the no gender predominance (sex ratio 1.02). Hypertension was the most common vascular risk factor (31%) and 17% of patients suffered from atrial fibrillation. 17 of 52 patients (32.7%) were treated within a 3 hours window of stroke onset and 35 of 52 (67.3%) patients were treated within 3-4.5 h. Twenty five patients (48%) had significant early improvements within 24 hours and twenty one (40.3%) patients had good outcomes at 3 months and fifteen patients (29%) died within the same period.

Does computed tomography permeability predict hemorrhagic transformation after ischemic stroke?

AIM: To use perfusion-derived permeability-surface area product maps to predict hemorrhagic transformation following thrombolytic treatment for acute ischemic stroke.

METHODS: We retrospectively analyzed our prospectively kept acute stroke database over five consecutive months for patients with symptoms of acute ischemic stroke (AIS) who had computed tomography (CT) perfusion (CTP) done at arrival. Patients included in the analyses also had to have a follow-up CT. The permeability-surface area product maps (PS) was calculated for the side of the ischemia and/or infarction and for the contralateral unaffected side at the same level. The cerebral blood flow map was used to delineate the ischemic territory. Next, a region of interest was drawn at the centre of this territory on the PS parametric map. Finally, a mirror region of interest was created on the contralateral side at the same level. The relative permeability-surface area product maps (rPS) provided an internal control and was calculated as the ratio of the PS on the side of the AIS to the PS on the contralateral side. A student t-test was performed after log conversion of rPS between patients with and without hemorrhagic transformation. Log conversion was used to convert the data into normal distribution to use t-test. For the group of patients who experienced intracranial bleed, a student t-test was performed between those with only petechial hemorrhage and those with more severe parenchymal hematoma with subarachnoid haemorrhage.

RESULTS: Of 84 patients with AIS and CTP at admission, only 42 patients had a follow-up CT. The rPS derived using the normal side as the internal control was significantly higher (P = 0.003) for the 15 cases of hemorrhagic transformation (1.71 + 1.64) compared to 27 cases that did not have any (1.07 + 1.30). Patients with values above the overall mean rPS of 1.3 had an increased likelihood of subsequent hemorrhagic transformation. The sensitivity of using this score to predict hemorrhagic transformation was 71.4, the specificity was 78.6, with a positive predictive value of 62.5 and negative predictive value of 84.6. The accuracy was 76.2. The odds ratio of an event occurring with such an rPS was 9.2. Of the 15 cases of hemorrhagic transformation, there was no difference (P = 0.35) in the rPS between the eight cases of petechial and the seven cases of more severe hemorrhagic events.

CONCLUSION: Pretreatment PS can predict the occurrence of hemorrhagic transformation on follow-up of AIS patients with relatively high sensitivity, specificity, positive and negative predictive value.

Safety and Efficacy of Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-Analysis of Observational Studies

Background: Although thrombolysis is considered to be the first-line treatment for ischemic stroke, there remains an ongoing controversy on the safety and efficacy of thrombolysis in cervical artery dissection (CAD). The aim of this meta-analysis was to assess observational data related to the safety and efficacy of thrombolysis in CAD-related ischemic stroke. Methods: We performed a systematic search of the efficacy of thrombolysis treatment in CAD-related ischemic stroke with appropriate observational studies identified for the study. The meta-analysis models in Comprehensive Meta-Analysis V2 software were applied to calculate the merged rates of favorable outcome (modified Rankin Scale, mRS 0-2), excellent outcome (mRS 0-1), intracranial hemorrhage (ICH), symptomatic ICH (SICH), mortality and recurrent stroke between thrombolysis and non-thrombolysis in CAD-related stroke. The difference of outcomes and adverse events between the 2 groups was compared by analyzing the pooled OR value and chi-square test using the software SPSS. Results: A total of 846 patients were identified from 10 studies (174 with thrombolysis; 672 with non-thrombolysis). The meta-analysis detected no significant statistical difference in the proportion of CAD-related stroke patients enjoying a favorable outcome at the 3 months' follow-up between the thrombolysis and non-thrombolysis groups (53.7 vs. 58.2%, OR 0.782, χ2 = 0.594, p > 0.05); non-thrombolysis was slightly superior than thrombolysis in terms of excellent outcome (52.4 vs. 34.4%, OR 0.489, χ2 = 9.143, p = 0.002). There was no significant difference in SICH, mortality and recurrent stroke rates between the 2 groups (all p > 0.05). ICH rate was higher in the thrombolysis group of CAD-related stroke patients compared to that in the non-thrombolysis group (12.3 vs. 7.4%, OR 2.647, χ2 = 4.127, p = 0.042). Conclusion: Thrombolysis seems to be equally safe and will achieve an efficacy similar to the efficacy of non-thrombolysis in patients with acute ischemic stroke due to CAD. It is also as effective as thrombolysis in stroke from miscellaneous causes. Therefore, CAD patients experiencing a stroke should not be denied thrombolysis therapy. However, this will need to be confirmed in large-scale randomized studies, especially involving intravenous thrombolysis treatment.

Effect of Treatment Delay, Stroke Type, and Thrombolysis on the Effect of Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome after Acute Stroke: A Systematic Review and Meta-Analysis of Individual Patient from Randomised Trials

Background. Nitric oxide (NO) donors are a candidate treatment for acute stroke and two trials have suggested that they might improve outcome if administered within 4–6 hours of stroke onset. We assessed the safety and efficacy of NO donors using individual patient data (IPD) from completed trials. Methods. Randomised controlled trials of NO donors in patients with acute or subacute stroke were identified and IPD sought from the trialists. The effect of NO donor versus control on functional outcome was assessed using the modified Rankin scale (mRS) and death, by time to randomisation. Secondary outcomes included measures of disability, mood, and quality of life. Results. Five trials (4,197 participants) were identified, all involving glyceryl trinitrate (GTN). Compared with control, GTN lowered blood pressure by 7.4/3.3 mmHg. At day 90, GTN did not alter any clinical measures. However, in 312 patients randomised within 6 hours of stroke onset, GTN was associated with beneficial shifts in the mRS (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.34–0.78) and reduced death (OR 0.32, 95% CI 0.14–0.78). Conclusions. NO donors do not alter outcome in patients with recent stroke. However, when administered within 6 hours, NO donors might improve outcomes in both ischaemic and haemorrhagic stroke.

Pre-hospital Delay as Determinant of Ischemic Stroke Outcome in an Italian Cohort of Patients Not Receiving Thrombolysis

BACKGROUND

Pre-hospital delay in acute stroke is critical to the administration of thrombolysis and affects patients' clinical outcome. In this study, the impact of pre-hospital delay on the outcome of ischemic stroke was investigated in an Italian cohort of patients who did not receive thrombolysis.

METHODS

Data from a cohort of 1847 patients, suffering from first-ever ischemic stroke and referred to an in-hospital clinical pathway were analyzed retrospectively. The relationship between pre-hospital delay and 1-month mortality was assessed with adjustment for demographics, premorbid disability, and stroke severity, which was graded according to the Scandinavian Stroke Scale, with higher scores indicating less severity.

RESULTS

Five hundred and twelve patients (27.7%) arrived at hospital within 2 hours of symptom onset. A significant correlation was found between early arrival and a reduced risk of 1-month mortality (hazard ratio .65; 95% confidence interval .48-.89; P = .02). There was a significant interaction (P = .01) between pre-hospital delay and the neurological score on mortality in the multivariate model, and the survival advantage of early admission was significant only for patients with scores on the Scandinavian Stroke Scale less than 18 (hazard ratio .54; 95% confidence interval .34-.85; P = .008).

CONCLUSIONS

Our study suggests that reducing pre-hospital delay can increase the probability of survival in patients with ischemic stroke, especially those who are most severely affected. Even if the patients cannot benefit from thrombolysis, survival rates can be increased provided that they are managed according to standardized care processes.

Effectiveness and safety of ShenXiong glucose injection for acute ischemic stroke: a systematic review and GRADE approach

BACKGROUND

To appraise critically whether published trials of ShenXiong glucose injection for patients with acute ischemic stroke (AIS) are of sufficient quality, and in addition to rate the quality of evidence by using the GRADE approach (grading of recommendations, assessment, development, and evaluation, GRADE).

METHODS

A literature search was performed in the Cochrane Library, MEDLINE, EMBASE, CBM, Chinese TCM (traditional Chinese medicine) Database, CNKI, VIP, WanFang Databases until January 2015. The limits were patients with AIS and randomized controlled trials (RCTs) or quasi-RCTs. Studies by which patients suffering intracerebral haemorrhage were excluded.

RESULTS

Twelve studies fulfilled the inclusion criteria. We found significant benefits of ShenXiong glucose injection compared with conventional treatment in improving activities of daily living function at 4 weeks (MD = 34.12, 95 % CI: 29.07, 39.17), neurological function deficit at 2 weeks (MD = -5.39, 95% CI: -6.90, -3.87), 4 weeks (MD = -5.16, 95 % CI: -6.49, -3.83), and clinical effects at 4 weeks (RR = 1.17, 95% CI: 1.10, 1.24). No trials reported the effects of ShenXiong glucose injection on the risk of early, deterioration, or quality of life. No adverse events were reported within the whole follow-up period.

CONCLUSIONS

The use of ShenXiong glucose injection may improve rehabilitation for patients with acute ischemic stroke, however, as the GRADE approach indicated low to moderate quality of available evidence as well as insufficient information about harm and patients preference, the recommendations were not provided for ShenXiong glucose injection taking as a therapeutic intervention to patients with acute ischemic stroke.

Estimating the potential contribution of stroke treatments and preventative policies to reduce the stroke and ischemic heart disease mortality in Turkey up to 2032: a modelling study

Background

Stroke and Ischemic Heart Diseases (IHD) are the main cause of premature deaths globally, including Turkey. There is substantial potential to reduce stroke and IHD mortality burden; particularly by improving diet and health behaviours at the population level. Our aim is to estimate and compare the potential impact of ischemic stroke treatment vs population level policies on ischemic stroke and IHD deaths in Turkey if achieved like other developed countries up to 2022 and 2032.

Methods

We developed a Markov model for the Turkish population aged >35 years. The model follows the population over a time horizon of 10 and 20 years. We modelled seven policy scenarios: a baseline scenario, three ischemic stroke treatment improvement scenarios and three population level policy intervention scenarios (based on target reductions in dietary salt, transfat and unsaturated fat intake, smoking prevalence and increases in fruit and vegetable consumption). Parameter uncertainty was explored by including probabilistic sensitivity analysis.

Results

In the baseline scenario, we forecast that approximately 655,180 ischemic stroke and IHD deaths (306,500 in men; 348,600 in women) may occur in the age group of 35–94 between 2012 and 2022 in Turkey. Feasible interventions in population level policies might prevent approximately 108,000 (62,580–326,700) fewer stroke and IHD deaths. This could result in approximately a 17 % reduction in total stroke and IHD deaths in 2022. Approximately 32 %, 29 %, 11 % and 6 % of that figure could be attributed to a decreased consumption of transfat, dietary salt, saturated fats and fall in smoking prevalence and 22 % could be attributed to increased fruit and vegetable consumption. Feasible improvements in ischemic stroke treatment could prevent approximately 9 % fewer ischemic stroke and IHD deaths by 2022.

Conclusions

Our modeling study suggests that effective and evidence-based food policies at the population level could massively contribute to reduction in ischemic stroke and IHD mortality in a decade and deliver bigger gains compared to healthcare based interventions for primary and secondary prevention.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2655-8) contains supplementary material, which is available to authorized users.

Tissue plasminogen activator deficiency preserves neurological function and protects against murine acute ischemic stroke

BACKGROUND

We tested the hypothesis that tissue plasminogen activator (tPA) deficiency protected against acute ischemic stroke (AIS)-induced brain injury.

METHODS AND RESULTS

Wild-type mice (n=54) were categorized into group 1 (sham control, n=18) and group 3 [AIS by permanent ligation of left common carotid artery (CCA) and cramping right CCA for 1h and then reperfusion followed by hypoxia (11% of oxygen supply for 2h), n=36]. Similarly, tPA knockout (tPA(-/-)) mice (n=54) were randomized into group 2 (sham control, n=18) and group 4 (AIS, n=36). By day 28 after AIS procedure, mortality rate was higher in group 3 (77.8%) than in group 4 (38.9%) and lowest in groups 1 (0%) and 2 (0%) (p<0.001). By days 3 and 28, MRI demonstrated a pattern of changes in brain-infarct volume identical to that of mortality among four groups (p<0.001). By day 28, protein expressions of inflammatory (MMP-9, TNF-α, NF-κB, iNOS, PAI-1, RANTES), oxidative (NOX-1, NOX-2, oxidized protein), apoptotic (cleaved caspase-3 & PARP, Bax), and fibrotic (Smad3, TGF-β) biomarkers and cellular expressions of inflammation (CD11, F4/80, GFAP), DNA-damage (γ-H2AX) and brain-edema (AQP4) markers exhibited an identical pattern compared to that of mortality (all p<0.001), whereas protein expressions of endothelial (eNOS, CD31), anti-fibrotic (Smad1/5, BMP-2) biomarkers, and number of small vessels displayed an opposite pattern (all p<0.001) among four groups. Expressions of protein and cellular angiogenesis markers (VEGF, SDF-1α, CXCR4) were progressively increased from groups 1 and 2 to group 4 (all p<0.0001).

CONCLUSION

tPA deficiency protected the brain from AIS injury.

Assessment of acute stroke cerebral CT examinations by anaesthesiologists

Background and purpose

It is essential to diagnose ischaemic stroke as soon as possible after symptom onset, so that thrombolytic treatment can be initiated as quickly as possible. This might be greatly facilitated if cerebral CT could be carried out in a pre‐hospital setting. The aim of this study was to evaluate if anaesthesiologists, who in Norway provide pre‐hospital medical care, could be trained to assess cerebral CT scans to exclude radiological contraindications for thrombolytic stroke treatment.

Methods

Thirteen anaesthesiologists attended an 8‐h course in acute stroke assessment, including a 2‐h introduction to the neuroradiology of acute stroke. Each participant then assessed 12 non‐contrast cerebral CT examinations of acute stroke patients with specific regard to radiological contraindications for thrombolytic therapy. Test results were compared with those of three experienced neuroradiologists. Inter‐rater agreement between anaesthesiologists and neuroradiologists was calculated using Cohen's Kappa statistics. Robustness of the results was assessed using the non‐parametric bootstrap.

Results

Among the neuroradiologists, Kappa was 1 for detecting radiological contraindications for thrombolytic therapy. Twelve of the 13 anaesthesiologists showed good or excellent agreement (Kappa > 0.60) with the neuroradiologists. The anaesthesiologists spent a median time of 2 min and 18 s on each CT scan.

Conclusions

This study suggests that anaesthesiologists who are experienced in pre‐hospital care may be quickly trained to assess cerebral CT examinations in acute stroke patients with regard to radiological contraindications for thrombolytic therapy.

Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke

Most of the contraindications to the administration of intravenous (IV) recombinant tissue plasminogen activator (rtPA) originated as exclusion criteria in major stroke trials. These were derived from expert consensus for the National Institute of Neurological Disorders and Stroke (NINDS) trial. Despite the fact that the safety and efficacy of IV rtPA has been repeatedly confirmed in large international observational studies over the past 20 years, most patients with acute ischemic stroke disappointingly still do not receive thrombolytic treatment. Some of the original exclusion criteria have proven to be unnecessarily restrictive in real-world clinical practice. It has been suggested that application of relaxed exclusion criteria might increase the IV thrombolysis rate up to 20% with comparable outcomes to thrombolysis with more conventional criteria. We review the absolute and relative contraindications to IV rtPA for acute ischemic stroke, discussing the underlying rationale and evidence supporting these exclusion criteria.

The Role of EMS in Regionalized Systems of Care

The parallel advancement of prehospital and in-hospital patient care has provided impetus for the development and implementation of regionalized systems of health care for patients suffering from acute, life-threatening injury and illness. Regardless of the patient's clinical condition, regionalized systems of care revolve around the premise of providing the right care to the right patient at the right time. Current regionalization strategies have shown improvements in the time to patient treatment and in patient outcome, with the incorporation of emergency medical services (EMS) bypass as a key component of the system of care. This article discusses the emerging role of EMS as a critical component of regionalized systems essential to ensure effective and efficient use of resources to improve patient outcome. We also examine some of the benefits and barriers to implementation of regionalized systems of care and avenues for future research.

Neuroprotection of Sanhua Decoction against Focal Cerebral Ischemia/Reperfusion Injury in Rats through a Mechanism Targeting Aquaporin 4

Sanhua decoction (SHD) is a famous classic Chinese herbal prescription for ischemic stroke, and aquaporin 4 (AQP4) is reported to play a key role in ischemic brain edema. This study aimed to investigate neuroprotection of SHD against focal cerebral ischemia/reperfusion (I/R) injury in rats and explore the hypothesis that AQP4 probably is the target of SHD neuroprotection against I/R rats. Lentiviral-mediated AQP4-siRNA was inducted into adult male Sprague-Dawley rats via intracerebroventricular injection. The focal cerebral ischemia/reperfusion model was established by occluding middle cerebral artery. Neurological examinations were performed according to Longa Scale. Brain water content, was determined by wet and dry weight measurement. Western blot was adopted to test the AQP4 expression in ipsilateral hippocampus. After the treatment, SHD alleviated neurological deficits, reduced brain water content and downregulated the expression of AQP4 at different time points following I/R injury. Furthermore, neurobehavioral function and brain edema after I/R were significantly attenuated via downregulation of AQP4 expression when combined with AQP4-siRNA technology. In conclusion, SHD exerted neuroprotection against focal cerebral I/R injury in rats mainly through a mechanism targeting AQP4.

Impact of a clinical pathway on end-of-life care following stroke: a mixed methods study

BACKGROUND

Death after stroke is common, but little is known about end-of-life care processes in acute stroke units.

AIM

(1) To identify family and health-care worker perceptions of an end-of-life care pathway for patients who die after acute stroke. (2) To determine whether patients with fatal stroke judged to require an end-of-life care pathway differ from patients with fatal stroke who die without introduction of such a pathway.

DESIGN

Mixed methods study integrating qualitative semistructured interviews with quantitative casenote review.

SETTING/PARTICIPANTS

In four Scottish acute stroke units, 17 relatives of deceased stroke patients and 23 health-care professionals were interviewed. Thematic analysis used a modified grounded theory approach. Multivariate analysis was performed on casenote data, identified prospectively from 100 consecutive stroke deaths.

RESULTS

Deciding pathway use was a consultative process, occurring within normal working hours. Families were commonly involved and could veto or trigger aspects of end-of-life care. Families sometimes felt responsible for decisions such as pathway use, resuscitation or hydration. Families were often led to expect their relative's death early in the post-stroke period. Prolonged dying processes, particularly where patients had severe dysphagia, added to distress for families. Preferences for place of care were discussed infrequently. No link was found between demographic or clinical characteristics and care pathway use.

CONCLUSION

Distressing stroke-related clinical problems dominated relatives' concerns rather than use of the end-of-life care pathway. At times, relatives felt primarily responsible for key aspects of decision-making. Relatives often felt unprepared for a prolonged dying process after stroke, particularly where patients had persistent major swallowing difficulties.

In vivo thrombolysis with targeted microbubbles loading tissue plasminogen activator in a rabbit femoral artery thrombus model

The increasingly high incidence of ischemic stroke caused by thrombosis of the arterial vessels is one of the major factors that threaten people's health and lives in the world. The present treatments for thrombosis are unsatisfactory yet. We developed the microbubbles loading tissue plasminogen activator (tPA) and their in vitro thrombolysis efficacy under ultrasound exposure has been proved previously. We tried to investigate their thrombolysis effect in vivo in this present study. Thrombus model was made by clamping bilateral femoral arteries in 70 arteries of 40 rabbits. The targeted tPA-loaded microbubbles were made by lyophilization, taking arginine-glycine-aspartic acid-serine peptide as the targeting ligand. Its thrombolysis efficacy, calculated as count rate and efficiency rate of recanalization, was evaluated by Pearson's χ(2) and One-way ANOVA, respectively. The count rate of recanalization of the targeted tPA-loaded microbubbles under ultrasound exposure (70%) was similar to that of the combination of tPA, microbubbles and ultrasound exposure (80%) (P = 0.61), while its tPA dosage (0.06 mg/kg) was much less than that of latter (0.9 mg/kg). Its efficiency rate of recanalization was the highest among all groups (53.22 ± 40.39%) (P < 0.01). Ultrasound-induced targeted tPA-loaded microbubbles release is a promising thrombolytic method with satisfactory thrombolytic efficacy, lowered tPA dose and potentially decreased hemorrhagic risk.

Development of a computerised decision aid for thrombolysis in acute stroke care

BACKGROUND

Thrombolytic treatment for acute ischaemic stroke improves prognosis, although there is a risk of bleeding complications leading to early death/severe disability. Benefit from thrombolysis is time dependent and treatment must be administered within 4.5 hours from onset of symptoms, which presents unique challenges for development of tools to support decision making and patient understanding about treatment. Our aim was to develop a decision aid to support patient-specific clinical decision-making about thrombolysis for acute ischaemic stroke, and clinical communication of personalised information on benefits/risks of thrombolysis by clinicians to patients/relatives.

METHODS

Using mixed methods we developed a COMPuterised decision Aid for Stroke thrombolysiS (COMPASS) in an iterative staged process (review of available tools; a decision analytic model; interactive group workshops with clinicians and patients/relatives; and prototype usability testing). We then tested the tool in simulated situations with final testing in real life stroke thrombolysis decisions in hospitals. Clinicians used COMPASS pragmatically in managing acute stroke patients potentially eligible for thrombolysis; their experience was assessed using self-completion forms and interviews. Computer logged data assessed time in use, and utilisation of graphical risk presentations and additional features. Patients'/relatives' experiences of discussions supported by COMPASS were explored using interviews.

RESULTS

COMPASS expresses predicted outcomes (bleeding complications, death, and extent of disability) with and without thrombolysis, presented numerically (percentages and natural frequencies) and graphically (pictographs, bar graphs and flowcharts). COMPASS was used for 25 patients and no adverse effects of use were reported. Median time in use was 2.8 minutes. Graphical risk presentations were shared with 14 patients/relatives. Clinicians (n = 10) valued the patient-specific predictions of benefit from thrombolysis, and the support of better risk communication with patients/relatives. Patients (n = 2) and relatives (n = 6) reported that graphical risk presentations facilitated understanding of benefits/risks of thrombolysis. Additional features (e.g. dosage calculator) were suggested and subsequently embedded within COMPASS to enhance usability.

CONCLUSIONS

Our structured development process led to the development of a gamma prototype computerised decision aid. Initial evaluation has demonstrated reasonable acceptability of COMPASS amongst patients, relatives and clinicians. The impact of COMPASS on clinical outcomes requires wider prospective evaluation in clinical settings.

Using 'dead or dependent' as an outcome measure in clinical trials in Parkinson's disease

BACKGROUND

Simple, robust, sensitive and clinically meaningful outcome measures are required for neuroprotective trials in Parkinson's disease (PD). We explored the feasibility of a composite binary outcome measure, 'dead or dependent', in such trials using data from a prospective follow-up study of an incident cohort of PD patients.

METHODS

Two hundred incident patients had an annual follow-up, including assessment of the Hoehn-Yahr stage (H-Y) and Schwab and England Activities of Daily Living Scale (S&E). Annual scores were converted into binary variables (H-Y <3 vs H-Y ≥3, and S&E ≥80% vs S&E <80%). A new outcome of 'dead or dependent' was also created, with dependence in activities of daily living defined as S&E <80%. Using these data, sample sizes were calculated for a hypothetical three-year randomised trial in which the trial outcome was defined by a binary clinical variable, all-cause mortality, or PD-related mortality.

RESULTS

At 3 years, 18.0% of patients were dead and 38.4% were dead or dependent. At 80% power, large sample sizes were required if PD-related mortality (n=1938 per study arm) or all-cause mortality (n=734) were used as the outcome, even for large treatment effects (30% reduction in relative risk). The new outcome of 'death or dependency' required the smallest sample sizes of all the outcome measures (n=277 for 30% reduction in relative risk, 627 for a 20% reduction).

CONCLUSIONS

'Death or dependency' is a feasible and potentially useful outcome measure in PD trials of neuroprotective agents, but further work is required to validate its use and define dependency.

Thrombolysis risk prediction: applying the SITS-SICH and SEDAN scores in South African patients

At present, the only specific medical treatment for acute ischaemic stroke is intravenous administration of recombinant tissue plasminogen activator within 4.5 hours of stroke onset. In the last year, two scores for risk stratification of intracranial haemorrhage have been derived from multicentric European trial groups, the Safe Implementation of Treatment in Stroke - Symptomatic IntraCerebral Haemorrhage risk score (SITS-SICH) and the SEDAN score. The aim of this study was to pilot their use in a cohort of patients treated at a South African tertiary hospital. Prospectively collected data were used from a cohort of 41 patients who underwent thrombolysis at Groote Schuur Hospital from 2000 to 2012. Computerised tomography brain imaging was available for review in 23 of these cases. The SITS-SICH and SEDAN scores were then applied and risk prediction was compared with outcomes. Two patients suffered symptomatic intracranial haemorrhage (SICH), representing 4.9% (95% CI: 0-11.5%) of the cohort. This was comparable to the SICH rate in both the SITS-SICH (5.1%) and SEDAN (6.5%) cohorts. Patient scores in the Groote Schuur Hospital cohort appeared similar to those of the validation cohorts of both SITS-SICH and SEDAN. With increasing use of thrombolysis in a resource-constrained setting, these scores represent a potentially useful tool in patient selection of those most likely to benefit from intravenous thrombolysis, reducing risk for SICH and with the added benefit of curtailing cost.

'It was like he was in the room with us': patients' and carers' perspectives of telemedicine in acute stroke

BACKGROUND

Telemedicine can facilitate delivery of thrombolysis in acute stroke. The aim of this qualitative study was to explore patients' and carers' views of their experiences of using a stroke telemedicine system in order to contribute to the development of reliable and acceptable telemedicine systems and training for health-care staff.

METHOD

We recruited patients who had, and carers who were present at, recent telemedicine consultations for acute stroke in three hospitals in NW England. Semi-structured interviews were conducted using an interview guide based on normalization process theory (NPT). Thematic analysis was undertaken.

RESULTS

We conducted 24 interviews with 29 participants (16 patients; 13 carers). Eleven interviews pertained to 'live' telemedicine assessments (at the time of admission); nine had mock-up telemedicine assessments (within 48 h of admission); four had both assessments. Using the NPT domains as a framework for analysis, factors relating to coherence (sense making) included people's knowledge and understanding of telemedicine. Cognitive participation (relational work) included interaction between staff and with patients and carers. Issues relating to collective action (operational work) included information exchange and support, and technical matters. Findings relating to reflexive monitoring (appraisal) included positive and negative impressions of the telemedicine process, and emotional reactions.

CONCLUSION

Although telemedicine was well accepted by many participants, its use added an additional layer of complexity to the acute stroke consultation. The 'remote' nature of the consultation posed challenges for some patients. These issues may be ameliorated by clear information for patients and carers, staff interpersonal skills, and teamworking.

Fibrinogen nitrotyrosination after ischemic stroke impairs thrombolysis and promotes neuronal death

Ischemic stroke is an acute vascular event that compromises neuronal viability, and identification of the pathophysiological mechanisms is critical for its correct management. Ischemia produces increased nitric oxide synthesis to recover blood flow but also induces a free radical burst. Nitric oxide and superoxide anion react to generate peroxynitrite that nitrates tyrosines. We found that fibrinogen nitrotyrosination was detected in plasma after the initiation of ischemic stroke in human patients. Electron microscopy and protein intrinsic fluorescence showed that in vitro nitrotyrosination of fibrinogen affected its structure. Thromboelastography showed that initially fibrinogen nitrotyrosination retarded clot formation but later made the clot more resistant to fibrinolysis. This result was independent of any effect on thrombin production. Immunofluorescence analysis of affected human brain areas also showed that both fibrinogen and nitrotyrosinated fibrinogen spread into the brain parenchyma after ischemic stroke. Therefore, we assayed the toxicity of fibrinogen and nitrotyrosinated fibrinogen in a human neuroblastoma cell line. For that purpose we measured the activity of caspase-3, a key enzyme in the apoptotic pathway, and cell survival. We found that nitrotyrosinated fibrinogen induced higher activation of caspase 3. Accordingly, cell survival assays showed a more neurotoxic effect of nitrotyrosinated fibrinogen at all concentrations tested. In summary, nitrotyrosinated fibrinogen would be of pathophysiological interest in ischemic stroke due to both its impact on hemostasis - it impairs thrombolysis, the main target in stroke treatments - and its neurotoxicity that would contribute to the death of the brain tissue surrounding the infarcted area.

Management of NCD in low- and middle-income countries

Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified "best buys" it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.

An audit of the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital

BACKGROUND

According to the Australian Bureau of Statistics, stroke is the second leading cause of death in Australia. The clinical Guidelines for stroke management published by the National Stroke Foundation provide a series of evidence based recommendations to assist clinicians in the management of stroke patients. Appropriate management of patients admitted to stroke units reduces death and disability by 20 %. Moreover, a multidisciplinary team approach also improves patient outcomes.

OBJECTIVE

To retrospectively review the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital, and to compare adherence with the guidelines for stroke management with the national stroke foundation data with and without pharmacist intervention.

METHOD

A retrospective audit of medical records was undertaken of all patients admitted to a large teaching hospital with the diagnosis of stroke or cerebral infarction from January 2013 to May 2013.

RESULTS

A total of 124 patients were included in the study. Most patients were discharged on appropriate pharmacological intervention for the prevention of secondary stroke: antihypertensive agents (71 %), lipid lowering agents (67 %) and antithrombotic (85 %) medications.

CONCLUSION

The majority of the cohort was discharged on the appropriate evidence based medications for the management of secondary stroke. Further improvement may be achieved by pharmacist intervening as part of a multidisciplinary team.