The future of stroke thrombolysis

Virtual Care With Digital Technologies for Rural Canadians Living With Cardiovascular Disease

Canada is a wealthy nation with a geographically diverse population, seeking health innovations to better serve patients in accordance with the Canada Health Act. In this country, population and geography converge with social determinants, policy, procurement regulations, and technological advances with the goal to achieve equity in the management and distribution of health care. Rural and remote patients are a vulnerable population; when managing chronic conditions like cardiovascular disease, there is currently inequity to accessing specialist physicians at the recommended frequency-increasing the likelihood of poor health outcomes. Ensuring equitable care for this population is an unrealized priority of several provincial and federal government mandates. Virtual care technology might provide practical, economical, and innovative solutions to remedy this discrepancy. We conducted a scoping review of the literature pertaining to the use of virtual care technologies to monitor patients living in rural areas of Canada with cardiovascular disease. A search strategy was developed to identify the literature specific to this context across 3 bibliographic databases. Two hundred thirty-two unique citations were ultimately assessed for eligibility, of which 37 met the inclusion criteria. In our assessment of these articles, we provide a summary of the interventions studied, their reported effectiveness in reducing adverse events and mortality, the challenges to implementation, and the receptivity of these technologies among patients, providers, and policy-makers. Furthermore, we glean insight into the barriers and opportunities to ensure equitable care for rural patients and conclude that there is an ongoing need for clinical trials on virtual care technologies in this context.

Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol

Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.

The cloud stroke unit: 24-hour acute stroke expertise-on-demand

The use of telemedicine, especially as it is relates to telestroke, has significantly expanded over the past one or two decades. The fact that stroke therapy is a time-critical disease process, coupled with the relative paucity of stroke-trained practitioners, makes telestroke an attractive technique of care. The authors' objective was to summarize the evidence that support the reliability of telemedicine for diagnosis and efficacy in acute stroke treatment in collaboration between hospitals in two different countries.