Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Abstract WP372: The Acute ICH Growth Score: Simple and Accurate Predictor of Hematoma Expansion in Patients with Acute Intracerebral Hemorrhage

Background and Purpose: Acute intracerebral hemorrhage (ICH) hematoma expansion predicts high mortality and morbidity, occurring in a third of patients presenting with this condition. Recent studies correlated ultra-early hematoma growth and hematoma morphologic appearance with ICH expansion. Our purpose was to develop simple and clinically useful score that would predict ICH hematoma expansion accurately.

Methods: This cohort included patients with primary or anticoagulation-associated ICH patients presenting <6 hours post ictus prospectively enrolled in the PREDICT study. Patients underwent baseline CT, CT angiography and 24-hour CT for hematoma expansion analysis. A risk score model was developed for predicting hematoma expansion (> 6 ml or > 33%). A 7-point acute ICH growth score was based on ultra-early hematoma growth > 5 mL/hour (yes=1), irregular morphology (yes=1), density heterogeneity (yes=1), presence of fluid-blood levels (yes=1), spot sign (yes=1), and use of anticoagulation (yes=2). Discrimination of the expansion score was assessed.

Results: We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients. The 7-point acute ICH growth score demonstrated good discrimination for hematoma expansion>6 mL or 33% (area under the curve of 0.76). Median and significant HE are shown in the table below (p<0.001).

Conclusions: In a multicenter prospective study, the ICH expansion score demonstrate good correlation with hematoma expansion, and included recently reported variables such as morphology and ultraearly growth.

Abstract W P56: Using The M2 Vessel Diameter And Baseline NIHSS To Identify Which M2 Occlusions Should Be Treated Endovascularly?

Introduction: IV tPA is the primary acute treatment for M2 occlusions yet outcomes and recanalization rates are less than optimal. Endovascular treatment may be a more suitable treatment option in some but not all M2 occlusions yet are excluded from most current endovascular trials. Current methodologies to characterize M2s are complex and quite subjective. A simple and practical approach to evaluating M2s quickly for endovascular treatment is needed. We measured M2 cross-sectional diameter to determine if this method predicted 24-hour infarct volumes.

Methods: Patients from the ongoing prospective multicenter INTERRSECT recanalization study with an M2 occlusion identified by baseline CTA were included. Two readers measured M2 diameter on baseline CTA at the most distal point of normal vessel upstream to the clot by consensus. Recanalization (modified AOL score 2-3) was assessed on 4 hour follow-up CTA. Infarct volume was measured on 24 hr CT/MRI.

Results: 103 patients (mean age 74.1 yrs, SD=12.7; 46.5% male; median baseline NIHSS 8, IQR=7) had M2 occlusion on baseline CTA. 76/103 received IV t-PA. Recanalization was noted in 46/92 (50%) patients. Median 24-hr infarct volume was 4.28 ml (IQR=22.67 ml). In multivariable linear regression, M2 diameter (p<0.01) and baseline NIHSS (p=0.01) were associated with final infarct volume but not recanalization (p=53). Median final infarct volume was 41.6 ml (IQR=50.4) in patients with M2 diameter>2mm and baseline NIHSS>5 vs < 10 ml in all the other 3 groups (p<0.01; equality of medians test; see figure).

Conclusion: Patients with M2 diameter > 2 mm just proximal to the occlusion and baseline NIHSS > 5 have much higher final infarct volumes suggesting a role for ultra-early recanalization that is offered by endovascular treatment. Such patients could be selected for endovascular therapy in future trials or clinical practice.

Neurofibromatosis Type 1 in a Pediatric Population: Ste-Justine's Experience

Background:

To date, few pediatric series of neurofibromatosis type 1 (NF-1) have been described in the literature even though it is the most frequently encountered phakomatosis.

Methods:

We reviewed 987 charts of pediatric patients with a presumptive diagnosis of NF-1 who were evaluated at Ste-Justine hospital from January 1, 1991 to July 31, 2002. Patients who presented with two or more cardinal criteria were diagnosed with NF-1. Clinical and laboratory data were retrospectively collected, including: demographics, neuroimaging and presence or absence of associated symptoms or signs of NF-1.

Results:

A total of 279 patients were diagnosed with NF-1. The mean age at diagnosis was 3.4 years. Ninety-nine percent of the patients had café au lait spots and 47% had a first degree relative with NF-1. Almost 60 percent (59.6%) of those seen by an ophthalmologist had Lisch nodules. Optic glioma was found in in 14.7%, cutaneous neurofibromas in 38.4%, plexiform neurofibromas in 24.7%, neurofibrosarcoma in 1.8%, learning disabilities in 39%, attention deficit disorder in 40.5%, osseous dysplasias in 7.2%, pseudoarthrosis in 3.6%, precocious puberty in 3.2% and short stature in 17.9%. Magnetic resonance, when performed, showed hyperintense T2 lesions in 87.1% of cases. The mean period of follow-up was 7.4 years.

Conclusion:

Neurofibromatosis type 1 is a multisystemic disorder associated with increased risk of malignancy. It can be diagnosed at a very young age and clinical follow-up is advised. To our knowledge, this is the largest single center study of NF-1 in a pediatric population.

Leukoaraiosis and intracerebral hemorrhage after thrombolysis in acute stroke

OBJECTIVES

To evaluate whether the presence of leukoaraiosis or multiple lacunes is associated with symptomatic intracerebral hemorrhage (ICH) and 90-day outcome after thrombolytic treatment with tissue plasminogen activator (tPA).

METHODS

Data were from a Canadian national registry of thrombolyzed patients with ischemic stroke. A total of 820 scans were assessed, blind to clinical features, for the presence of severe vs no/moderate leukoaraiosis, and of multiple (>2) vs no/single lacunar infarcts. Logistic regression was used to determine if an independent interaction existed between the presence and degree of leukoaraiosis/lacunes and risk of symptomatic ICH, and to evaluate the predictive role of leukoaraiosis and lacunes in relation to 90-day outcome.

RESULTS

An overall symptomatic ICH rate of 3.5% was observed. The rate of symptomatic ICH increased up to 10% in patients with severe leukoaraiosis and multiple lacunes. A significant association was observed between ICH risk and either severe leukoaraiosis (RR = 2.7 [95% CI 1.1 to 6.5]) or multiple lacunes (RR = 3.4 [95% CI 1.5 to 7.6]). Patients with multiple lacunes, but not leukoaraiosis, had higher mortality at 90 days compared to those with one or no lacunes (OR = 2.9, 95% CI 1.3 to 6.2, p = 0.008). No difference was observed in the good outcome rate among patients with and without leukoaraiosis or lacunes or both.

CONCLUSION

The presence of small vessel disease on CT scan does not affect overall clinical outcome at 3 months in routine community use of tPA for ischemic stroke. A significant increase in the risk of symptomatic ICH is observed.

Hypertension and stroke: 2005 Canadian Hypertension Educational Program recommendations

BACKGROUND

Hypertension is the most important modifiable cause of stroke. The Canadian Hypertension Educational Program, representing Canada's experts in the field of hypertension, publishes annual evidence-based recommendations on the diagnosis and treatment of hypertension.

METHODS

We present the 2005 Canadian Hypertension Educational Program guidelines regarding the management of hypertension in patients with stroke.

RESULTS

The diagnosis of hypertension should be expedited and can be made as early as the second visit in patients with stroke. Unless contraindicated, a combination of angiotensin-converting-enzyme (ACE) inhibitors and diuretics is the preferred therapy in these patients. A target blood pressure below 140/90 mmHg for non-diabetic patients, below 130 mmHg/80 mmHg for diabetic patients and below 125 mmHg/75 mmHg for those with renal disease and proteinuria (> 1 gram per day) should be reached. Lifestyle interventions may be as effective as medication and should be used in conjunction with medical management. Waist circumference should be less than 102 cm for men and 88 cm for women. There remains uncertainty about the management of high blood pressure in the context of acute stroke.

CONCLUSIONS

A combination of ACE-inhibitors and diuretics is recommended in hypertensive stroke patients. Blood pressure should be maintained below 140/90 mmHg.

Enterococcal bacteremia in a pediatric institution: a four-year review

We identified 77 cases of enterococcal bacteremia in 76 children hospitalized at a tertiary care pediatric institution from 1985 to 1989. To define the clinical characteristics of children with enterococcal bacteremia and to assess the bacteriologic features of the infecting isolates, we retrospectively reviewed the charts and reanalyzed the bacteriologic data for 50 cases. Eighty-two percent of cases of bacteremia were nosocomial, and 26% were polymicrobial. Ninety-two percent of patients had significant underlying medical problems and/or had undergone recent surgery. Associated sites of infection included endovascular sites (two cases), the skin (two), and the urinary tract (one). Forty-eight percent of the patients had received antibiotics within 7 days preceding enterococcal bacteremia. Crude mortality figures for patients receiving appropriate two-drug therapy, appropriate monotherapy, and either no therapy or inappropriate therapy were 7%, 20%, and 6.25%, respectively. Children with enterococcal bacteremia constitute a heterogeneous group, although the great majority of cases are acquired in the hospital by children with serious underlying disease. Studies delineating appropriate antibiotic treatment for varied situations are needed.