Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015

Hyperoxemia and hypoxemia impair cellular oxygenation: a study in healthy volunteers

INTRODUCTION

Administration of oxygen therapy is common, yet there is a lack of knowledge on its ability to prevent cellular hypoxia as well as on its potential toxicity. Consequently, the optimal oxygenation targets in clinical practice remain unresolved. The novel PpIX technique measures the mitochondrial oxygen tension in the skin (mitoPO2) which allows for non-invasive investigation on the effect of hypoxemia and hyperoxemia on cellular oxygen availability.

RESULTS

During hypoxemia, SpO2 was 80 (77-83)% and PaO2 45(38-50) mmHg for 15 min. MitoPO2 decreased from 42(35-51) at baseline to 6(4.3-9)mmHg (p < 0.001), despite 16(12-16)% increase in cardiac output which maintained global oxygen delivery (DO2). During hyperoxic breathing, an FiO2 of 40% decreased mitoPO2 to 20 (9-27) mmHg. Cardiac output was unaltered during hyperoxia, but perfused De Backer density was reduced by one-third (p < 0.01). A PaO2 < 100 mmHg and > 200 mmHg were both associated with a reduction in mitoPO2.

CONCLUSIONS

Hypoxemia decreases mitoPO2 profoundly, despite complete compensation of global oxygen delivery. In addition, hyperoxemia also decreases mitoPO2, accompanied by a reduction in microcirculatory perfusion. These results suggest that mitoPO2 can be used to titrate oxygen support.

Pharmacological Prevention of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH) include early brain injury and delayed neurologic deterioration, which may result from delayed cerebral ischemia (DCI). Complex pathophysiological mechanisms underlie DCI, which often includes angiographic vasospasm (aVSP) of cerebral arteries.

METHODS

Despite the study of many pharmacological therapies for the prevention of DCI in aSAH, nimodipine-a dihydropyridine calcium channel blocker-remains the only drug recommended universally in this patient population. A common theme in the research of preventative therapies is the use of promising drugs that have been shown to reduce the occurrence of aVSP but ultimately did not improve functional outcomes in large, randomized studies. An example of this is the endothelin antagonist clazosentan, although this agent was recently approved in Japan.

RESULTS

The use of the only approved drug, nimodipine, is limited in practice by hypotension. The administration of nimodipine and its counterpart nicardipine by alternative routes, such as intrathecally or formulated as prolonged release implants, continues to be a rational area of study. Additional agents approved in other parts of the world include fasudil and tirilazad.

CONCLUSIONS

We provide a brief overview of agents currently being studied for prevention of aVSP and DCI after aSAH. Future studies may need to identify subpopulations of patients who can benefit from these drugs and perhaps redefine acceptable outcomes to demonstrate impact.

Lower Versus Higher Oxygenation Targets for Critically Ill Patients: A Systematic Review

Supplemental oxygen is a standard therapeutic intervention for critically ill patients such as patients suffering from cardiac arrest, myocardial ischemia, traumatic brain injury, and stroke. However, the optimal oxygenation targets remain elusive owing to the paucity and inconsistencies in the relevant literature. A comprehensive analysis of the available scientific evidence was performed to establish the relative efficacy of the lower and higher oxygenation targets. A systematic literature search was conducted in PubMed, MEDLINE, and Scopus databases from 2010 to 2023. Further, Google Scholar was also searched. Studies evaluating the efficacy of oxygenation targets and the associated clinical outcomes were included. Studies that included participants with hyperbaric oxygen therapy, chronic respiratory diseases, or extracorporeal life support were excluded. The literature search was performed by two blinded reviewers. A total of 19 studies were included in this systemic review, including 72,176 participants. A total of 14 randomized control trials were included. A total of 12 studies investigated the efficacy of lower and higher oxygenation targets in ICU-admitted patients, and seven were assessed in patients with acute myocardial infarction and stroke. For ICU patients, the evidence was conflicting, with some studies showing the efficacy of conservative oxygen therapy while others reported no difference. Overall, nine studies concluded that lower oxygen targets are favorable. However, most studies (n=4) in stroke and myocardial infarction patients showed no difference in lower or higher oxygenation targets whereas only two supported lower oxygenation targets. Available evidence suggests that lower oxygenation targets result in either improved or equivalent clinical outcomes compared with higher oxygenation targets.

Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support

BACKGROUND AND OBJECTIVES

Despite decades of increasingly sophisticated neurocritical care, patient outcomes after spontaneous intracerebral hemorrhage (ICH) remain dismal. Whether this reflects therapeutic nihilism or the effects of the primary injury has been questioned. In this contemporary cohort, we determined the 30- and 90-day mortality, cause-specific mortality, functional outcome, and the effect of surgical intervention in a culture of aggressive medical and surgical support.

METHODS

This was a retrospective cohort study of consecutive adult patients with spontaneous ICH admitted to a tertiary neurocritical care unit. Patients with secondary ICH and those subject to limitation of care before 72 hours were excluded. For each ICH score, mortality at 30- and 90-days, and the modified Rankin Scale (mRS) within 1-year were examined. The effect of craniotomy/craniectomy ± hematoma evacuation on the outcome of supratentorial ICH was determined using propensity score matching. Median patient follow-up after discharge was 2.2 (interquartile range [IQR] 0.4-4.4) years.

RESULTS

Among 319 patients with spontaneous ICH (median age was 69 [IQR 60-77] years, 60% male), 30- and 90-day mortality were 16% and 22%, respectively, and unfavorable functional outcome (mRS score 4-6) was 50% at a median 3.1 months after ICH. Admission predictors of mortality mirrored those of the original ICH score. Unfavorable outcomes for ICH scores 3 and 4 were 73% and 86%, respectively. The most common adjudicated primary causes of mortality were direct effect or progression of ICH (54%), refractory cerebral edema (21%), and medical complications (11%). In matched analyses, lifesaving surgery for supratentorial ICH did not significantly alter mortality or unfavorable functional outcome in patients overall. In subgroup analyses restricted to (1) surgery with hematoma evacuation and (2) ICH score 3 and 4 patients, the odds of 30-day mortality were reduced by 71% (odds ratio [OR] 0.29, 95% CI 0.09-0.9, p = 0.032) and 80% (OR 0.2, 95% CI 0.04-0.91, p = 0.038), respectively, but no difference was observed for 90-day mortality or unfavorable functional outcome.

DISCUSSION

This study demonstrates that poor outcomes after ICH prevail despite aggressive treatment. Unfavorable outcomes appear related to direct effects of the primary injury and not to premature care limitations. Lifesaving surgery for supratentorial lesions delayed mortality but did not alter functional outcomes.

Mechanical Thrombectomy for Stroke Due to Acute Basilar Artery Occlusion, a Safety and Efficacy Analysis

BACKGROUND

Acute basilar artery occlusion accounts for 1% of all ischemic strokes but often leads to devastating neurological injury and mortality. Many institutions still opt for best medical therapy for these patients; however, there is increasing evidence that mechanical thrombectomy (MT) for these patients leads to better outcomes.

OBJECTIVE

To assess the safety and efficacy of MT for patients presenting with acute basilar artery occlusion (BAO).

METHODS

This study was a retrospective chart review of a prospectively maintained database for patients with acute BAO treated with MT from January 2014 through March 2022.

RESULTS

Our study included a total of 74 patients. The mean age was 62.7 years, and 55.4% were male. The most common comorbidity was hypertension (73%). The mean door to puncture time was 75 minutes, and the mean procedure time was 54 minutes. 86.5% of patients had a good modified treatment in cerebral ischemia score (≥2b). There were 4 patients who had procedural complications and 3 who had symptomatic intracerebral hemorrhage. At 90 days, 62.5% of patients had a modified Rankin Scale, 0 to 3. The mortality rate was 32.4% and 2% during hospital admission and 90 days, respectively. On univariate analysis, adjunctive angioplasty/stenting and higher presenting National Institutes of Health Stroke Scale score were associated with modified Rankin Scale 4 to 6 at 90 days ( P -value, .03 and <.001, respectively). Shorter procedure time was associated with modified treatment in cerebral ischemia score ≥ 2b ( P -value, .0015).

CONCLUSION

Our findings showed that MT is safe and effective for patients presenting with acute BAO and is in conjunction with previous literature. The results from upcoming trials should hopefully establish MT as gold standard for these patients.

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

BACKGROUND

There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines.

AIMS

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

SUMMARY OF REVIEW

Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited.

CONCLUSION

The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

Collaterals and Elusive Ischemic Penumbra

As alternative blood supply routes, collateral blood vessels can play a crucial role in determining patient outcomes in acute and chronic intracranial occlusive diseases. Studies have shown that increased collateral circulation can improve functional outcomes and reduce mortality, particularly in those who are not eligible for reperfusion therapy. This article aims to discuss the anatomy and physiology of collateral circulation, describe current imaging tools used to measure collateral circulation, and identify the factors that influence collateral status.

Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy

Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians' preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.

A Clinical Prediction Model Based on Post Large Artery Atherosclerosis Infarction Pneumonia

BACKGROUND AND PURPOSE

Stroke-associated pneumonia (SAP) has been found as a common complication in acute ischemic stroke (AIS) patients. Large artery atherosclerosis (LAA) infarct is a major subtype of AIS. This study aimed to build a clinical prediction model for SAP of LAA type AIS patients.

METHODS

This study included 295 patients with LAA type AIS. Univariate analyses and logistic regression analyses were conducted to determine the independent predictors for the modeling purpose. Nomogram used receiver operating characteristics to assess the accuracy of the model, and the calibration plots were employed to assess the fitting degree between the model and the practical scenario. One hundred and five patients were employed for the external validation to test the stability of the model.

RESULTS

From the univariate analysis, patients' ages, neutrophil-to-lymphocyte ratios, National Institute of Health Stroke scale (NIHSS) scores, red blood cell, sex, history of coronary artery disease, stroke location and volume-viscosity swallow test showed statistical difference in the development group for the occurrence of SAP. By incorporating the factors above into a multivariate logistic regression analysis, patients' ages, neutrophil-to-lymphocyte ratios, NIHSS, and volume-viscosity swallow test emerged as the independent risk factors of the development of SAP. The nomogram based on the mentioned 4 variables above achieved a receiver operating characteristic of 0.951 and a validation group of 0.946.

CONCLUSIONS

The proposed nomogram is capable of predicting predict the occurrence of SAP in LAA type AIS patients, and it may identify high-risk patients in time and present information for in-depth treatment.

Pharmacological Strategies for Stroke Intervention: Assessment of Pathophysiological Relevance and Clinical Trials

OBJECTIVES

The present review describes stroke pathophysiology in brief and discusses the spectrum of available treatments with different promising interventions that are in clinical settings or are in clinical trials.

METHODS

Relevant articles were searched using Google Scholar, Cochrane Library, and PubMed. Keywords for the search included ischemic stroke, mechanisms, stroke interventions, clinical trials, and stem cell therapy.

RESULTS AND CONCLUSION

Stroke accounts to a high burden of mortality and morbidity around the globe. Time is an important factor in treating stroke. Treatment options are limited; however, agents with considerable efficacy and tolerability are being continuously explored. With the advances in stroke interventions, new therapies are being formulated with a hope that these may aid the ongoing protective and reparative processes. Such therapies may have an extended therapeutic time window in hours, days, weeks, or longer and may have the advantage to be accessible by a majority of the patients.

Methodological assessment of guidelines for the diagnosis and management of cerebral vasospasm using the AGREE-II tool

OBJECTIVE

Rupture of an intracranial aneurysm is the most common cause of spontaneous subarachnoid hemorrhage. Despite the recent advances in its early detection, diagnosis, and proper treatment, the outcome of patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) remains poor. It is well known that cerebral vasospasm is the most troublesome complication of aSAH, while delayed cerebral ischemia related to cerebral vasospasm constitutes the major cause of unfavorable outcomes in patients with aSAH. The need for evidence-based guidelines is of great importance for the prevention, early detection, and efficient management of aSAH-induced vasospasm. Moreover, guidelines provide young physicians with a valuable tool for practicing defensible medicine. However, the methodology, clinical applicability, reporting clarity, and biases of guidelines must be periodically assessed. In this study, the authors sought to assess the reporting clarity and methodological quality of published guidelines and recommendations.

METHODS

A search was performed in the PubMed, Scopus, and Web of Science databases. The search terms used were "clinical practice guidelines," "recommendations," "stroke," "subarachnoid hemorrhage," and "vasospasm" in all possible combinations. The search period extended from 1964 to September 2021 and was limited to literature published in the English language. All published guidelines and recommendations reporting on the diagnosis and management of vasospasm were included. Studies other than those reporting guidelines and recommendations were excluded. The eligible studies were evaluated by three blinded raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool.

RESULTS

A total of 10 sets of guidelines were evaluated in this study. The American Heart Association/American Stroke Association issued guidelines found to have the highest methodological quality and reporting clarity, followed by the European Stroke Organization guidelines and the English edition of the Japanese guidelines issued by the Japanese Society on Surgery for Cerebral Stroke. The interrater agreement was moderate in the current analysis.

CONCLUSIONS

These findings support the idea that improvement of currently existing guidelines is feasible in the following domains: the rigor of guidelines and recommendations development, clinical applicability, editorial independence, and stakeholder involvement. Furthermore, periodic updating of published guidelines requires improvement in the future.

Pediatric Acute Stroke Protocols in the United States and Canada

OBJECTIVE

To describe existing pediatric acute stroke protocols to better understand how pediatric centers might implement such pathways within the context of institution-specific structures.

STUDY DESIGN

We administered an Internet-based survey of pediatric stroke specialists. The survey included questions about hospital demographics, child neurology and pediatric stroke demographics, acute stroke response, imaging, and hyperacute treatment.

RESULTS

Forty-seven surveys were analyzed. Most respondents practiced at a large, freestanding children's hospital with a moderate-sized neurology department and at least 1 neurologist with expertise in pediatric stroke. Although there was variability in how the hospitals deployed stroke protocols, particularly in regard to staffing, the majority of institutions had an acute stroke pathway, and almost all included activation of a stroke alert page. Most institutions preferred magnetic resonance imaging (MRI) over computed tomography (CT) and used abbreviated MRI protocols for acute stroke imaging. Most institutions also had either CT-based or magnetic resonance-based perfusion imaging available. At least 1 patient was treated with intravenous tissue plasminogen activator (IV-tPA) or mechanical thrombectomy at the majority of institutions during the year before our survey.

CONCLUSIONS

An acute stroke protocol is utilized in at least 41 pediatric centers in the US and Canada. Most acute stroke response teams are multidisciplinary, prefer abbreviated MRI over CT for diagnosis, and have experience providing IV-tPA and mechanical thrombectomy. Further studies are needed to standardize practices of pediatric acute stroke diagnosis and hyperacute management.

TACTICS - Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship: evaluating the effectiveness of an 'implementation intervention' in providing better patient access to reperfusion therapies: protocol for a non-randomised controlled stepped wedge cluster trial in acute stroke

INTRODUCTION

Stroke reperfusion therapies, comprising intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), are best practice treatments for eligible acute ischemic stroke patients. In Australia, EVT is provided at few, mainly metropolitan, comprehensive stroke centres (CSC). There are significant challenges for Australia's rural and remote populations in accessing EVT, but improved access can be facilitated by a 'drip and ship' approach. TACTICS (Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship) aims to test whether a multicomponent, multidisciplinary implementation intervention can increase the proportion of stroke patients receiving EVT.

METHODS AND ANALYSIS

This is a non-randomised controlled, stepped wedge trial involving six clusters across three Australian states. Each cluster comprises one CSC hub and a minimum of three primary stroke centre (PSC) spokes. Hospitals will work in a hub and spoke model of care with access to a multislice CT scanner and CT perfusion image processing software (MIStar, Apollo Medical Imaging). The intervention, underpinned by behavioural theory and technical assistance, will be allocated sequentially, and clusters will move from the preintervention (control) period to the postintervention period.

PRIMARY OUTCOME

Proportion of all stroke patients receiving EVT, accounting for clustering.

SECONDARY OUTCOMES

Proportion of patients receiving IVT at PSCs, proportion of treated patients (IVT and/or EVT) with good (modified Rankin Scale (mRS) score 0-2) or poor (mRS score 5-6) functional outcomes and European Quality of Life Scale scores 3 months postintervention, proportion of EVT-treated patients with symptomatic haemorrhage, and proportion of reperfusion therapy-treated patients with good versus poor outcome who presented with large vessel occlusion at spokes.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Hunter New England Human Research Ethics Committee (18/09/19/4.13, HREC/18/HNE/241, 2019/ETH01238). Trial results will be disseminated widely through published manuscripts, conference presentations and at national and international platforms regardless of whether the trial was positive or neutral.

TRIAL REGISTRATION NUMBER

ACTRN12619000750189; UTNU1111-1230-4161.

Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis

BACKGROUND AND OBJECTIVES

Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6.

MATERIALS AND METHODS

A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not.

RESULTS

Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03).

CONCLUSIONS

Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.

Shortening Door-to-Needle Time by Multidisciplinary Collaboration and Workflow Optimization During the COVID-19 Pandemic

OBJECTIVES

This study aims to evaluate shortening door-to-needle time of intravenous recombinant tissue plasminogen activator of acute ischemic stroke patients by multidisciplinary collaboration and workflow optimization based on our hospital resources.

MATERIALS AND METHODS

We included patients undergoing thrombolysis with intravenous recombinant tissue plasminogen activator from January 1, 2018, to September 30, 2020. Patients were divided into pre- (January 1, 2018, to December 31, 2019) and post-intervention groups (January 1, 2020, to September 31, 2020). We conducted multi-department collaboration and process optimization by implementing 16 different measures in prehospital, in-hospital, and post-acute feedback stages for acute ischemic stroke patients treated with intravenous thrombolysis. A comparison of outcomes between both groups was analyzed.

RESULTS

Two hundred and sixty-three patients received intravenous recombinant tissue plasminogen activator in our hospital during the study period, with 128 and 135 patients receiving treatment in the pre-intervention and post-intervention groups, respectively. The median (interquartile range) door-to-needle time decreased significantly from 57.0 (45.3-77.8) min to 37.0 (29.0-49.0) min. Door-to-needle time was shortened to 32 min in the post-intervention period in the 3rd quarter of 2020. The door-to-needle times at the metrics of ≤ 30 min, ≤ 45 min, ≤ 60 min improved considerably, and the DNT> 60 min metric exhibited a significant reduction.

CONCLUSIONS

A multidisciplinary collaboration and continuous process optimization can result in overall shortened door-to-needle despite the challenges incurred by the COVID-19 pandemic.

Intravenous Thrombolysis After First-Ever Ischemic Stroke and Reduced Incident Dementia Rate

BACKGROUND AND PURPOSE

The use of intravenous thrombolysis is associated with improved clinical outcomes. Whether thrombolysis is associated with reduced incidence of poststroke dementia remains uncertain. We sought to estimate if the use of thrombolysis following first-ever ischemic stroke was associated with a reduced rate of incident dementia using a pragmatic observational design.

METHODS

We included first-ever ischemic stroke patients from the Ontario Stroke Registry who had not previously been diagnosed with dementia. The primary outcome was incident dementia ascertained by a validated diagnostic algorithm. We employed inverse probability of treatment-weighted Cox proportional hazard models to estimate the cause-specific hazard ratio for the association of thrombolysis and incident dementia at 1 and 5 years following stroke.

RESULTS

From July 2003 to March 2013, 7072 patients with ischemic stroke were included, 3276 (46.3%) were female and mean age was 71.0 (SD, 12.8) years. Overall, 38.2% of the cohort (n=2705) received thrombolysis, 77.2% (n=2087) of which was administered within 3 hours of stroke onset. In the first year following stroke, thrombolysis administration was associated with a 24% relative reduction in the rate of developing dementia (cause-specific hazard ratio, 0.76 [95% CI, 0.58-0.97]). This association remained significant at 5 years (cause-specific hazard ratio, 0.79 [95% CI, 0.66-0.91]) and at the end of follow-up (median 6.3 years; cause-specific hazard ratio, 0.79 [95% CI, 0.68-0.89]).

CONCLUSIONS

Thrombolysis administration following first-ever ischemic stroke was independently associated with a reduced rate of dementia. Incident dementia should be considered as a relevant outcome when evaluating risk/benefit of thrombolysis in ischemic stroke patients.

The effectiveness of systemic and endovascular intra-arterial thrombectomy protocol for decreasing door-to-recanalization time duration

Objective

Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization.

Methods

A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012–Apr 2014) and post-IAT protocol (May 2014–Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration.

Results

Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p＞0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p＜0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p＞0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p＜0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p＜0.05), and 79.1±47.5 vs. 58.4±75.3 (p＜0.05) in three steps, respectively.

Conclusions

We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.

Overview of Acute Ischemic Stroke Evaluation and Management

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Reporting quality evaluation of the stroke clinical practice guidelines: a systematic review

OBJECTIVES

To analyze the effectiveness and quality of stroke clinical practice guidelines (CPGs) published in recent years in order to guide future guideline developers to develop better guidelines.

PARTICIPANTS

No patient involved METHOD: PubMed, China Biology Medicine (CBM), Wanfang, CNKI, and CPG-relevant websites were searched from January 2015 to December 2019 by two researchers independently. The RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was used to assess the reporting quality in terms of domains and items. Then, a subgroup analysis of the results was performed.

PRIMARY AND SECONDARY OUTCOME MEASURES

RIGHT checklist reporting rate RESULTS: A total of 66 CPGs were included. Twice as many CPGs were published internationally as were published in China. More than half were updated. Most CPGs are published in journals, developed by societies or associations, and were evidence-based grading. The average reporting rate for all included CPGs was 47.6%. Basic information got the highest (71.7% ± 19.7%) reporting rate, while review and quality assurance got the lowest (22.0% ± 24.6%). Then, a cluster analysis between countries, publishing channels, and institutions was performed. There were no statistically significant differences in the reporting quality on the CPGs between publishing countries (China vs. international), publishing channels (journals vs. websites), and institutions (associations vs. non-associations).

CONCLUSIONS

Current stroke CPGs reports are of low quality. We recommend that guideline developers improve the quality of reporting of key information and improve the management of conflicts of interest. We recommend that guideline developers consider the RIGHT checklist as an important tool for guideline development.

TRIAL REGISTRATION

https://doi.org/10.17605/OSF.IO/PBWUX .

State of the Art Stroke Imaging: A Current Perspective

Acute stroke is a widespread, debilitating disease. Fortunately, it also has one of the most effective therapeutic options available in medicine, endovascular treatment. Imaging plays a major role in the diagnosis of stroke and aids in appropriate therapy selection. Given the rapid accumulation of evidence for patient subgroups and concurrent broadening of therapeutic options and indications, it is important to recognize the benefits of certain imaging technologies for specific situations. An effective imaging protocol should: 1) be fast, 2) easily implementable, 3) produce reliable results, 4) have few contraindications, and 5) be safe, all with the goal of providing the patient the best chance of achieving a favorable outcome. In the following, we provide a review of the currently available imaging technologies, their advantages and disadvantages, as well as an overview of the future of stroke imaging. Finally, we offer a perspective.

Quality of stroke guidelines in low- and middle-income countries: a systematic review

OBJECTIVE

To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.

METHODS

We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.

FINDINGS

We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.

CONCLUSION

Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.

Return on Investment in Endovascular Care: The Case of Endovascular Reperfusion Alberta

OBJECTIVE

We examined the return on investment (ROI) from the Endovascular Reperfusion Alberta (ERA) project, a provincially funded population-wide strategy to improve access to endovascular therapy (EVT), to inform policy regarding sustainability.

METHODS

We calculated net benefit (NB) as benefit minus cost and ROI as benefit divided by cost. Patients treated with EVT and their controls were identified from the ESCAPE trial. Using the provincial administrative databases, their health services utilization (HSU), including inpatient, outpatient, physician, long-term care services, and prescription drugs, were compared. This benefit was then extrapolated to the number of patients receiving EVT increased in 2018 and 2019 by the ERA implementation. We used three time horizons, including short (90 days), medium (1 year), and long-term (5 years).

RESULTS

EVT was associated with a reduced gross HSU cost for all the three time horizons. Given the total costs of ERA were $2.04 million in 2018 ($11,860/patient) and $3.73 million in 2019 ($17,070/patient), NB per patient in 2018 (2019) was estimated at -$7,313 (-$12,524), $54,592 ($49,381), and $47,070 ($41,859) for short, medium, and long-term time horizons, respectively. Total NB for the province in 2018 (2019) were -$1.26 (-$2.74), $9.40 ($10.78), and $8.11 ($9.14) million; ROI ratios were 0.4 (0.3), 5.6 (3.9) and 5.0 (3.5). Probabilities of ERA being cost saving were 39% (31%), 97% (96%), and 94% (91%), for short, medium, and long-term time horizons, respectively.

CONCLUSION

The ERA program was cost saving in the medium and long-term time horizons. Results emphasized the importance of considering a broad range of HSU and long-term impact to capture the full ROI.

Determining a safe upper limit of oxygen supplementation for adult patients: a systematic review

OBJECTIVE

This systematic review aimed to describe the connection between the inspired oxygen fraction and pulmonary complications in adult patients, with the objective of determining a safe upper limit of oxygen supplementation.

METHODS

MEDLINE and Embase were systematically searched in August 2019 (updated July 2020) for studies fulfilling the following criteria: intubated adult patients (Population); high fractions of oxygen (Intervention) versus low fractions of (Comparison); atelectasis, acute respiratory distress syndrome (ARDS), pneumonia and/or duration of mechanical ventilation (Outcome); original studies both observational and interventional (Studies). Screening, data extraction and risk of bias assessment was done by two independent reviewers.

RESULTS

Out of 6120 records assessed for eligibility, 12 were included. Seven studies were conducted in the emergency setting, and five studies included patients undergoing elective surgery. Eight studies reported data on atelectasis, two on ARDS, four on pneumonia and two on duration of mechanical ventilation. There was a non-significant increased risk of atelectasis if an oxygen fraction of 0.8 or above was used, relative risk (RR): 1.37 (95% CI 0.95 to 1.96). One study showed an almost threefold higher risk of pneumonia in the high oxygen fraction group (RR: 2.83 (95% CI 2.25 to 3.56)). The two studies reporting ARDS and the two studies with data on mechanical ventilation showed no association with oxygen fraction. Four studies had a high risk of bias in one domain.

CONCLUSIONS

In this systematic review, we found inadequate evidence to identify a safe upper dosage of oxygen, but the identified studies suggest a benefit of keeping inspiratory oxygen fraction below 0.8 with regard to formation of atelectases.

PROSPERO REGISTRATION NUMBER

CRD42020154242.

Targeted temperature management at 33 degrees Celsius in patients with high-grade aneurysmal subarachnoid hemorrhage: a protocol for a multicenter randomized controlled study

Background

Studies on the use of therapeutic hypothermia (TH) to improve the outcome of high-grade aneurysmal subarachnoid hemorrhage (aSAH), show promising, though conflicting results because of the lack of high-quality trials. The aim of this study is to evaluate the safety and efficacy of TH (maintaining bladder temperature at 33 °C for ≥72 h) to treat patients with high-grade aSAH (Hunt-Hess grade IV-V).

Methods

A multicenter, randomized, controlled clinical trial will be conducted for October 2020 to September 2024 involving 10 clinics. Patients who meet the inclusion criteria will be randomized 1:1 to a TH group and a normothermia group. The trial will enroll 96 participants in TH group and normothermia one, respectively. The trial was registered with ClinicalTrials.gov (NCT03442608) on February 22, 2018. Following conventional treatment for aSAH, patients will undergo either TH for at least 72 h or normothermia. The primary endpoint is the Glasgow outcome scale at 6 months after bleeding. The secondary endpoints are: (I) mortality at 6 months after bleeding; (II) intracranial pressure; (III) intensive care unit stay; and (IV) hospital stay. The safety endpoints include neurological, infectious, intestinal, circulatory, coagulation, and bleeding complications, electrolyte disorders, and other complications.

Discussion

If the study hypothesis is confirmed, TH at 33 °C in patients with high-grade aSAH may become a promising treatment strategy for improving 6-month outcome.

Trial registration

The trial has been registered at ClinicalTrials.gov (ID: NCT03442608).

A Prospective Economic Evaluation of Rapid Endovascular Therapy for Acute Ischemic Stroke

BACKGROUND

During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient's lifetime.

METHODS

Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis.

RESULTS

The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (-$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care.

CONCLUSIONS

Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient's lifetime.Clinical Trial Registration: NCT01778335.

Role of the nurse in the hyperacute care and management of patients following stroke

Stroke is a medical emergency that affects millions of people worldwide each year. The first 24-72 hours following a stroke is a critical stage in the patient's management because deterioration can occur during this period. Hyperacute care is a time-sensitive method of managing stroke that has improved the provision of holistic and evidence-based stroke care. This article describes the care and management that patients require in the first 24-72 hours following stroke. It details the evidence-based practice that this involves, and explains the role of the nurse in providing hyperacute care.

Oxygen therapy and inpatient mortality in COPD exacerbation

BACKGROUND

In hospitalised patients with exacerbation of Chronic Obstructive Pulmonary Disease, European and British guidelines endorse oxygen target saturations of 88%-92%, with adjustment to 94%-98% if carbon dioxide levels are normal. We assessed the impact of admission oxygen saturation level and baseline carbon dioxide on inpatient mortality.

METHODS

Patients were identified from the prospective Dyspnoea, Eosinopenia, Consolidation, Acidaemia and Atrial Fibrillation (DECAF) derivation study (December 2008-June 2010) and the mixed methods DECAF validation study (January 2012 to May 2014). In six UK hospitals, of 2645 patients with COPD exacerbation, 1027 patients were in receipt of supplemental oxygen at admission. All had a clinical history of COPD and obstructive spirometry. These patients were subdivided into the following groups: admission oxygen saturations of 87% or less, 88%-92%, 93%-96% or 97%-100%. Inpatient mortality was calculated for each group and expressed as ORs. The DECAF score and National Early Warning Score 2 (excluding oxygen saturation) were used in binary logistic regression to adjust for baseline risk.

RESULTS

In patients with COPD receiving supplemental oxygen, oxygen saturations above 92% were associated with higher mortality and an adverse dose-response. Compared with the 88%-92% group, the adjusted risk of death (OR) in the 93%-96% and 97%-100% groups was 1.98 (95% CI 1.09 to 3.60, p=0.025) and 2.97 (95% CI 1.58 to 5.58, p=0.001). In the subgroup with normocapnia, the mortality signal remained significant in both the 93%-96% and 97%-100% groups.

CONCLUSIONS

Inpatient mortality was lowest in those with oxygen saturations of 88%-92%. Even modest elevations in oxygen saturations above this range (93%-96%) were associated with an increased risk of death. A similar mortality trend was seen in both patients with hypercapnia and normocapnia. This shows that the practice of setting different target saturations based on carbon dioxide levels is not justified. Treating all patients with COPD with target saturations of 88%-92% will simplify prescribing and should improve outcome.

TRIAL REGISTRATION NUMBER

UKCRN ID 14214.

A fast and fully-automated deep-learning approach for accurate hemorrhage segmentation and volume quantification in non-contrast whole-head CT

This project aimed to develop and evaluate a fast and fully-automated deep-learning method applying convolutional neural networks with deep supervision (CNN-DS) for accurate hematoma segmentation and volume quantification in computed tomography (CT) scans. Non-contrast whole-head CT scans of 55 patients with hemorrhagic stroke were used. Individual scans were standardized to 64 axial slices of 128 × 128 voxels. Each voxel was annotated independently by experienced raters, generating a binary label of hematoma versus normal brain tissue based on majority voting. The dataset was split randomly into training (n = 45) and testing (n = 10) subsets. A CNN-DS model was built applying the training data and examined using the testing data. Performance of the CNN-DS solution was compared with three previously established methods. The CNN-DS achieved a Dice coefficient score of 0.84 ± 0.06 and recall of 0.83 ± 0.07, higher than patch-wise U-Net (< 0.76). CNN-DS average running time of 0.74 ± 0.07 s was faster than PItcHPERFeCT (> 1412 s) and slice-based U-Net (> 12 s). Comparable interrater agreement rates were observed between “method-human” vs. “human–human” (Cohen’s kappa coefficients > 0.82). The fully automated CNN-DS approach demonstrated expert-level accuracy in fast segmentation and quantification of hematoma, substantially improving over previous methods. Further research is warranted to test the CNN-DS solution as a software tool in clinical settings for effective stroke management.

Aneurysmal Subarachnoid Hemorrhage: the Last Decade

Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.

Thrombolysis with alteplase 3-4.5 hours after acute ischaemic stroke: trial reanalysis adjusted for baseline imbalances

OBJECTIVES

Alteplase is commonly recommended for acute ischaemic stroke within 4.5 hours after stroke onset. The Third European Cooperative Acute Stroke Study (ECASS III) is the only trial reporting statistically significant efficacy for clinical outcomes for alteplase use 3-4.5 hours after stroke onset. However, baseline imbalances in history of prior stroke and stroke severity score may confound this apparent finding of efficacy. We reanalysed the ECASS III trial data adjusting for baseline imbalances to determine the robustness or sensitivity of the efficacy estimates.

DESIGN

Reanalysis of randomised placebo-controlled trial. We obtained access to the ECASS III trial data and replicated the previously reported analyses to confirm our understanding of the data. We adjusted for baseline imbalances using multivariable analyses and stratified analyses and performed sensitivity analysis for missing data.

SETTING

Emergency care.

PARTICIPANTS

821 adults with acute ischaemic stroke who could be treated 3-4.5 hours after symptom onset.

INTERVENTIONS

Intravenous alteplase (0.9 mg/kg of body weight) or placebo.

MAIN OUTCOME MEASURES

The original primary efficacy outcome was modified Rankin Scale (mRS) score 0 or 1 (ie, being alive without any disability) and the original secondary efficacy outcome was a global outcome based on a composite of functional end points, both at 90 days. Adjusted analyses were only reported for the primary efficacy outcome and the original study protocol did not specify methods for adjusted analyses. Our adjusted reanalysis included these outcomes, symptom-free status (mRS 0), dependence-free status (mRS 0-2), mortality (mRS 6) and change across the mRS 0-6 spectrum at 90 days; and mortality and symptomatic intracranial haemorrhage at 7 days.

RESULTS

We replicated previously reported unadjusted analyses but discovered they were based on a modified interpretation of the National Institutes of Health Stroke Scale (NIHSS) score. The secondary efficacy outcome was no longer significant using the original NIHSS score. Previously reported adjusted analyses could only be replicated with significant effects for the primary efficacy outcome by using statistical approaches not reported in the trial protocol or statistical analysis plan. In analyses adjusting for baseline imbalances, all efficacy outcomes were not significant, but increases in symptomatic intracranial haemorrhage remained significant.

CONCLUSIONS

Reanalysis of the ECASS III trial data with multiple approaches adjusting for baseline imbalances does not support any significant benefits and continues to support harms for the use of alteplase 3-4.5 hours after stroke onset. Clinicians, patients and policymakers should reconsider interpretations and decisions regarding management of acute ischaemic stroke that were based on ECASS III results.

TRIAL REGISTRATION NUMBER

NCT00153036.

Reducing Door-to-Needle Time for Tissue Plasminogen Activator Administration in a Community Hospital: An Operations Study

BACKGROUND AND OBJECTIVES

The benefit of tissue plasminogen activator (tPA) in acute ischemic stroke is time dependent. A 15-minute decrease in door-to-needle (DTN) time has been associated with increased odds of ambulating independently, faster discharge, and decreased odds of death. We investigated common causes of delay in DTN times in a community hospital setting in order to identify areas for improvement.

METHODS

A retrospective medical record review was conducted at a 574-bed community hospital. This included 100 patients who received tPA from 2016 to 2019. Time segments were classified a priori to reflect key work elements from the time between hospital arrival to tPA and recorded for each chart. Linear regression models were used to identify work elements associated with increased DTN time.

RESULTS

Median DTN time was 54:29 minutes. Linear regression analyses determined that differences in NIHSS score (P = .030), triage to computed tomography (CT) start (P = .017), triage to stroke physician page (P = .016), and CT report to tPA administration (P < .001) were associated with increased DTN time. CT report to tPA administration was most strongly associated with a Pearson coefficient of 0.868 (P < .001) with increased DTN time.

CONCLUSIONS

The DTN time at our institution was above the recommended target. Our findings suggest that reducing the CT report time interval may decrease DTN time.

Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries

Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.

Lessons from Recent Advances in Ischemic Stroke Management and Targeting Kv2.1 for Neuroprotection

Achieving neuroprotection in ischemic stroke patients has been a multidecade medical challenge. Numerous clinical trials were discontinued in futility and many were terminated in response to deleterious treatment effects. Recently, however, several positive reports have generated the much-needed excitement surrounding stroke therapy. In this review, we describe the clinical studies that significantly expanded the time window of eligibility for patients to receive mechanical endovascular thrombectomy. We further summarize the results available thus far for nerinetide, a promising neuroprotective agent for stroke treatment. Lastly, we reflect upon aspects of these impactful trials in our own studies targeting the Kv2.1-mediated cell death pathway in neurons for neuroprotection. We argue that recent changes in the clinical landscape should be adapted by preclinical research in order to continue progressing toward the development of efficacious neuroprotective therapies for ischemic stroke.

Nitroglycerin Is Not Associated with Improved Cerebral Perfusion in Acute Ischemic Stroke

OBJECTIVE

The study was conducted to test the hypothesis that nitroglycerin (NTG) increases cerebral perfusion focally and globally in acute ischemic stroke patients, using serial perfusion-weighted imaging (PWI) magnetic resonance imaging measurements.

PATIENTS AND METHODS

Thirty-five patients underwent PWI immediately before and 72 h after administration of a transdermal NTG patch or no treatment. Patients with baseline mean arterial pressure (MAP) > 100 mmHg (NTG group, n = 20) were treated with transdermal NTG (0.2 mg/h) for 72 h, without a nitrate-free interval. Patients with MAP ≤ 100 mmHg (untreated group, n = 15) were not treated. The primary outcome measure was absolute cerebral blood flow (CBF) in the hypoperfused region at 72 h.

RESULTS

The mean baseline absolute CBF in the hypoperfused region was similar in the NTG group (33.3 ± 10.2 ml/100 g/min) and untreated (32.7 ± 8.4 ml/100 g/min, p = 0.4) groups. The median (IQR) baseline infarct volume was 10.4 (2.5-49.3) ml in the NTG group and 32.6 (8.6-96.7) ml in the untreated group (p = 0.09). MAP change in the NTG group was 1.2 ± 12.6 and 8 ± 20.7 mmHg at 2 h and 72 h, respectively. Mean absolute CBF in the hypoperfused region at 72 h was similar in the NTG (29.9 ± 12 ml/100 g/min) and untreated groups (24.1 ± 10 ml/100 g/min, p = 0.8). The median infarct volume increased in untreated (11.8 (5.7-44.2) ml) than the NTG group (3.2 (0.5-16.5) ml; p = 0.033) on univariate analysis, however, there was no difference on regression analysis.

CONCLUSION

NTG was not associated with improvement in cerebral perfusion in acute ischemic stroke patients.

Information model of post stroke rehabilitation conception

Currently, the new model of stroke care is actively implemented. There is a number of problems thereby related to digitalization. The study was aimed to work up the information model of the post-stroke rehabilitation at the first stage. The following basic objects of the rehabilitation system information model were identified and described using system analysis and business process modelling, based on studying laws, regulatory and legal acts, clinical guidelines, the “Development of the System of Medical Rehabilitation in Russia” pilot project protocol, and the problem area experts’ findings: patient, health information system (HIS) of a healthcare organization, document management. The objects’ properties and interaction are discussed, the information model is been constructed, main directions are described.

Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population

Background and Purpose:

Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes.

Methods:

A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback.

Results:

Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline ( P <0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% ( P <0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) ( P =0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% ( P =0.0990).

Conclusions:

The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.

Improving timely treatment with a stroke emergency map: The case of northern China

OBJECTIVE

The Chinese stroke emergency map (SEM) was implemented in 2017 to reduce prehospital and hospital delays for acute ischemic stroke (AIS) patients suitable for intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis. However, data on the time delay following the implementation of an SEM in China are limited.

METHODS

Data for suspected stroke patients from the SEM registry center of Taiyuan, Shanxi Province, from August 2017 to July 2019, patients' characteristics, thrombolysis rate, and functional outcome at 90 days were analyzed.

RESULTS

One thousand seven hundred and eighty six patients who arrived at hospitals within 4.5 hr of onset were included; 35.9% arrived by emergency medical services (EMSs), and 1,207 (67.6%) of the population received intravenous rt-PA. As a result of the SEM, the number of patients treated with rt-PA increased from 63.9% in phase 1 (August 2017 to July 2018) to 70.5% in phase 2 (August 2018 to July 2019). The median onset-to-door and onset-to-needle times decreased by five minutes (100 [IQR: 62-135] vs. 105 [IQR: 70-145], p = .005) and nine minutes (158 [IQR: 124-197] vs. 167 [IQR: 132-214], p = .001), respectively. Patients in phase 2 achieved greater independent function outcome at 90 days (79.9% vs. 72.1%; adjusted odds ratio, 2.010; 95% confidence interval, 1.444-2.798). The binary logistic regression models revealed that shorter onset-to-needle time (OR: 0.994; 95% CI: 0.992-0.997; p < .001) and lower baseline NIHSS scores (OR: 39.120; 95% CI: 23.477-65.188; p < .001 and OR: 18.324; 95% CI: 11.425-29.388; p < .001 and OR: 3.123; 95% CI: 2.044-4.773; p < .001) were significant predictors for the independent function outcome.

CONCLUSION

The implementation of a stroke emergency map is more likely to reduce prehospital delays and improve function outcomes. Future efforts should attempt to increase EMS usage.

Successful dabigatran reversal after subdural hemorrhage using idarucizumab in a mobile stroke unit: A case report

RATIONALE

Idarucizumab is a specific reversal agent for patients with bleeding related to the anticoagulant dabigatran. There are no prior descriptions of Idarucizumab administration in the prehospital setting for intracranial hemorrhage.

PATIENT CONCERNS

An 82-year-old woman treated with dabigatran for atrial fibrillation developed acute focal weakness. This led to activation of emergency medical services and assessment in the mobile stroke unit (MSU).

DIAGNOSIS

Computed tomography of the brain performed in the MSU revealed an acute subdural hematoma.

INTERVENTIONS

The patient was treated with Idarucizumab in the MSU.

OUTCOMES

The subdural hematoma was treated with a burr hole evacuation and the patient was discharged to a rehabilitation facility without residual focal neurological deficits.

LESSONS

Idarucizumab can be used safely and effectively to treat dabigatran-associated intracranial hemorrhage in the prehospital setting.

Clinical and Imaging Determinants of Collateral Status in Patients With Acute Ischemic Stroke in MR CLEAN Trial and Registry

Background and Purpose- Collateral circulation status at baseline is associated with functional outcome after ischemic stroke and effect of endovascular treatment. We aimed to identify clinical and imaging determinants that are associated with collateral grade on baseline computed tomography angiography in patients with acute ischemic stroke due to an anterior circulation large vessel occlusion. Methods- Patients included in the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; n=500) and MR CLEAN Registry (n=1488) were studied. Collateral status on baseline computed tomography angiography was scored from 0 (absent) to 3 (good). Multivariable ordinal logistic regression analyses were used to test the association of selected determinants with collateral status. Results- In total, 1988 patients were analyzed. Distribution of the collateral status was as follows: absent (7%, n=123), poor (32%, n=596), moderate (39%, n=735), and good (23%, n=422). Associations for a poor collateral status in a multivariable model existed for age (adjusted common odds ratio, 0.92 per 10 years [95% CI, 0.886-0.98]), male (adjusted common odds ratio, 0.64 [95% CI, 0.53-0.76]), blood glucose level (adjusted common odds ratio, 0.97 [95% CI, 0.95-1.00]), and occlusion of the intracranial segment of the internal carotid artery with occlusion of the terminus (adjusted common odds ratio 0.50 [95% CI, 0.41-0.61]). In contrast to previous studies, we did not find an association between cardiovascular risk factors and collateral status. Conclusions- Older age, male sex, high glucose levels, and intracranial internal carotid artery with occlusion of the terminus occlusions are associated with poor computed tomography angiography collateral grades in patients with acute ischemic stroke eligible for endovascular treatment.

Health Utility Weighting of the Modified Rankin Scale: A Systematic Review and Meta-analysis

IMPORTANCE

The utility-weighted modified Rankin Scale (UW-mRS) has been proposed as a patient-centered alternative primary outcome for stroke clinical trials. However, to date, there is no clear consensus on an approach to weighting the mRS.

OBJECTIVE

To characterize the between-study variability in utility weighting of the mRS in a population of patients who experienced stroke and its implications when applied to the results of a clinical trial.

DATA SOURCES

In this systematic review and meta-analysis, MEDLINE, Embase, and PsycINFO were searched from January 1987 through May 2019 using major search terms for stroke, health utility, and mRS.

STUDY SELECTION

Original research articles published in English were reviewed. Included were studies with participants 18 years or older with ischemic or hemorrhagic stroke, transient ischemic attack, or subarachnoid hemorrhage, with mRS scores and utility weights evaluated concurrently. A total of 5725 unique articles were identified. Of these, 283 met criteria for full-text review, and 24 were included in the meta-analysis.

DATA EXTRACTION AND SYNTHESIS

PRISMA guidelines for systematic review were followed. Data extraction was performed independently by multiple researchers. Data were pooled using mixed models.

MAIN OUTCOMES AND MEASURES

The mean utility weights and 95% CIs were calculated for each mRS score and health utility scale. Geographic differences in weighting for the EuroQoL 5-dimension (EQ-5D) and Stroke Impact Scale-based UW-mRS were explored using inverse variance-weighted linear models. The results of 18 major acute stroke trials cited in current guidelines were then reanalyzed using the UW-mRS weighting scales identified in the systematic review.

RESULTS

The meta-analysis included 22 389 individuals; the mean (SD) age of participants was 65.9 (4.0) years, and the mean (SD) proportion of male participants was 58.2% (7.5%). For all health utility scales evaluated, statistically significant differences were observed between the mean utility weights by mRS score. For studies using an EQ-5D-weighted mRS, between-study variance was higher for worse (mRS 2-5) compared with better (mRS 0-1) scores. Of the 18 major acute stroke trials with reanalyzed results, 3 had an unstable outcome when using different UW-mRSs.

CONCLUSIONS AND RELEVANCE

Multiple factors, including cohort-specific characteristics and health utility scale selection, can influence mRS utility weighting. If the UW-mRS is selected as a primary outcome, the approach to weighting may alter the results of a clinical trial. Researchers using the UW-mRS should prospectively and concurrently obtain mRS scores and utility weights to characterize study-specific outcomes.

Clinical Performance Measures for Neurocritical Care: A Statement for Healthcare Professionals from the Neurocritical Care Society

BACKGROUND

Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care.

METHODS

The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form.

RESULTS

A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care.

CONCLUSIONS

This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.

Advances in stroke medicine

In recent years, reperfusion therapies such as intravenous thrombolysis and endovascular thrombectomy for ischaemic stroke have dramatically reduced disability and revolutionised stroke management. Thrombolysis with alteplase is effective when administered to patients with potentially disabling stroke, who are not at high risk of bleeding, within 4.5 hours of the time the patient was last known to be well. Emerging evidence suggests that other thrombolytics such as tenecteplase may be even more effective. Treatment may be possible beyond 4.5 hours in patients selected using brain imaging. Endovascular thrombectomy (via angiography) effectively reduces risk of death or dependency in patients with large vessel occlusion (internal carotid, proximal middle cerebral and basilar arteries) if applied within 6 hours of the time they were last known to be well. Endovascular thrombectomy is also beneficial 6-24 hours from the last known well time in selected patients with favourable brain imaging. Thus, some patients with wake-up stroke are now treatable, and protocols for stroke need to include computed tomography (CT) perfusion scan and CT angiography as routine, in addition to the non-contrast CT brain scan. Optimised pre-hospital and emergency department systems (eg, code stroke response teams, pre-notification by ambulance, direct transport from triage to CT scanner) are essential to maximise the benefit of these strongly time-dependent therapies. Telemedicine is increasingly providing specialist guidance for these more complex treatment decisions in rural areas. Important developments in secondary stroke prevention include the use of direct oral anticoagulants or left atrial appendage occlusion for atrial fibrillation, and endovascular closure of patent foramen ovale.

Ischaemic stroke and transient ischaemic attack on anticoagulants: outcomes in the era of direct oral anticoagulants

Clinical and imaging characteristics of patients receiving direct oral anticoagulants presenting with transient ischaemic attack or stroke are lacking. A retrospective review of all patients who presented to a high-volume primary stroke centre with acute stroke symptoms while prescribed an oral anticoagulant between January 2012 and June 2017. Clinical, radiological characteristics and functional outcomes were examined. Anticoagulated patients diagnosed with stroke or transient ischaemic attack shared similar disease and outcome characteristics irrespective of anticoagulants used. One-third of warfarin patients with sub-therapeutic international normalised ratios were treated with thrombolytics but no direct oral anticoagulants level was performed in any of the patients, with only one treated by intravenous thrombolysis.

Single Centre Experience on Decision Making for Mechanical Thrombectomy Based on Single-Phase CT Angiography by Including NCCT and Maximum Intensity Projection Images - A Comparison with Magnetic Resonance Imaging after Non-Contrast CT

Objective

The purpose of this study was to suggest that computed tomography angiography (CTA) is valuable as the only preliminary examination for mechanical thrombectomy (MT). MT after single examination of CTA including non-contrast computed tomography (NCCT) and maximum intensity projection (MIP) improves door-to-puncture time as well as results in favorable outcomes.

Methods

A total of 157 patients who underwent MT at Dong Kang Medical Center from April 2015 to March 2019 were divided into two groups based on the examination performed prior to MT : CTA group who underwent CTA with NCCT and MIP, and NCCT+magnetic resonance image (MRi) group who underwent MRI including perfusion images after NCCT. In the two groups, time to CTA imaging or NCCT+MRi imaging after symptom onset, and time to arterial puncture and reperfusion were characterized as time-related outcomes. The evaluation of vascular recanalization after MT was defined as a modified thrombolysis in cerebral infarction (mTICI) scale. National Institutes of Health Stroke Scale (NIHSS) was assessed at the time of the visit to the emergency room and modified Rankin Scale (mRS) was assessed after 90 days.

Results

Typically, there were 34 patients in the CTA group and 33 patients in the NCCT+MRi group. A significantly shorter delay for door-to-puncture time was observed (mean, 86±22.1 vs. 176±47.5 minutes; p<0.01). Also, a significantly shorter door-to-imege time in the CTA group was observed (mean, 13±6.8 vs. 93±30.8 minutes; p<0.01). Moreover, a significantly shorter onset-to-puncture time was observed (mean, 195±128.0 vs. 314±157.6 minutes; p<0.01). Reperfusion result of mTICI ≥2b was 100% (34/34) in the CTA group and 94% (31/33) in the NCCT+MRi group, and mTICI 3 in 74% (25/34) in the CTA group and 73% (24/33) in the NCCT+MRi group. Favorable functional outcomes (mRS score ≤2 at 90 days) were 68% (23/34) in the CTA group and 60% (20/33) in the NCCT+MRi group.

Conclusion

A single-phase CTA including NCCT and MIP images was performed as a single preliminary examination, which led to a reduction in the time of the procedure and resulted in good results of prognosis. Consequently, it is concluded that this method is of sufficient value as the only preliminary examination for decision making.

National trends in hospital admission, case fatality, and sex differences in atrial fibrillation-related strokes

BACKGROUND AND AIM

Atrial fibrillation is associated with increased risk of ischemic stroke and its global prevalence is increasing. We aimed to describe the contemporary temporal trends in hospital admissions, case fatality rate, as well as sex differences in atrial fibrillation-related stroke in Canada.

METHODS

We conducted a retrospective cohort study using Canadian national administrative data to identify admissions to hospital for stroke with comorbid atrial fibrillation between 1 April 2007 and 31 March 2016. We determined temporal trends in the crude and the age- and sex-standardized admission and case fatality rates. We also evaluated for any sex differences in these outcomes.

RESULTS

There were 222,100 admissions to hospital for ischemic (n = 182,990) or hemorrhagic (n = 39,110) stroke. Comorbid atrial fibrillation was present in 20.2% of admissions for ischemic strokes and 10.1% for hemorrhagic strokes. Over the study period, the age-sex adjusted proportion of admissions with atrial fibrillation increased from 16.3% to 20.5% (p = 0.02) for ischemic stroke and was stable for hemorrhagic stroke. In-hospital case fatality rate decreased for ischemic stroke with and without comorbid atrial fibrillation. Women aged 65 years and older with ischemic stroke were more likely to have comorbid atrial fibrillation compared to men, while this association was reversed in younger women. There were no sex differences in the case fatality rate for people with atrial fibrillation-related ischemic stroke.

CONCLUSION

Atrial fibrillation is present in an increasing proportion of people hospitalized in Canada with ischemic stroke and disproportionately affects older women. Renewed focus is needed on atrial fibrillation-related stroke prevention with particular attention to sex disparities.