Acute Therapies Research Articles

Abstract WP434: Effect of Race on Rates of Hemicraniectomy During Acute Ischemic Stroke Hospitalization in the United States

Background: surgical decompressive techniques have shown a significant reduction in mortality in acute ischemic stroke (AIS) compared to medical treatment. Limitations in acute stroke therapies have been described among Hispanic and African American populations compared to other races. Objective: To investigate trends in hemicraniectomy among hospitalized patients in the United States, with emphasis on treatment by race. Methods: The Nationwide Inpatient Sample was queried from 2006 to 2015 for all patients older than 18-years of age with a primary diagnosis of AIS who had procedure codes for craniotomy excluding posterior fossa territory infarctions. Frequency of hemicraniectomy in patients with AIS hospitalization was determined. We utilized multivariable logistic regression analyses to study the independent association between race and trends in hemicraniectomy. Results: A population of patients with AIS (n=715649) was analyzed. The queried was divided by hemicraniectomy (n=1514) and no hemicraniectomy (n=714135). Demographic variables included age, gender (male or female), race (White, African American, Hispanic, others) and payer status (Medicare, Medicaid, private, other). In multivariable analysis, adjusted for potential confounders the odds to have a hemicraniectomy was greatest in the 18-44 age group [age 45-64 (Odds Ratio [OR]: 0.49, 95% CI: 0.42-0.58); age 65-84 (OR: 0.16, 95% CI: 0.13-0.20); age ≥85 (OR: 0.007, 95% CI: 0.003-0.01)]. Medicare insurance [Medicaid (OR: 1.5, 95% CI: 1.2-1.9); Private insurance (OR: 1.7, 95% CI: 1.43-2.03)]; urban teaching hospital (OR: 1.57, 95% CI: 3.63-12.05); prior administration of intravenous tPA (OR: 2.64, 95% CI: 2.21-3.16); being admitted after 2009 (2009-2011 OR: 1.68, 95% CI: 1.13-2.13; 2012-2014 OR: 1.81, 95% CI: 1.44-2.27) and coma status (OR: 15.8, 95% CI: 13.1-19.2) were found to increase the likelihood of having a hemicraniectomy after an AIS. The Hispanic population was more likely to have a hemicraniectomy when compared to White (OR: 1.28, 95% CI: 1.02-1.60). Conclusions: Over the last decade in the United States, being Hispanic was independently associated with an increased likelihood to have a hemicraniectomy.

Abstract TP283: Ambulance Service Use and Associations With Hospital Care and 90-day Outcomes for Acute Stroke: The Australian Stroke Clinical Registry (AuSCR)

Introduction: Hospital arrival via ambulance may influence treatment options and outcomes of acute stroke. A national study for Australia has not previously been reported, and inclusion of long-term outcomes is rare. We aimed to determine differences in the characteristics of patients and their outcomes by route of hospital presentation. Methods: Patient-level data linkage of Australian Stroke Clinical Registry (AuSCR) patients with first-ever strokes between January 2010 and December 2013 (n=40 hospitals) were merged with emergency and hospital admissions, and death records. Multilevel regression models were used to determine associations with hospital care and outcome by type of transport to hospital. Results: Among 9315 patients with first-ever stroke, 5601 (60%) arrived by ambulance (52% male; 79% ischemic). Compared to patients arriving by private transport, those arriving by ambulance were older (ambulance, median 77 vs. private, 72 years; P<0.001), more often had an intracerebral hemorrhage (ICH, ambulance 18% vs 15%; P<0.001), and were unable to walk (proxy for stroke severity: ambulance 73% vs. 50%; P<0.001). Median times to hospital were shorter via ambulance (135 vs. 229 mins; P<0.001), and patients arriving by private transport were less likely to receive acute therapies (rtPA for ischemic stroke, ambulance 16% vs 8%; aspirin <48 hrs, ambulance 75% vs 63%) or swallow screen/assessment (ambulance 89% vs 75%). After accounting for patient/hospital characteristics, compared with patients arriving by private transport, those using ambulances more often received inpatient rehabilitation (aOR 1.57, 95%CI 1.30-1.64), but more often died within 30-days (aOR 1.23) or reported worse quality-of-life at 90-180 days (coefficient: -4.4, 95%CI -7.4 to -1.4). Conclusion: Patients with first-ever stroke who take private transport to hospital experience treatment disadvantages but not worse outcomes. Public education on calling an ambulance for stroke symptoms remains important.

Abstract WP324: Factors Associated With Clinicians’ Intention to Use Acute Stroke Telemedicine Service: Perceived Usefulness Critical to Uptake

Introduction: Benefits of acute telestroke services include improving equity of access to acute therapies. However, these benefits require a change in clinicians’ usual practice and there may be resistance to use of technology. We aimed to examine factors associated with clinicians’ intentions to use a new acute telestroke service within rural hospital settings. Methods: A pre-post 6 month design was used during the implementation of the Victorian Stroke Telemedicine (VST) Program in 16 rural hospitals in a south-eastern state of Australia. A survey based on an extended Technology Acceptance Model (TAM) was administered to clinicians involved in the VST program. Five factors comprised between 4-6 items, with responses on a 7 point Likert scale (1=strongly disagree, 7=strongly agree). Surveys were completed between February 2014 and May 2017. Analyses included t-tests and linear regressions. Results: Participants were 303 clinicians (pre-implementation n=167, 66% female, 46% nurses; post-implementation n=136, 74% female, 68% nurses). Mean scores were significantly higher post-implementation than pre-implementation: Perceived Usefulness (pre 5.91, post 6.27; p<.001), Perceived Ease of Use (pre 5.12, post 5.92; p<.001), Social Influence (pre 5.03, post 5.84; p<.001), Facilitating Conditions (pre 5.17, post 6.16; p<.001) and Intention to Use (pre 5.83, post 6.36; p<.001). Intention to Use Telemedicine pre-implementation [Adj R 2 =.41, F(4, 132)=24.26, p<.001] was predicted by Perceived Usefulness ( β =.29, p<.001), Perceived Ease of Use ( β =.22, p=.02), Social Influence ( β =.20, p=.02) but not Facilitating Conditions ( β =.13, p=.16). Post-implementation [Adj R 2 =.69, F(4, 117)=67.07, p<.001], only Perceived Usefulness ( β =.59, p<.001) predicted intentions to use telemedicine. Conclusion: Factors driving intentions to use acute telestroke vary pre- and post-implementation of a new service. Influential colleagues and managers should emphasise the usefulness and ease of use to facilitate uptake by clinicians.

Patterns of initial migraine treatment in Denmark: A population-based study.

Population-based data are sparse on utilization of prophylactic versus acute therapies for newly diagnosed migraine. We examined initial migraine treatment patterns and associated patient characteristics in Denmark. We used population-based health databases to assemble a nationwide cohort of adult migraine patients in 2005 to 2013. Migraine was defined as a first hospital diagnosis of migraine or a second redeemed outpatient prescription for triptans, ergots, pizotifen, or flunarizine. We classified the initial migraine treatment received after migraine onset as "no treatment," "acute only," "prophylactic only," and "both acute and prophylactic" and described distributions of sex, age, comorbidities, and comedications. Among 97431 migraine patients (78% women, median age of 41y [interquartile range of 32-50y]), the initial migraine treatments received were "acute only" (88.2%), "prophylactic only" (1.9%), and "both acute and prophylactic" (5.2%) whereas 4.6% had no record of treatment. Initiators of prophylactic treatment-with or without acute treatment-were less likely than initiators of acute treatment to be women (71% and 77% versus 79%), were older (median ages: 45 and 44y versus 41y), and had more comorbidities (including hypertension [31% and 24% versus 7%] and diabetes [6% and 5% versus 3%]). Nonpersistence with initial prophylactic treatment was common: within the first year, 35% of initiators stopped therapy fully, 50% stopped and restarted, and 15% switched drugs. For 88% of patients with incident migraine, the initial migraine treatment was acute treatment only. Use of prophylactic medication as initial treatment was low and correlated with higher age and comorbidity.

CGRP ligand and receptor monoclonal antibodies for migraine prevention: Evidence review and clinical implications.

Monoclonal antibodies that target calcitonin gene-related peptide or the canonical calcitonin gene-related peptide receptor have emerged as effective and well tolerated for the preventive treatment of migraine. These large molecules appear ideally suited for migraine prevention. They have an extended biological half-life, are administered either monthly or quarterly either by subcutaneous injection or intravenous infusion, require minimal or no dose-titration and have the potential for a rapid onset of effect compared to conventional oral preventive drugs. There is high selectivity and they target an important mediator in the pathogenesis of migraine. Phase II and pivotal phase III studies have all yielded positive results with a favorable adverse event profile. No serious treatment-related adverse outcomes have thus far been reported in controlled or long-term open-label extension studies. This tolerability profile promises to improve adherence and, possibly, long-term outcomes. Calcitonin gene-related peptide monoclonal antibodies are effective and well tolerated for the preventive treatment of migraine. They have distinct advantages over currently available oral preventive drugs. While treatment-related serious adverse events have not been observed in open-label extension studies, long-term outcomes and safety will require broad exposure in heterogeneous patient populations in clinical practice. In addition, their safety in women, especially during pregnancy, will require longitudinal surveillance. Given the overlapping mechanism(s), the effectiveness of existing (triptans) and emerging (calcitonin gene-related peptide receptor antagonists) acute therapies in those using a calcitonin gene-related peptide mAb will require further study.

Infarct Volume Predicts Hospitalization Costs in Anterior Circulation Large-Vessel Occlusion Stroke.

Anterior circulation large-vessel occlusion stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. We aimed to identify predictors of increased acute care hospitalization costs associated with anterior circulation large-vessel occlusion stroke. Comprehensive cost-tracking software was used to calculate acute care hospitalization costs for patients with anterior circulation large-vessel occlusion stroke admitted July 2012 to October 2014. Patient demographics and stroke characteristics were analyzed, including final infarct volume on follow-up neuroimaging. Predictors of hospitalization costs were determined using multivariable linear regression including subgroup cost analyses by treatment technique (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses incorporating patients initially excluded due to early withdrawal of care. Three hundred forty-one patients (median age, 69 years; interquartile range, 57-80 years; median NIHSS score, 16; interquartile range, 13-21) were included in our primary analysis. Final infarct volume, parenchymal hematoma, baseline NIHSS score, ipsilateral carotid stenosis, age, and obstructive sleep apnea were significant predictors of acute care hospitalization costs. Final infarct volume alone accounted for 20.87% of the total cost variance. Additionally, final infarct volume was consistently the strongest predictor of increased cost in primary, subgroup, and sensitivity analyses. Final infarct volume was the strongest predictor of increased hospitalization costs in anterior circulation large-vessel occlusion stroke. Acute stroke therapies that reduce final infarct volume may not only improve clinical outcomes but may also prove cost-effective.

Acute Limb Ischemia Therapies: When and How to Treat Endovascularly.

Acute limb ischemia is an emergent limb and life-threatening condition with high morbidity and mortality. An understanding of the presentation, clinical evaluation, and initial workup, including noninvasive imaging evaluation, is critical to determine an appropriate management strategy. Modern series have shown endovascular revascularization for acute limb ischemia to be safe and effective with success rates approaching surgical series and with similar, or even decreased, perioperative morbidity and mortality. A thorough understanding of endovascular techniques, associated pharmacology, and perioperative care is paramount to the endovascular management of patients presenting with acute limb ischemia. This article discusses the diagnosis and strategies for endovascular treatment of acute limb ischemia.

The COAST stroke advance directive: A novel approach to preserving patient autonomy.

Within the field of neurology, there has been limited discussion of how to best respect patient autonomy in patients presenting with an acute stroke, who often have impairments in language and cognition. In addition to performing a detailed neurologic examination and providing a thorough timeline of their current presentation and medical history, these patients and their families are then asked to quickly make critical medical decisions regarding acute stroke therapies (thrombolysis and endovascular therapy). These discussions are often limited by time constraints and inadequate opportunities for patient education regarding acute stroke care. This article discusses some of the challenges of preserving patient autonomy in patients presenting with acute stroke and the advent of a stroke advance directive (Coordinating Options for Acute Stroke Therapy [COAST]) aimed to overcome these obstacles.

Editors' note: Personalizing acute therapies for ischemic stroke: Thrombolysis or thrombectomy?

In the editorial “Personalizing acute therapies for ischemic stroke: Thrombolysis or thrombectomy?,” Drs. Lee and Dziedzic qualified neuroimaging in stroke as the equivalent of precision medicine, personalizing care based on advanced imaging measures. They cited multiple clinical trials demonstrating that endovascular thrombectomy early after acute ischemic stroke (AIS) onset is highly effective for reducing long-term disability. They added that the use of rapid and robust neuroimaging methods that helped select appropriate patients based on clot location or core/penumbral signatures was critical to the success of these trials. The rest of the editorial addressed the work by Bustamante et al., which studied a potential blood biomarker that may help guide therapeutic decision making in the setting of AIS. Commenting on the article, Dr. Munakomi expresses the need to better identify those patients who would benefit from thrombolysis and thrombectomy through stroke awareness via community education and upgrading facilities for teletherapy management. In response, Dr. Lee points to the need for research to enhance diagnostic tests that would help guide the most appropriate and effective treatments in AIS. In the editorial “Personalizing acute therapies for ischemic stroke: Thrombolysis or thrombectomy?,” Drs. Lee and Dziedzic qualified neuroimaging in stroke as the equivalent of precision medicine, personalizing care based on advanced imaging measures. They cited multiple clinical trials demonstrating that endovascular thrombectomy early after acute ischemic stroke (AIS) onset is highly effective for reducing long-term disability.

Intravenous infusion of mesenchymal stem cells for protection against brainstem infarction in a persistent basilar artery occlusion model in the adult rat.

Morbidity and mortality in patients with posterior circulation stroke remains an issue despite advances in acute stroke therapies. The intravenous infusion of mesenchymal stem cells (MSCs) elicits therapeutic efficacy in experimental supratentorial stroke models. However, since there are few reliable animal models of ischemia in the posterior circulation, the therapeutic approach with intravenous MSC infusion has not been tested. The objective of this study was to test the hypothesis that intravenously infused MSCs provide functional recovery in a newly developed model of brainstem infarction in rats. Basilar artery (BA) occlusion (BAO) was established in rats by selectively ligating 4 points of the proximal BA with 10-0 nylon monofilament suture. The intravenous infusion of MSCs was performed 1 day after BAO induction. MRI and histological examinations were performed to assess ischemic lesion volume, while multiple behavioral tests were performed to evaluate functional recovery. The MSC-treated group exhibited a greater reduction in ischemic lesion volume, while behavioral testing indicated that the MSC-infused group had greater improvement than the vehicle group 28 days after the MSC infusion. Accumulated infused MSCs were observed in the ischemic brainstem lesion. Infused MSCs may provide neuroprotection to facilitate functional outcomes and reduce ischemic lesion volume as evaluated in a newly developed rat model of persistent BAO.

Potential Role of Selective Serotonin Reuptake Inhibitors in Improving Functional Outcome after Stroke.

The great advances in acute stroke treatment during the last decades have changed life after stroke considerably. However, the use of intravenous thrombolysis and endovascular thrombectomy is limited by a relatively narrow time window or contraindications for treatment. Further, patients receiving acute reperfusion therapies may still have cognitive and emotional complications due to underlying brain infarcts even though physical problems may almost disappear. Consequently, stroke is still a frequent cause of adult disability and death worldwide, and an effort to identify additional treatments to enhance recovery, preferably also feasible in the time after the acute phase, is warranted. Albeit several drugs and treatment modalities have been studied for their potential to enhance recovery after stroke, no treatment has unambiguously proven to potentiate the rehabilitation process. A promising candidate for pharmacological treatment is selective serotonin reuptake inhibitors (SSRIs), a group of commonly used antidepressants that may also possess neuro-regenerative properties. The current paper reviews the evidence for SSRIs as potential enhancers of stroke recovery and discusses the potential mechanisms behind the effects reported and the implications for the management of patients post-stoke, including potential adverse events and drug-drug interactions.

Long-Term Consequences of Worsened Poststroke Status in Patients With Premorbid Disability.

Background and Purpose- Patients with premorbid disability, generally defined as modified Rankin Scale (mRS) score ≥2, are often excluded from trials of acute stroke therapies. However, increased disability in such patients will adversely affect long-term outcomes if treatments are withheld in routine practice. We assessed the extent to which increased disability poststroke influences 5-year mortality, institutionalization, and costs in premorbidly disabled patients. Methods- In a population-based, prospective cohort of patients with ischemic stroke (OXVASC [Oxford Vascular Study], 2002-2014), we tracked mortality, institutionalization, and healthcare/social-care costs during follow-up. We compared 5-year mortality and poststroke institutionalization (Cox regressions) and 5-year healthcare/social-care costs (generalized linear model) in 3-month survivors with premorbid mRS of 2 to 4 (excluding extreme disability, mRS=5), based on the degree of change in mRS(ΔmRS) from prestroke to 3 months poststroke, adjusting analyses for age/sex/initial National Institutes of Health Stroke Scale. Results- Among 1607 patients, 530 (33.0%) had premorbid mRS of 2 to 4. Only 2 premorbidly disabled patients received thrombolysis, but 421 (79.4%) were alive at 3 months. ΔmRS was independently associated with 5-year mortality/institutionalization (adjusted hazard ratio for ΔmRS=1 versus 0: 1.59; 95% CI, 1.20-2.11; ΔmRS=2: 2.39; 95% CI, 1.62-3.53; ΔmRS=3: 4.12; 95% CI, 1.98-8.60; P<0.001) and costs (margin for ΔmRS ≥2 versus 0: $30 011, 95% CI, $4222-55 801; P=0.023). Results were similar on examining patients with premorbid mRS of 2, 3, and 4 separately (eg, 5-year mortality/institutionalization adjusted hazard ratio for premorbid mRS=3 with ΔmRS=1 versus 0: 1.60; 95% CI, 1.06-2.42; P=0.027; ΔmRS=2: 3.20; 95% CI, 1.85-5.54; P<0.001). Conclusions- Patients with stroke with premorbid disability have higher mortality, institutionalization, and costs if they accumulate additional disability because of the stroke. These findings highlight the long-term outcomes expected if acute interventions are routinely withheld in patients with mild-moderate premorbid disability and suggest that trials/registries should include such patients.

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

Background: Failure to recognise acute stroke may result in worse outcomes due to missed opportunity for acute stroke therapies. Our study examines factors associated with stroke misdiagnosis in patients admitted to a large comprehensive stroke centre. Methods: Retrospective review comparing 156 consecutive stroke patients misdiagnosed in emergency department (ED) with 156 randomly selected stroke controls matched for age, gender, language spoken and stroke subtype for the period 2014–2016. Results: There were 141 ischemic and 15 hemorrhagic misdiagnosed strokes (median age: 77 years, male:female = 1.3: 1). Symptom resolution, altered mental status, nausea/vomiting, dizziness and vertigo favored misdiagnosis (p < 0.05). Hemiparesis and dysarthria favored an accurate diagnosis (p < 0.05). Misdiagnosed patients were more commonly triaged into a lower ED category (62 vs. 42%, p = 0.001), clinically assessed as Face, Arm, Speech and Time (FAST) – negative (78 vs. 22%, p < 0.001) and underwent delayed CT imaging (median 4.1 vs. 1.5 h, p < 0.001). Misdiagnosed patients were more likely to have posterior circulation stroke (PCS; 39 vs. 22%, p = 0.01) and be admitted under non-neurological services (35 vs. 11%, p < 0.001) with worse discharge outcomes including increased mortality. Conclusions: Patients with stroke misdiagnosis were commonly FAST-negative with nonspecific symptoms including altered mental status, dizziness and nausea/vomiting often associated with PCS. Improved diagnostic accuracy may increase access to acute therapies.

Safety and efficacy of recanalization therapy in pediatric stroke: A systematic review and meta-analysis.

Safety and efficacy of intravenous (IV) thrombolysis and endovascular therapy in children with acute ischemic stroke (AIS) are unknown to date. We aimed to review and synthesize currently available evidence on these acute recanalization therapies in pediatric stroke patients. We performed a systematic review and meta-analysis of all available data on safety and efficacy of acute treatment including thrombolysis and endovascular therapy in pediatric AIS patients aged <18 years. We searched the electronic databases Medline and Cochrane Library for eligible studies published from the earliest date available until August 31, 2016. Safety outcomes included intracerebral hemorrhage (ICH) post-treatment and in-hospital mortality. Efficacy outcomes included functional outcome 3-6 months after index stroke. We identified 222 records, of which 3 studies with a total of 16,987 pediatric stroke patients met our eligibility criteria of whom 181 received IV thrombolysis. No data exists from randomized trials and no data is available on endovascular thrombectomy. Risk of any ICH was increased in children receiving thrombolysis (risk ratio=3.48, 95%CI: 1.66-7.29; p=0.001) compared with controls, with no evidence of heterogeneity (I2=0%). None of the included studies reported complete data on symptomatic ICH. In-hospital mortality was similar between pediatric stroke patients treated with thrombolysis and controls (risk ratio=1.44, 95%CI: 0.39-5.40; p=0.586), with evidence of heterogeneity (I2=62%). Efficacy of revascularization therapies could not be analyzed due to lack of outcome data. Our analyses demonstrate a substantial lack of data on efficacy and safety of acute recanalization therapies in children with AIS. URL: http://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42016047140.

Blood-brain barrier permeability assessed by perfusion computed tomography predicts hemorrhagic transformation in acute reperfusion therapy.

Hemorrhagic transformation (HT) is one of the most feared complications of acute recanalization therapies. The aim of this study was to evaluate whether blood-brain barrier permeability (BBBP) imaging can predict HT in the setting of acute recanalization therapy and to determine the sensitivity and specificity of BBBP for the prediction of HT according to the type of reperfusion therapy. We assessed a total of 46 patients who received recanalization therapy (intravenous (IV) recombinant tissue plasminogen activator (tPA), mechanical thrombectomy with a stent retriever or both) for acute ischemic stroke within the internal carotid artery or middle cerebral artery. BBBP above the threshold was significantly associated with HT after adjustment for confounding factors in all patients (OR 45.4, 95% CI 2.9~711.2, p = 0.007), patients who received IV tPA (OR 20.1, 95% CI 1.2-336.7, p = 0.037), and patients who received endovascular therapy (OR 47.2, 95% CI 1.9-1252.5, p = 0.022). The sensitivity and specificity of the initial BBBP measurement as a predictor of HT in the overall 46 patients were 80 and 71%, respectively. These values were 75 and 64% in only IV tPA group, 100 and 80% in only endovascular group, 77 and 67% in IV tPA with or without endovascular therapy group, and 86 and 76% in endovascular therapy with or without bridging IV tPA therapy group. Increased pretreatment BBBP values were significantly associated with HT after acute recanalization therapy. This correlation with HT was stronger in patients receiving endovascular mechanical thrombectomy than in patients receiving IV rtPA.

Relapsing Painful Ophthalmoplegic Neuropathy: No longer a "Migraine," but Still a Headache.

Recurrent painful ophthalmoplegic neuropathy (RPON), formerly known as ophthalmoplegic migraine, is an uncommon disorder with repeated episodes of ocular cranial nerve neuropathy associated with ipsilateral headache. This review discusses the clinical presentation, current understanding of the pathophysiology, key differential diagnoses, and evaluation and treatment of RPON. The literature is limited due to the rarity of the disorder. Recent case reports and series continue to suggest the age of first attack is most often during childhood or adolescence as well as a female predominance. Multiple recent case reports and series demonstrate focal enhancement of the affected cranial nerve, as the nerve root exits the brainstem. This finding contributed to the current classification of the disorder as a neuropathy, with the present understanding that it is due to a relapsing-remitting inflammatory or demyelinating process. The link to migraine remains a cause of disagreement in the literature. RPON is a complex disorder with features of inflammatory neuropathy and an unclear association with migraine. Regardless, the overall prognosis is good for individual episodes, but permanent nerve damage may accumulate with repeated attacks. A better understanding of the pathogenesis is needed to clarify whether it truly represents a single disorder and to guide its treatment. Until that time, a combined approach with acute and preventive therapies can mitigate acute symptoms as well as attempt to limit recurrence of this disabling syndrome.

Association between different acute stroke therapies and development of post stroke seizures

BackgroundEpilepsy is a major complication of stroke. We aimed to establish whether there is an association between intravenous thrombolysis, intra-arterial thrombolysis and post stroke seizure (PSS) development. Improved understanding of the relationship between reperfusion therapies and seizure development may improve post-stroke monitoring and follow-up.MethodsThis was a retrospective, multicentre cohort study conducted at the Royal Melbourne Hospital and Jingling Hospital Nanjing. We included patients with anterior circulation ischemic stroke admitted 2008–2015. Patients were divided into four treatment groups 1. IV-tPA only, 2. Intra-arterial therapies (IAT) only, 3. IAT + IV-tPA and 4. stroke unit care only (i.e. no IV-tPA or IAT). To assess the association between type of reperfusion treatment and seizure incidence we used multivariable logistic regression models adjusted for age, stroke severity, 3-month functional outcome and prognostic factors.ResultsThere were 1375 stroke unit care-only patients, of whom 28 (2%) developed PSS. There were 363 patients who received only IV-tPA, of whom 21 (5.8%) developed PSS. There were 93 patients who received IAT only, of whom 12 (12.9%) developed PSS and 112 that received both IV-tPA + IAT, of which 5 (4.5%) developed PSS. All reperfusion treatments were associated with seizure development compared to stroke unit care-only patients: IV-tPA only adjusted odds ratio (aOR) 3.7, 95%CI 1.8–7.4, p < 0.0001; IAT aOR 5.5, 95%CI 2.1–14.3, p < 0.0001, IAT + IV-tPA aOR 3.4, 95% CI 0.98–11.8, p = 0.05. These aORs did not differ significantly between treatment groups (IV-tPA + IAT versus IV-tPA p = 0.89, IV-tPA + IAT versus IAT, p = 0.44).ConclusionsPatients receiving thrombolytic or intra-arterial reperfusion therapies for acute ischemic stroke are at higher risk of epilepsy and may benefit from longer follow-up. No evidence for an additive or synergistic effect of treatment modality on seizure development was found.

Boosting recovery after brain damage

In the minutes after a stroke, the sudden loss of blood supply to a region of a person’s brain can start damaging brain cells. Acute therapies to restore blood flow can protect neurons near the damaged cells, if the person receives treatment in the hours after the stroke. But once that window closes, doctors have few therapeutic options. Damaged neurons can impair stroke patients’ cognitive abilities and motor skills. However, with rehabilitation, affected people can recover some lost function thanks to the brain’s ability to rewire its circuitry—known as synaptic plasticity. Now, scientists at Yokohama City University and Fujifilm’s Toyama Chemical report that the small molecule edonerpic maleate, when administered in combination with physical training, accelerates the recovery of lost motor function caused by a brain injury in mice and monkeys (Science 2018, DOI: 10.1126/science.aao2300). Toyama had previously sponsored Phase I/II clinical trials of edonerpic maleate for treating Alzheimer’s disease.

Evolution of a US County System for Acute Comprehensive Stroke Care.

In Orange County, California, patients with suspected acute stroke are taken to stroke neurology receiving centers that are designated by County Emergency Medical Services authorities as either hubs or spokes based on endovascular treatment capability. We examined relationships between stroke details, reperfusion therapies, hospital transfers, and their change over time. All patients from January 1, 2013, to December 31, 2015, for whom 911 was called within 7 hours of onset in whom Emergency Medical Services personnel suspected acute stroke were evaluated. Among 6132 patients, 3924 (64%) had confirmed diagnosis of stroke (74% ischemic/26% hemorrhagic), yielding diagnostic precision of 64% in the field. Of the 2892 patients with acute ischemic stroke, acute reperfusion therapy was given to 29.2% (21.7% intravenous tPA [tissue-type plasminogen activator] only and 7.5% endovascular treatment). Rates of endovascular treatment of patients with ischemic stroke increased over time, more than doubling from 5.6% in 2013 to 12.5% (odds ratio per 3-month quarter=1.09; 95% confidence interval, 1.04-1.14; P<0.0001). Only 3.4% of patients with acute ischemic stroke were transferred from a spoke to a hub hospital; transfer rates were inversely related to age (P<0.0001), and reperfusion therapy rates did not vary according to transfer status. Favorable features of this acute stroke care system include reperfusion therapy in 29.2% of patients with ischemic stroke and substantial increases in endovascular treatment rates over time. Continued efforts to optimize acute stroke systems of care can be directed toward improving access to best acute stroke therapies.

The network of Shanghai Stroke Service System (4S): A public health-care web-based database using automatic extraction of electronic medical records.

Background Several stroke outcome and quality control projects have demonstrated the success in stroke care quality improvement through structured process. However, Chinese health-care systems are challenged with its overwhelming numbers of patients, limited resources, and large regional disparities. Aim To improve quality of stroke care to address regional disparities through process improvement. Method and design The Shanghai Stroke Service System (4S) is established as a regional network for stroke care quality improvement in the Shanghai metropolitan area. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Site-specific education and training program will be designed and administrated according to their baseline characteristics. Both acute reperfusion therapies including thrombectomy and thrombolysis in the acute phase and subsequent care were measured and monitored with feedback. Primary outcome is to evaluate the differences in quality metrics between baseline characteristics (including rate of thrombolysis in acute stroke and key performance indicators in secondary prevention) and post-intervention. Conclusions The 4S system is a regional stroke network that monitors the ongoing stroke care quality in Shanghai. This project will provide the opportunity to evaluate the spectrum of acute stroke care and design quality improvement processes for better stroke care. A regional stroke network model for quality improvement will be explored and might be expanded to other large cities in China. Clinical Trial Registration-URL http://www.clinicaltrials.gov . Unique identifier: NCT02735226.