Management Of Stroke Research Articles

Abstract TP101: Disposition Disparities: Differences in Discharge and Rehabilitation Post-Stroke Between Racial and Ethnic Groups

Background and Purpose: Racial and ethnic disparities affect stroke treatment, altering patient outcomes. Previous studies have shown that white patients often arrive at the Emergency Department more quickly and use Emergency Medical Services more than minority patients. They also receive specific treatments more frequently, including tPA. Our study investigates whether these disparities continue in post-stroke care in Florida. Methods: We conducted a retrospective review using our comprehensive Get with the Guidelines database. We categorized patients by stroke type, risk factors, and stroke severity. The focus was comparing discharge dispositions and rehabilitation plans across racial and ethnic groups. Results: Data gathered from Get with the Guidelines database, including 6,426 records between 2012-present. Discharge disposition disparities were observed across racial and ethnic groups with comparable stroke severity (p<0.001). Black people were more frequently discharged home compared to White people (p=0.029), and Asian people more often went to hospice, especially inpatient (p<0.001). Asian people and White people had the highest in-hospital death rates (p<0.001), while Hispanic people had lower in-hospital deaths(p=0.26) and were more likely discharged home (p=0.001). Black people received the greatest in-patient rehabilitation services (p<0.001), whereas Asian people were least likely to get in-patient or outpatient rehabilitation (p=0.016). Hispanic people had higher inpatient rehabilitation rates than non-Hispanic people (p=0.007). Conclusions: Our study highlights post-stroke disparities across racial and ethnic groups. Recognizing and addressing these disparities may improve outcomes in these populations, increasing stroke management equity. Elucidating the causes of these findings is the next step in this research.

Abstract WP96: Impact of Stroke Severity and Social Determinants of Health on Arrival to Last Known Well Time

Introduction: Timely administration of thrombolytic therapy remains the cornerstone of ischemic stroke management and is associated with better functional outcomes. The population served by our hospital is notable for a large socioeconomic range of patients. We examined arrival times for ischemic strokes and the timeliness of intervention with our goal to better understand our population and develop methods for improved community outreach and education. Methods: This retrospective study looked at ischemic stroke patients discharged between January-May 2023. Patient characteristics and demographics were mined from the Get With The Guidelines™-Stroke database from NYC Health+Hospitals/Kings County. A total of 284 patients were reviewed. Covariates included in this study: age, sex, ethnicity, initial NIHSS score, payment source, and history of previous stroke. Adjusted linear regressions were used to analyze data at alpha = 0.05. Results: The median time of arrival to hospital from last known well time (LKWT) is 296min; 37.32% of patients arrived within the 4.5hr window. The average NIHSS score on arrival for patients within the 4.5 hours window is 7.3; patients outside of the 4.5hr window (or unknown LKWT) have an average NIHSS of 5.17. (See distribution of NIHSS score by LKWT category in Fig. 1 below.) Out of the 284 patients, a noted association was seen between severity of NIHSS and LKWT reported: the LKWT was lower by 16.47min (23.68-9.24, p > 0.02) for every increase in NIHSS point. Additionally, compared to patients with no health insurance, those with private insurance have a decrease in LKWT of 1506.04min (1878.6-1133.5, p < 0.0001), and those with Medicare/Medicaid have a decrease in time of 1291.83min (1652.1-931.5, p > 0.0004). Conclusion: Review of patients in early 2023 showed a relationship between LKWT reporting and stroke severity as well as insurance status. These findings will help direct future projects in community education and outreach.

Abstract HUP18: Clinical Characteristic of a Haitian Stroke Cohort and a Scoping Review of the Literature of Stroke Among the Haitian Population

Background: There are significant disparities in stroke care and outcomes between low- and middle-income country like Haiti, which suffers from a lack of resources for acute stroke management. This study is the first to report the epidemiological profile of the Haitian population at the largest academic hospital in the nation. Methods: This is an observational study conducted over a period of 5 months from April 2021 to August 2021 in the Internal Medicine Department of the State University Hospital of Haiti. There were 51 included patients who were suspected to have had an acute stroke. A descriptive statistical analysis was conducted. A scoping review of the literature was also conducted. Results: Over 50% of included patients were between 19 and 65 years old. The mean age at presentation was 61 years, patients were predominantly female (64.7%). The prevalence of severe motor deficits was over 96%. The mean National Institutes of Health Stroke Scale was 12. Only 15.7% of patients (8/51) had a computed tomography (CT) scan during their hospitalization. The median time to CT scan was 84 h after symptom onset. About 80% of those with complications took more than 24 h to arrive at the hospital after the onset of symptoms. Eleven percent of patients had complications, and the mortality rate was 3.9%. There was a significant association between the Modified Rankin Scale and the occurrence of complications (p = 0.016). National Institutes of Health Stroke Scale (NIHSS) score had a significant association with the Glasgow score (F = 6.3; p < 0.001) where an inversely proportional correlation was observed between them (r = –0.7; p < 0.001) and a proportional correlation with the Rankin prediction score and the NIHSS (r = 0.3, p = 0.04). Little is known about the epidemiology of stroke patients in Haiti, and this limits the ability to develop targeted interventions to improve outcomes. In our scoping review, only three pertinent studies were identified over a 25-year period, this leads to a lack of data in regard to stroke care in Haiti mainly due to the absence of trained personnel. Conclusion: Urgent assistance is needed to strengthen personnel and infrastructure dedicated to stroke. Neurological assessment based on NIHSS and Rankin score should be systematic in stroke evaluation in Haiti.

Abstract TP69: Development of System-Wide Stroke-Specific Nursing Education for a Hospital System

Background: Stroke nursing education is a requirement for Stroke Center designation. Providing eight hours of stroke-specific education to hundreds of nurses annually can be challenging for any medical institution. Purpose: The purpose of our project was to improve the quality of stroke nursing education for a seven-hospital system in New York City and to reach a larger audience of nurses by creating a learning environment that is strong, evidence-based, engaging and interactive. Methods: We recruited stroke neurologists, nurse practitioners, and experienced stroke nurses to provide lectures during monthly stroke education days. The eight-hour curriculum was designed by stroke program directors and stroke coordinators. Topics included acute stroke management, imaging, stroke complications, NIHSS review, post-stroke rehab, swallow screen, and stroke trivia. At least two presenters were recruited for each topic to ensure coverage. We used a zoom platform to provide stroke education. We assessed nurses’ performance during the educational process. Lectures were interactive with multiple-choice questions, polling and trivia, and allowed nurses to engage and ask questions. Educational days were offered monthly, and the schedule was posted for the entire year on the system-wide educational platform. We continued to improve the quality and delivery of the content based on nurses’ feedback. Results: Following initiation of this program, monthly education days via a virtual platform allowed us to reach a wider nursing audience across the system and to achieve consistency and quality of stroke nursing education. Over 2,000 nurses took part in our educational days during years of 2020-2023. Based on 1575 nurses’ reviews and feedback, the ability to interact with the presenters, ask questions, and the interactive content delivered by stroke experts were most appreciated.: Conclusions: Virtual technology and our nurse-oriented stroke curriculum allowed us to reach a wider audience of nurses. Assigning designated topic-specific partner-lecturers ensured coverage in case of an unexpected event. This method allows nurse educators to provide system-wide evidence-based interactive nursing education by specialty experts and emphasize material in real time.

Abstract WMP78: Mobile Stroke Units Enable Hyperacute Interventions for Intracerebral Hemorrhage

Introduction: Mobile stroke units (MSUs) are an evolving means to expedited acute stroke management. Recent landmark trials BEST-MSU and B_PROUD have proven that MSUs facilitate quicker thrombolysis times and improved functional outcomes at 90 days when compared to conventional emergency medical services (EMS) for acute ischemic stroke patients. Despite the growing body of literature surrounding MSUs and acute ischemic stroke, literature describing the intracerebral hemorrhage experience in MSUs has been lacking. Methods: Retrospective analysis of consecutive patients with acute intracerebral hemorrhage triaged by MSU or EMS from January 2018 to December 2022 was performed at two tertiary institutions. In the EMS cohort, only patients seen between 8 am to 8 pm, corresponding to the operating hours of the MSU, were included. Goal blood pressure was defined as systolic blood pressure <160. Chi-squared test for categorical variables and t-test for continuous variables were used for statistical analysis. Results: A total of 146 MSU patients were compared to 221 EMS patients. Both cohorts had similar baseline demographics. Median initial blood pressure in the MSU was 190/99, which dropped to a median blood pressure of 157/80 upon arrival to the hospital. Initial systolic blood pressure in the hospital was significantly higher for EMS compared to MSU patients (166 vs 157, p=0.011). The majority (77%) of MSU patients received anti-hypertensive medications while in the MSU. Times from door to CT completion (14 vs 33 min, p=0.000), anticoagulation reversal (99 vs 139 min, p=0.013), anti-hypertensive medication administration (21 vs 45 min, p=0.020), and goal blood pressure (35 vs 51 min, p=0.000) were significantly faster in the MSU cohort. Conclusions: MSUs provide faster medical treatment for patients with acute intracerebral hemorrhage. The target blood pressure goal was met much quicker in the MSU. Faster time metrics convey a hypothetical benefit towards improved patient outcomes.

Abstract WP77: Changes in Acute Stroke Management and Outcomes in Korea Between 2013-2014 and 2018

Purpose: The quality of acute stroke care can be improved through the nationwide compulsory quality assessment. Acute stroke quality assessment (ASQA) covers most acute stroke patients treated in acute care hospitals in Korea. We evaluated the changes of acute stroke management and outcomes between 2013/2014 and 2018 in Korea. Methods: We compared the most recent available ASQA data from 2018 with the data from 2013/2014. Patients with ischemic stroke (IS), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH), who were admitted via emergency rooms within 7 days of onset at hospitals treating 10 or more cases during the each 3-month (2013, 2014) and 6-month (2018) survey period were selected. We grouped 2013 and 2014 into one group and compared them with 2018. Results: A total of 19,599 acute stroke cases in 2013/2014 and 28,286 cases in 2018 were enrolled at 216 and 248 nationwide hospitals, respectively. Age of stroke patients increased slightly (67.1±13.5 vs 68.2±13.8, p <0.001), and the proportion of stroke types slightly increased ICH and decreased SAH. The proportion of severe stroke was decreased. The number of hospitals equipped with stroke units increased. Mean bed size increased, but there was no difference in the number of stroke specialists by hospital. IVT and EVT were performed in 8.7% and 5.3% among IS patients in 2013/2014, respectively. In 2018, IVT rates decreased to 6.3% ( p <0.001), and EVT rates increased to 9.8% ( p <0.001). In particular, IVT rates significantly decreased from 1.3% to 0.2% in those over 80 years of age, and EVT rates increased from 0.7% to 2.4%. Decompressive surgery rates in ICH patients decreased slightly from 28.0% to 25.2% ( p =0.009). In SAH, clipping rates decreased from 34.7% to 24.3% ( p <0.001), and coiling rates increased significantly from 39.8% to 53.0% ( p <0.001). One-year mortality significantly decreased from 22.0% to 18.2% in all stroke patients ( p <0.001). Mortality decreased at 1 month and 3 months, also, and decreased in all patients with IS, ICH, and SAH. Conclusions: This study showed that while stroke patients had improved outcomes from 2013/2104 to 2018 in Korea, there is still room for improvement, particularly in IVT rates.

Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review.

To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.

Nutrition Management for Acute Stroke with Right-Sided Hemiparesis: A Case Study

This case study aims to report on the nutrition management of acute stroke with right-sided hemiparesis using an approach of early enteral feeding intervention to prevent malnutrition. Mr. R, a 77-year-old Malay man was admitted to the hospital due to an acute stroke with right hemiparesis with underlying disease of Atrial Fibrillation (AF), hypertension, type 2 Diabetes Mellitus (DM), Chronic Kidney Disease (CKD) stage 3b, and significant Peripheral Artery Disease (PAD). His BMI was 24kg/m2 with a weight of 67kg and height of 1.67m, and he was presented with abnormal blood results. All his vital signs were normal, and he appeared lethargic. The patient was on bolus Nasogastric (NG) feeding via Ryle’s tube with polymeric formula. Inadequate enteral nutrition infusion related to infusion volume not yet reached, as evidenced by a 47% energy and 60% protein adequacy feeding history. The polymeric formula was changed to a diabetic-specific formula for better blood sugar control, and feeding was given according to the patient's needs. Mr. R required at least 70% of 1,675 kcal of energy and 53.6 g of protein (0.8 g/kg body weight) to prevent malnutrition. The patient was still on Ryle’s tube feeding and already achieved the targeted energy and protein requirements. Before being discharged, the patient was allowed orally, and a sample menu was given as guidance to avoid weight loss and muscle wasting during longterm recovery. This case highlights the importance of early enteral feeding support in stroke recovery and the need to prioritize meeting nutritional needs in stroke patient care. Mr. R showed improvement in health and nutrition and concluded that early and focused enteral nutrition support can lead to improved results and better quality of life for stroke survivors.

Mechanical Thrombectomy for All LVO – Is It Feasible? – Recent Evidence to Expand the Current Stroke Guidelines

Mechanical thrombectomy (MT) has established its role as a standard care of acute ischemic stroke due to large vessel occlusion (LVO). Current early stroke management guidelines have defined certain selection criteria for LVO patients undergoing MT to achieve the most benefit. However, it is still uncertain if some other LVO patients who do not meet these criteria can also benefit from MT. In this review, we research the latest evidence on efficacy and safety of MT for LVO in various unique stroke populations, such as advanced age, pre-stroke disability, LVO with minor stroke, large infarct volume, poor mismatch profile, very late time window, posterior circulation LVO and distal medium-sized vessel occlusions. By comparing the benefits and risks of MT with best medical management only, we may develop further subgroup-specific criteria to expand our capacity to best treat these unique LVO populations.

Sex differences in acute stroke metrics and outcome dependent on COVID status.

Biological sex is known to have an impact on quality metrics of acute stroke. We aimed to determine whether COVID positivity accentuates this effect and constitutes worse outcome. The present analysis was based on the Global COVID-19 Stroke Registry, a retrospective, international, cohort study of consecutive ischemic stroke patients receiving intravenous thrombolysis and/or endovascular thrombectomy between 1 March 2020 and 30 June 2021. We investigated differences between the sexes in patient characteristics, acute stroke metrics as well as post-stroke outcome in COVID-positive and COVID-negative stroke patients undergoing acute revascularization procedures. A total of 15,128 patients from 106 centers were recorded in the Global COVID-19 Stroke Registry, 853 (5.6%) of whom were COVID-positive. Overall, COVID-positive individuals were treated significantly slower according to every acute stroke metric compared to COVID-negative patients. We were able to show that key quality indicators in acute stroke treatment were unfavorable for COVID-negative women compared to men (last-seen-well-to-door time + 11 min in women). Furthermore, COVID-negative women had worse 3-month outcomes (3-month modified Rankin Scale score [interquartile range] 3.0 [4.0] vs. 2.0 [3.0]; p < 0.01), even after adjusting for confounders. In COVID-positive individuals no such difference between the sexes, either in acute management metrics or in 3-month outcome, was seen. Known sex-related differences in acute stroke management exist and extend to times of crisis. Nevertheless, if patients were COVID-19-positive at stroke onset, women and men were treated the same, which could be attributed to structured treatment pathways.

Enhancing Ischemic Stroke Management with Cluster Nursing: A Comparative Study on the Effects of Ginkgo biloba Diterpene Lipid Amine Treatment

This study aimed to investigate the effect of cluster nursing on the management of ischemic stroke patients receiving Ginkgo biloba diterpene lipid amine treatment. This study was conducted on 197 patients from the Neurology Department of the author’s hospital from December 2021 to December 2022. These patients were divided based on their admission time into two groups: a control group comprising 98 patients who received routine nursing care and an observation group of 99 patients who were administered cluster nursing. This study evaluated and compared the incidence of nutritional intolerance events, nursing-related adverse events, and the overall quality of life among these groups. Results indicated a statistically significant reduction in the incidence of nutritional intolerance (P &lt; 0.05) and nursing adverse events associated with enteral nutrition support (P &lt; 0.05) in the observation group compared to the control group. Furthermore, the observation group exhibited higher scores in family role, energy, and verbal ability (P &lt; 0.05), suggesting an improvement in the quality of life. These findings highlight the effectiveness of the cluster nursing approach in improving the management and outcomes for ischemic stroke patients in terms of reducing nutritional intolerance and nursing adverse events, thereby significantly enhancing the quality of life.

The effectiveness of the algorithm Stroke Gadjah Mada’s (ASGM) and Guy's Hospital Stroke Score (GHSS) in determining the type of etroke emergency in the emergency room of Dr. H. Moch Ansari Saleh hospital

Introduction: Good stroke management depends on the speed and accuracy of the assessment system in diagnosing the type of stroke, in order to reduce mortality and morbidity. CT scan is a tool to differentiate the type of stroke, determine the location of the lesion and determine the severity of the disease. However, this tool is expensive and not all areas have it and the procedure takes quite a long time. Nurses need a diagnostic tool in the form of a simple assessment system including the Gadjah Mada Stroke Algorithm (ASGM) and Guy's Hospital Stroke Score (GHSS) which are easy, valid, reliable assessment tools in determining the type of stroke and preventing delays. Objectives: Analyzing the comparison of the ASGM and GHSS scoring systems in determining the type of stroke emergency in the Emergency room. Methods: This research method is quantitative pre-experimental design (posttest only design). The population was all stroke patients in the emergency room with 30 samples and the collection technique was accidental sampling. As for the stages, each respondent undergoes an ASGM assessment which consists of 3 components and GHSS 9 components. The statistical test used is the Paired Sample T-test, then an accuracy test is carried out by looking at the level of sensitivity and specificity. Results: Based on the results of the Paired Sample T-test, the Sig value. amounting to 0.000 &lt;0.05, which means there is a significant difference between the ASGM and GHSS scoring systems in determining the type of emergency in stroke patients. The average difference in the duration of determining the type of emergency and nursing diagnosis in the assessment system and ASGM and GHSS is 7.6 minutes. Furthermore, it also shows lower data of 7,066 and upper data of 8,134. This shows that the duration range for determining the type of emergency using ASGM is around 7.1 – 8.1 minutes faster compared to GHSS. Based on the accuracy test, the ASGM sensitivity level is 86.66% and the specificity level is 96.66%, while the GHSS sensitivity level is 56.66% and the specificity level is 63.33%.This difference is thought to be due to ASGM having more specific assessment variables for the brain, so that detecting suspected types of stroke in the acute phase is more accurate compared to GHSS. Conclusions: The ASGM and GHSS assessment methods are effective in determining the type of emergency in stroke patients in the ERHowever, in terms of duration, determining the type of emergency and.

The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation

BackgroundVariation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres. .We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework.MethodsThe sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo.ResultsIndividual (n = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework).ConclusionA cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs.

Impact of Comorbid Sleep-Disordered Breathing and Atrial Fibrillation on the Long-Term Outcome After Ischemic Stroke.

Sleep-disordered breathing (SDB) and atrial fibrillation (AF) are highly prevalent in patients with stroke and are recognized as independent risk factors for stroke. Little is known about the impact of comorbid SDB and AF on long-term outcomes after stroke. In this prospective cohort study, 353 patients with acute ischemic stroke or transient ischemic attacks were analyzed. Patients were screened for SDB by respiratory polygraphy during acute hospitalization. Screening for AF was performed using a 7-day ECG up to 3× in the first 6 months. Follow-up visits were scheduled at 1, 3, 12, 24, and 36 months poststroke. Cox regression models adjusted for various factors (age, sex, body mass index, hypertension, diabetes, dyslipidemia, and heart failure) were used to assess the impact of comorbid SDB and AF on subsequent death or cerebro-cardiovascular events. Among 353 patients (299 ischemic stroke and 54 transient ischemic attacks), median age, 67 (interquartile range, 57-74) years with 63% males. Moderate-to-severe SDB (apnea-hypopnea index score, ≥15/h) was present in 118 (33.4%) patients. Among the 56 (15.9%) patients with AF, 28 had comorbid moderate-to-severe SDB and AF. Over 36 months, there were 12 deaths and 67 recurrent cerebro-cardiovascular events. Patients with comorbid moderate-to-severe SDB and AF had a higher risk of subsequent death or cerebro-cardiovascular events compared with those with only moderate-to-severe SDB without AF (hazard ratio, 2.49 [95% CI, 1.18-5.24]) and to those without moderate-to-severe SDB or AF (hazard ratio, 2.25 [95% CI, 1.12-4.50]). However, no significant difference was found between the comorbid moderate-to-severe SDB and AF group and the group with only AF without moderate-to-severe SDB (hazard ratio, 1.64 [95% CI, 0.62-4.36]). Comorbid moderate-to-severe SDB and AF significantly increase the risk of long-term mortality or recurrent cerebro-cardiovascular events after acute ischemic stroke. Considering both conditions as cumulative and modifiable cerebro-cardiovascular risk factors is of interest for the management of acute stroke. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02559739.

Critical care management of acute ischemic stroke – An overview of current concepts

Acute ischemic stroke is a major cause of morbidity and mortality globally. Early recognition and prompt revascularisation are the cornerstones of treatment. Advances in the management of stroke, notably with the endovascular interventions has led to improved functional outcomes. Identification of stroke subtype, timely decision making, institution of specific therapy and periprocedural care in an intensive care unit make the difference between a favourable and an unfavourable outcome. To this effect, dedicated stroke centres, multidisciplinary teams with trained experts and critical care management play an important role. Improvements in the understanding of the disease process, ever expanding literature and development of promising novel therapeutic strategies, not withstanding, stroke is still a leading cause of acquired long term disability and mortality worldwide. End of life care and associated decision making precariousness, pose a significant prognostication challenge to the critical care team. The aim of this review is to discuss the current evidence regarding diagnosis, revascularisation modalities and optimal critical care management strategies.

Automated evaluation of collateral circulation for outcome prediction in acute ischemic stroke

IntroductionThe assessment of collateral circulation in acute ischemic stroke management is essential. Modern tools, such as Brainomix's e-CTA, powered by artificial intelligence, provide detailed insights into collateral assessment. This retrospective study aims to identify factors contributing to favorable collateral status and compare outcomes between patients with good collaterals (grade 3) and fair collaterals (grade 0–2). MethodThis retrospective study included 97 patients admitted to the Stroke Unit at the Hospital de Clínicas of the Federal University of Paraná, Brazil, from September 2021 to January 2023. Comparative analyses involved demographic factors, cardiovascular risk factors, and the combined outcome of mortality and moderate to severe disability at discharge, 30-day, and 90-day follow-ups. ResultsAmong the 97 cases, 58.8 % showed 'good collaterals' with a grade 3 status. Variables affecting collateral status included age (p = 0.042), neutrophil-lymphocyte ratio (p = 0.005), and initial NIHSS scores (p<0.001). The presence of good collaterals according to e-CTA reduced the odds of death and moderate-severe disability at discharge (p = 0.003; OR 0.27) and at 30 days (p = 0.015; OR 0.33), although this effect diminished at the 90-day mark after multivariate analysis. DiscussionAutomated collateral assessment through e-CTA is a valuable tool in acute ischemic stroke evaluation. Good e-CTA collateral score serve as a promising imaging biomarker, guiding informed clinical decisions during Stroke Unit hospitalizations. This study highlights the relationship between collaterals and stroke outcomes and underscores the potential for AI-driven tools to enhance stroke care management.

Posterior circulation lesions are more frequently associated with early seizures after a stroke

Background. Early seizures (ES) following stroke are prevalent among the elderly population, representing the most common type of acquired seizures. This study aimed to determine the incidence of ES and investigate potential associations with various clinical and radiological factors. Materials and Methods. 260 stroke patients (mean age 72±13.2, 48.5% females) were prospectively enrolled and followed. Baseline demographic data, clinical data, stroke subtype, ES occurrence, National Institutes of Health Stroke Scale (NIHSS) scores, and Alberta Stroke Program Early CT Score (ASPECT) were collected and analyzed. Results. ES was observed in 11.6% of patients with ischemic stroke compared to 7.1% among patients with hemorrhagic stroke. ES occurred more frequently in those with posterior circulation stroke (18.5% vs. 7.1%, P=0.008) and those with NIHSS &gt;15 (19.4% vs. 8.4%, P=0.04). In a logistic regression analysis that adjusted for vascular risk factors and NIHSS, posterior circulation stroke remained significantly associated with ES, with an odds ratio of 3.14 (95% CI 1.20 to 7.73, P=0.012). Conclusions. This study revealed that ES following stroke is more common in patients with posterior circulation lesions. These findings emphasize the need for further investigation into additional factors that may influence ES occurrence and its impact on stroke management and patient outcomes.

Challenges and needs in cerebrovascular disease pathway: A qualitative descriptive study from the patients' and healthcare professionals' perspectives.

To understand patients' and healthcare professionals' experiences to improve care in and across different domains of the cerebrovascular disease pathway. A qualitative descriptive study. Semi-structured in-person interviews were conducted among 22 patients diagnosed with acute cerebrovascular disease and 26 healthcare professionals taking care of them in a single tertiary-level hospital from August 2021 to March 2022. Data were analysed using deductive and inductive content analysis. The consolidated criteria for reporting qualitative research was used to ensure reliable reporting. Overall, 19 generic and 79 sub-categories describing perceived challenges with 17 generic and 62 sub-categories describing perceived needs were identified related to primary prevention, organization of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment, and life after stroke. Several challenges and needs were identified in and across the different domains of the cerebrovascular disease pathway. There is a requirement for adequate resources, early initiation of treatment, early diagnostics and recanalization, dedicated rehabilitation services, long-term counselling and support, and impact evaluation of services to improve cerebrovascular disease care. Future research on caregivers', and clinical leadership experiences in and across the cerebrovascular disease pathway is needed to explore the provision of services. The results of this study can be applied by organizations, managers and research for developing and improving services in the cerebrovascular disease pathway. This study identified several patient-related, organizational and logistical needs and challenges, with suggestions for required actions, that can benefit the provision of effective, high-quality cerebrovascular disease care. We have adhered to relevant EQUATOR guidelines with the COREQ reporting method. No patient or public involvement.

A Review of an Interfacility Transport Program Pediatric Stroke Clinical Practice Guideline.

Pediatric acute ischemic stroke is a rare diagnosis that requires timely recognition and definitive management to prevent morbidity and mortality. Children often present to primary care offices, urgent care clinics, and adult emergency departments for evaluation of symptoms that may be signs and symptoms of stroke. Currently, there are no published prehospital or transport protocols specific to pediatric acute ischemic stroke. The Children's Mercy Hospital Critical Care Transport Team (CMCCT) created a pediatric-specific clinical practice guideline (CPG) for suspected acute ischemic stroke. This retrospective, descriptive study reports pediatric patients aged younger than 18 years who met criteria for the pediatric stroke CPG and required interfacility transport by CMCCT over a 4- year period. Large vessel occlusion (LVO) scores used in adults were calculated retrospectively. Seventeen patients met inclusion criteria. Four (24%) of 17 had radiographic evidence of acute thrombus, 3 of whom received alteplase and/or endovascular clot retrieval. Median age of confirmed stroke was 83 months (interquartile range, 65-148) compared with 177 months for nonstroke (interquartile range, 169-191), P = 0.126. The most common presenting symptom was hemiplegia in the confirmed stroke group. The confirmed stroke group scored significantly lower on the Glasgow Coma Scale (median of 8 vs 15, P = 0.014), significantly higher on the Los Angeles Motor Scale LVO score (median 4 vs 0, P = 0.021), and significantly higher on the Rapid Arterial Occlusion Evaluation LVO (median 4 vs 0, P = 0.036). To our knowledge, the CMCCT CPG is the first pediatric transport protocol aimed at recognition and management of pediatric stroke described in the literature. Retrospective calculation of LVO scores show that they may be helpful in application to pediatric patients.

Systematic Review and Case of Thrombectomy for Pediatric Stroke Due to Myxoma Embolism

BackgroundStroke presentation secondary to a cardiac myxoma thromboembolism are rare in the pediatric population. Because of its rarity, the reported cases in the literature are primarily case reports. Additionally, general pediatric stroke management lacks evidence-based guidelines because of its low incidence and lack of clinical trials. In pediatric strokes identified from a cardiac myxoma, the incidence favors boys with classical presentation of unilateral weakness and aphasia. We present a pediatric patient who presented with stroke-like symptoms secondary to an intracranial embolus from a previously undiagnosed cardiac myxoma. MethodsWe performed a systematic review by searching PubMed, Google Scholar, Web of Science, and Embase databases for cases of pediatric myxoma causing stroke (n=2431) and identified 19 reported uses of surgical management in treating pediatric patients who present with stroke symptoms secondary to a cardiac myxoma thromboembolism. ResultsThe most common imaging modality was MRI in 42% of cases, CT in 36.8%, followed by CTA in 31.6% of cases. Of these 19 children treated with procedures, 36.8% of pediatric patients aged between 4 and 14 years underwent neurosurgery (n=7). ConclusionsWe describe an urgent mechanical thrombectomy, share preoperative and postoperative images and pathology slides confirming a stroke from myxoma origin. We provide added insight in the safe use of mechanical thrombectomy as treatment for pediatric strokes secondary to a thromboembolism.