Stroke Pathway Research Articles

The stroke pathway: an integrated approach to health care of stroke patients.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

The long-term challenges faced by stroke survivors and their caregivers following a stroke in Bangladesh: a qualitative study

# Background Strokes result in devastating consequences to both the survivors and caregivers, therefore it is important that it is appropriately managed and caregivers are well supported. In order to do this effectively, we need a better understanding of the challenges faced by stroke survivors and their caregivers, in a country with limited provisions for rehabilitation. Our aim was to explore the experiences of stroke survivors and their caregivers' 1-year post discharge from stroke rehabilitation in Bangladesh. # Methods Twenty stroke survivors and their caregivers were selected for our qualitative, single-centred study. Participants were chosen using a convenience sampling method. A semi-structured questionnaire was used to collect data during face-to-face interviews. Six themes were deciphered following analysis of the data collected. # Results There was a low return to work rate and poor awareness of stroke and its risk factors. There was no provision of rehabilitation whilst in hospital or at home and a lack of advice on how to access rehabilitation after hospital. Stroke survivors and caregivers\' experienced physical, social and emotional wellbeing challenges. # Conclusions Schemes to increase the awareness of stroke and its risk factors are needed to reduce the incidence of stroke. Earlier access to rehabilitation and ongoing support and training through implementation of a stroke pathway may improve outcomes for stroke survivors and caregivers. Future research should investigate the challenges of returning to work and the experiences of stroke survivors and caregivers who did not receive rehabilitation.

Temporal Trends and Predictors of Drug Utilization and Outcomes in First-Ever Stroke Patients: A Population-Based Study Using the Singapore Stroke Registry.

Drug utilization and outcomes research in multi-ethnic Asian stroke populations is lacking. Our objective was to examine temporal trends and predictors of drug utilization and outcomes in a multi-ethnic Asian stroke population. This registry-based study included ischemic and hemorrhagic first-ever stroke patients hospitalized between 2009 and 2016. Utilization of medications included in-hospital thrombolytic agents, early antithrombotics (antiplatelets, anticoagulants) within 48h of admission, and antithrombotics and statins at discharge. Outcomes analyzed were in-hospital all-cause mortality; 28-day, 90-day, and 1-year case fatality (CF); and discharge destination. Of the 36,615 included patients, 81.6% had ischemic stroke and 18.4% had hemorrhagic stroke (15.5% intracerebral hemorrhage [ICH] and 2.8% subarachnoid hemorrhage [SAH]). For ischemic stroke, the combined use of all three guideline medications (in-hospital thrombolytic therapy, as well as antithrombotics and statins at discharge) increased (P = 0.006). Being on the stroke pathway was associated with prescription of all three guideline medications in ischemic stroke. Decreasing trends for in-hospital mortality, 28-day, 90-day, and 1-year CF and proportion of patients discharged home without rehabilitation appointment were observed in ischemic stroke (P < 0.05) but not in ICH or SAH (apart from 28-day CF). Ischemic stroke patients who received guideline medications were less likely to die or be discharged to nursing homes and chronic sick hospitals. Hemorrhagic stroke patients prescribed statins at discharge were less likely to have 28-day and 1-year CF. Prescription of secondary stroke preventive medications (particularly in ischemic stroke) was associated with more favorable outcomes, highlighting the importance of physician adherence to evidence-based pharmacotherapy.

036 The impact of a clinical support tool on stroke key performance indicators

IntroductionAdherence to key performance indicators (KPIs) in stroke care is associated with better outcomes.1–6 The complexity in management of acute strokes, however, has created barriers towards delivering best care with plateauing of KPIs as measured by The National Stroke Foundation Clinical Audit.We examined the impact on stroke KPIs in our local health district of a web-based decision support stroke platform which provides clinicians with up-to-date information about the patient’s management flagging potential areas for improvement, allowing treatment to be optimised in real time.MethodsSix months following the introduction of the platform we performed a retrospective analysis of Electronic medical records of patients admitted to Gosford hospital with acute stroke between June 2018 and September 2018 assessing access to the stroke unit as well as being discharged on appropriate secondary prophylactics, including antihypertensives and correct antithrombotic therapy. Patients whose direction of care was palliative and patients with documented contraindication to secondary prophylactics were excluded.ResultsOver four months, 136 patients presented with acute ischaemic stroke and 11 patients had a haemorrhagic stroke. 49 ischaemic stroke patients had atrial fibrillation. Stroke unit access was higher following its introduction in 2018 compared to 2017 (97% vs 76%, respectively). Similar findings were noted for patients with atrial fibrillation who received oral anticoagulants on discharge (90% vs 50%) and patients discharged on antihypertensives (95% vs 80%).ConclusionUse of a clinical support platform in managing acute stroke is an intervention that improves stroke care.ReferencesUrimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. European Stroke Journal 2017;2(4):287–307. https://doi.org/10.1177/2396987317735426Sandercock P, Gubitz G, Foley P. Antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2003;2: CD000029. Google ScholarKwan J, Sandercock P. In-hospital care pathways for stroke. Cochrane Database Syst Rev2004;4: CD002924. Google ScholarSaxena R, Koudstaal PJ. Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack. Cochrane Database Syst Rev 2004;4: CD000187. Google ScholarGoyal M, Menon BK, van Zwam WH. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trial. Lancet 2016;387:1723–1731. Google Scholar | Crossref | Medline | ISIMiddleton S, McElduff P, Ward J. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011;378:1699–1706. Google Scholar | Crossref | Medline | ISI

Dual Effects of Chinese Herbal Medicines on Angiogenesis in Cancer and Ischemic Stroke Treatments: Role of HIF-1 Network.

Hypoxia-inducible factor-1 (HIF-1)–induced angiogenesis has been involved in numerous pathological conditions, and it may be harmful or beneficial depending on the types of diseases. Exploration on angiogenesis has sparked hopes in providing novel therapeutic approaches on multiple diseases with high mortality rates, such as cancer and ischemic stroke. The HIF-1 pathway is considered to be a major regulator of angiogenesis. HIF-1 seems to be involved in the vascular formation process by synergistic correlations with other proangiogenic factors in cancer and cerebrovascular disease. The regulation of HIF-1–dependent angiogenesis is related to the modulation of HIF-1 bioactivity by regulating HIF-1α transcription or protein translation, HIF-1α DNA binding, HIF-1α and HIF-1α dimerization, and HIF-1 degradation. Traditional Chinese herbal medicines have a long history of clinical use in both cancer and stroke treatments in Asia. Growing evidence has demonstrated potential proangiogenic benefits of Chinese herbal medicines in ischemic stroke, whereas tumor angiogenesis could be inhibited by the active components in Chinese herbal medicines. The objective of this review is to provide comprehensive insight on the effects of Chinese herbal medicines on angiogenesis by regulating HIF-1 pathways in both cancer and ischemic stroke.

‘HINTS’ At The Front Door: An Acute Stroke Service Quality Improvement Project

Background/Aims Differential diagnosis of acute vertigo syndrome is challenging. In the acute medical setting, it is difficult to ascertain whether a person has definite peripheral vestibular pathology or a posterior circulation stroke. Mismanagement of these groups within our service is costly, with regards to correct medical input, MRI scan use and bed use within acute stroke services and the hospital setting. Research has demonstrated that the Head Impulse, Nystagmus, and Test of Skew (HINTS) test is efficacious, specific and sensitive in non-UK countries in determining if acute vertigo patients have dangerous (stroke) or benign (peripheral vestibular) pathology. It is not widely used in the UK. This may be due to well-known themes in implementation evidence such as cultural and clinician factors, as well as the lengthy time it takes to embed research into clinical settings. Methods We have started exploring, using Plan Do Study Act cycles, if the HINTS test can be successfully used in a large acute stroke service and the quality improvement effects this may have for patients (correct diagnosis, education/management and follow-up), financially to the Trust (efficient use of MRI scanning) and to the Stroke Pathway (effective bed use/acute medical management). Results Early results in round one of the quality improvement plan show that HINTS is a feasible bedside test to complete with 100% accuracy in the patients it was used on within the acute stroke pathway. This involved one stroke consultant and the patients' diagnosis with HINTS was assessed against routine follow-up MRI as appropriate. HINTS training has now been provided to all the stroke consultant and registrar team, A&amp;E registrars and A&amp;E advanced clinical practitioners, to senior physiotherapists in the acute stroke pathway and to the stroke alert nurses. Data gathering has commenced for round two, focusing further on bed use effects, as well as consideration of staff satisfaction with HINTS, and development of a recommended pathway for acute vertigo syndrome patients.

Pre-hospital stroke recognition in a UK centralised stroke system: a qualitative evaluation of current practice.

Background:A significant number of patients conveyed via ambulance to hyper acute stroke units (HASU) with suspected stroke have other diagnoses. This may delay treatment for non-stroke patients and cause burden to stroke teams. The Greater Manchester (GM) Connected Health Cities (CHC) stroke project links historical North West Ambulance Service NHS Trust (NWAS) data with Salford Royal Hospital electronic data to study stroke pathway compliance and accuracy of paramedic diagnosis and aims to use these data to improve pre-hospital clinicians’ accurate recognition of stroke through development of service improvement innovations. We report on supplementary qualitative work required to understand stroke recognition from the pre-hospital clinician’s perspective.Methods:Focus groups and semi-structured interviews were conducted with pre-hospital clinicians of various grades, working in the GM area of NWAS. Focus groups and interviews were audio recorded and transcribed verbatim. We used thematic analysis informed by normalisation process theory (NPT) to analyse the data. This theory helps us to understand how innovations are developed, implemented and sustained into healthcare practice.Results:Sixteen pre-hospital clinicians took part in two focus groups, one dyad interview and five one-to-one interviews. Analysis identified that respondents were unaware of false positive stroke rates entering onto the stroke pathway. Pre-hospital clinicians receive limited feedback from jobs and this impedes their ability to learn from their experiences. Respondents reported difficulty in ruling out stroke in certain patient cohorts and difficulty in recognising differential diagnoses. They expressed a lack of confidence to rule out stroke in the pre-hospital setting. They also expressed greater concern for ‘missed strokes’.Conclusion:The qualitative findings support the development of innovations to improve accurate recognition of stroke in the pre-hospital setting.An enhanced FAST tool, better relations with HASU clinicians, feedback and education on the stroke pathway and differential diagnoses were all considered useful to improve accurate stroke recognition.

P.115 Saskatchewan experience with mechanical thrombectomy under general anaesthesia

Background: While recent clinical trials have demonstrated immense efficacy of mechanical thrombectomy (MT) in the setting of acute stroke, there remains debate over the safety in performing this procedure under general anesthesia (GA). In the Saskatchewan Acute Stroke Pathway, all patients presenting with LVO have endovascular thrombectomy performed under GA. Methods: Data was retrospectively reviewed on 108 consecutive LVO in 2016-2017. All MT were done under GA. Anatomical location of LVO, pre-MT ASPECTS score, post-MT TICI scores and 90-day NIHSS and mRS were recorded. Results: Of 108 LVO, 103 went on to have MT. 44 were right anterior circulation, 50 were left anterior circulation and 9 were posterior circulation. Of 94 anterior circulation strokes, 47 (50.0%), 43 (45.7%) and 4 (4.3%) had good, moderate and poor collateral circulation respectively, and the average pre-MT ASPECTS was 8.6. The average pre-MT NIHSS was 14.7. 81/90 (90.0%) achieved thrombolysis in cerebral infarction (TICI) perfusion scale grade of 2b/3 after recanalization. Average documented 90-day NIHSS was 2.4 and mRS was 2.5. Overall mortality was 21/103 (20.4%). Conclusions: In the Saskatchewan acute stroke pathway, general anesthesia is a safe modality for MT. This adds to the body of evidence supporting GA as a viable option for sedation in MT.

Modelling capacity along a patient pathway with delays to transfer and discharge

This article presents a versatile model to estimate capacity requirements along a patient pathway with delays to transfer and discharge caused by blocking after service. Blocking after service is a common property in health systems where patients requiring uninterrupted care can only leave a service when they can be admitted downstream to another. Unlike many studies, the approach appreciates both variability in arrivals and length of stay at each service point and the stochastic queuing dynamics between them. This is crucial to the understanding and identification of blockages which can present a significant source of inefficiency. The problem is framed as a continuous-time Markov chain where patient arrivals, transfers, and discharges are modelled through state transitions, with length of stay approximated by the Erlang distribution. The solution is through simulating movements around this chain by dynamically sampling the next state accessible from the neighbourhood of the current, thus bypassing the need for time-intensive manipulations of equations involving the entire transition matrix. This is packaged in easy-to-use code in free software so as to be readily available to healthcare practitioners. An example of use is illustrated for a stroke pathway reconfiguration where move to a centralised hyper-acute service is assessed.

Abstract TP172: Global Insight into Long-term Stroke Outcomes Using the Post Stroke Checklist

Objectives: There are long-term consequences following an individual suffering from a stroke. Despite clinical recommendations, there remains an absence of continued follow-up support for patients in most regions of the world. Estimates in the current literature estimate that 50% of patients are discharged without rehabilitation input and within two weeks, 50% of patients report having unmet needs. The Post Stroke Checklist (PSC) was designed for the long-term surveillance of continuing difficulties post stroke. This study aimed to evaluate international patterns of unmet needs following stroke, using the PSC. Methods: The PSC (endorsed by the World Stroke Organization and incorporated into the Canadian Stroke Best Practice Recommendations) identifies common long-term problems after stroke and appropriate referral pathways to address them. The PSC has been administered internationally including publications from Italy, Singapore and the UK’s stroke populations. This study follows this succession and trialed the PSC in an Australian (n=112) and Chinese (n=97) population at six months post stroke. Results: Between the samples (n=209), adjusted comparisons found a significantly higher proportion of unmet needs in China (mean= 4.67) compared with Australia (mean= 3.49). On the PSC, the most common unmet needs for both countries were similar including: absence of information regarding secondary prevention of stroke, cognitive difficulties and difficulties participating in life activities. The proportions affected on the PSC items differed between the two countries; with significantly greater difficulties in daily living activities, mobility, mood changes for China (p&lt;.05). In Australia, greater incidences were reported for spasticity, incontinence (p&lt;.05) and communication. The paper will also contrast these results with the other published international studies. Conclusion: Recording long-term functional disability post stroke highlights specific unmet needs and can encourage better support for community follow-up from governments, funding agencies and clinical programs. Providing international perspectives on these outcomes can also inspire changes in the post-hospital phase where pathways for treatment remain disjointed.

Abstract TP487: Data Dashboard: Making the Electronic Medical Record Work for You

Background: Stroke care is becoming increasingly complex in the 21st century. In order to assure optimal patient outcomes, our health network developed a stroke care pathway based on evidence-based practices and expert consensus. Overall goals for the project include increased adherence to practice standards and defined process metrics. This project is part of a larger institutional initiative for specific disease states. An integral aspect of the project was the development and implementation of a dashboard allowing for a global view of the stroke population as well as the ability to drill down to the patient or provider level. Purpose: The purpose of the dashboard is to use data to evaluate trends and develop data driven interventions. This tool is available to key stakeholders including administration, quality, program leadership and care providers. Methods: The pathway initiative is a collaboration between quality, clinical, and data analytic teams. It used a multidisciplinary approach and included input from services throughout the care continuum. Clinical pathways for stroke alert, reperfusion, neurointerventional care, and nursing care were developed and recently launched. The dashboard auto-populates from discreet fields within the electronic medical record. It is an informational tool that allows for data transparency through the use of interactive charts and graphs which provides temporal trending. Results: Utilization of this approach supports system level data trending and analysis. Preliminary results demonstrate improved provider engagement, reduction in variability in several care processes, and data transparency through accessible real-time reporting. Conclusions: Disease specific dashboards using automatic data feeds from the electronic medical record allow for evaluation of program efficiencies, population trends, and provider level data without additional manual abstraction or analysis. Evaluating data in real time allows for identification of variations in practice, real-time interventions targeting identified variances, as well as determining the effectiveness of interventions on quality and cost of care.

Abstract TP374: Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, estimated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In January 2017, length of stay (LOS) peaked at 5.25 days, as did variable and total cost/case (Table). In fiscal year 2017 the 30-d readmission rate was 9% and the mortality rate was 12%. Compliance with stroke admission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. Pathways are discussed in stroke multidisciplinary rounds and rapid discharge rounds daily to ensure compliance and identify opportunities for improvement. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 6/2018 and compared it the 1/2017 report. Results: A total of 83 cases where available for 1/2017 and of 456 for 12/2017 through 6/2018. There was a reduced LOS by 10% (4.74 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d readmission rate to 6%, and reduced the mortality rate to 9%. Case mix index was 6% higher at 1.2753 (vs. 1.2055 previously). Order set compliance improved to 91% (Table). Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost ¼ reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates.

Abstract TP497: The Development and Implementation of a Pediatric Stroke Pathway

Introduction: Diagnostic delay is a common difficulty in pediatric stroke care, driven by poor recognition, non-specific symptoms, and difficulty obtaining magnetic resonance imaging (MRI). In prior studies, pediatric stroke algorithms improved recognition and decreased diagnostic delay. Our hospital recently developed a pediatric stroke care guideline incorporating a fast MRI protocol. This study presents the process of algorithm development, barriers to implementation, and effects of the guideline on stroke care. Methods: Representatives were identified from neurology, critical care, cardiology, emergency medicine, hematology, nursing, pharmacy, radiology and quality improvement. The group was surveyed to identify algorithm goals and barriers to implementation. An algorithm and order sets were developed to provide children with an acute focal neurologic deficit immediate neuroprotective care and urgent MRI. New MRI workflows, metal screening protocols, and a rapid MRI sequence (including diffusion and gradient echo) that did not require sedation were implemented. Results: Between October 2017 and June 2018, 55 patients were treated via the new pathway. Median time from presentation to our hospital to diagnostic imaging decreased from 223 minutes to 86 minutes post-algorithm. 20% of children were diagnosed with acute arterial ischemic stroke (AIS). Other diagnoses included migraine (30.9%) and seizure (16.4%). All children with AIS were admitted to the intensive care unit, while no children with migraine or a functional disorder were. Conclusions: This study provides a unique description of the steps involved in development and implementation of a pediatric stroke pathway. Implementation of the algorithm decreased time to diagnosis and standardized early treatment. Stroke mimics were common; however, use of the pathway prevented unnecessary admission of children ultimately found to have benign diagnoses.

Abstract WP508: Improved Access to Stroke Care in Saskatchewan Canada

Background: The province of Saskatchewan, Canada represents a large geographic territory with 1.2 million residents. Approximately 2000 Saskatchewan residents per year are hospitalized due to stroke, with care being provided at a variety of facilities. Method: The Saskatchewan Acute Stroke Pathway (ASP) was established to implement Canadian Stroke Best Practice Recommendations (CSBPR) province wide. Recommendations included: creation of primary and comprehensive stroke centers, expansion of emergency medical service (EMS) stroke alert bypass window, increased use of telehealth technologies, twenty-four-hour access to computer tomography and angiography, standardized assessment, and diagnostic and treatment tools that integrate best practice guidelines into workflow. All stroke centres are accountable to report key metrics. Results: A significant improvement in access to acute stroke care was achieved. Eight primary stroke centres (PSC) and 1 comprehensive stroke centre (CSC) were established, and a 12 hour EMS bypass window was implemented. EMS adopted the FAST tool to correctly identify stroke patients 78% of the time. Sixty-eight percent of patients arrived at the stroke centre within 4.5 hours of symptom onset, in 2016. The median provincial door to needle time decreased from 82 minutes to 66 minutes. Pathway implementation saw an increase in mechanical thrombectomy from 42, in 2016 to 70 per year in 2017. Conclusion: Standard processes were adopted by all stroke centers. Lower volume centres continue to experience challenges in meeting CSBPRs resulting in ongoing improvement work. The primary limitation has been resistance to CTA and limited use of existing telestroke resources. Transfer of patients requiring endovascular therapy has improved provincial mechanical thrombectomy numbers to 58 patients per 1 million population. Further process improvements are focusing on increasing access to this service from more remote centers. Our results show that the implementation of a comprehensive provincial acute stroke pathway leads to significant improvements in access to optimal care.

Hypothermia treatment ameliorated cyclin-dependent kinase 5-mediated inflammation in ischemic stroke and improved outcomes in ischemic stroke patients

OBJECTIVES:The inflammatory response is a key mechanism of neuronal damage and loss during acute ischemic stroke. Hypothermia has shown promise as a treatment for ischemic stroke. In this study, we investigated the molecular signaling pathways in ischemic stroke after hypothermia treatment.METHODS:Cyclin-dependent kinase 5 (CDK5) was overexpressed or silenced in cultured cells. Nuclear transcription factor-κB (NF-κB) activity was assessed by measurement of the luciferase reporter gene. An ischemic stroke model was established in Sprague-Dawley (SD) rats using the suture-occluded method. Animals were assigned to three groups: sham operation control, ischemic stroke, and ischemic stroke + hypothermia treatment groups. Interleukin 1β (IL-1β) levels in the culture supernatant and blood samples were assessed by ELISA. Protein expression was measured by Western blotting.RESULTS:In HEK293 cells and primary cortical neuronal cultures exposed to hypothermia, CDK5 overexpression was associated with increased IL-1β, caspase 1, and NF-κB levels. In both a murine model of stroke and in patients, increased IL-1β levels were observed after stroke, and hypothermia treatment was associated with lower IL-1β levels. Furthermore, hypothermia-treated patients showed significant improvement in neurophysiological functional outcome.CONCLUSIONS:Overall, hypothermia offers clinical benefit, most likely through its effects on the inflammatory response.

Towards an asset-based approach to promoting and sustaining well-being for people with aphasia and their families: an international exploratory study

ABSTRACTBackground: There is growing interest in interventions that promote positive outcomes and well-being for people with aphasia (PWA) and their families, but provision is inconsistent. An asset-based approach, based on the theory of salutogenesis, focuses on what makes you well rather than ill. This approach has been used successfully across a variety of research fields, including health and social care research and practice, and has the potential to provide coherent strategies to support people living successfully with aphasia.Aim: To explore the relevance and potential of an asset-based approach to promoting and sustaining well-being for PWA and their families, across contexts and cultures.Methods & procedures: Exploratory case studies were carried out in the United Kingdom (UK), Norway, Israel, Ireland, and Denmark in a variety of settings. Following an interpretative paradigm, we used qualitative methods including: interviews; appreciative inquiry; group discussions; and participatory action research. 95 PWA and 25 family members were asked to identify assets within themselves and their communities that promote, sustain and maintain well-being, by responding to: “What makes you feel good/well/healthy?” Data were analysed using thematic analysis.Outcomes & results: An asset-based approach proved to be a powerful means for PWA and family members to explore what helps them live well with aphasia. Key themes were identified: (1) personal journey; (2) helping others; (3) connecting to self; (4) connecting to others; (5) recreation; and (6) personal attributes. Self-identification of assets, within the person and their community, and connections to these, helped PWA and their family members to maintain well-being, overcome barriers and regain confidence. Using this approach, focusing on the person’s recognition, activation and mobilisation of assets, could enhance the person’s understanding and restore meaning around the stroke and onset of aphasia.Conclusion: This novel exploratory research demonstrates the relevance and potential across diverse cultural contexts of taking an asset-based approach to promoting and sustaining well-being for PWA and their families. Focusing on maintaining connections to these assets and developing meaning around the event, could prevent some of the negative sequela of stroke. The “patient–professional” relationship must transform into a collaborative partnership, with time and flexibility needed to introduce this approach. Further research should examine how service providers and PWA could develop and operationalise an asset-based approach in clinical and community settings and identify if there is an optimum timing for introducing this approach along the stroke pathway.

Necroptosis Signaling Pathways in Stroke: From Mechanisms to Therapies

It has been confirmed that apoptosis, autophagy and necrosis are the three major modes of cell death. For a long time, necrosis is regarded as a deranged or accidental cell demise. In recent years, there is evidence showing that necrotic cell death can be a well regulated and orchestrated event, which is also known as programmed cell death or “necroptosis”. Necroptosis can be triggered by a variety of external stimuli and regulated by a caspase-independent pathway. It plays a key role in the pathogenesis of some diseases including neurological diseases. In the past two decades, a variety of studies have revealed that the necroptosis related pathway is activated in stroke, and plays a crucial role in the pathogenesis of stroke. Moreover, necroptosis may serve as a potential target in the therapy of stroke because genetic or pharmacological inhibition of necroptosis has been shown to be neuroprotective in stroke in vitro and in vivo. In this review, we briefly summarize re-cent advances in necroptosis, introduce the mechanism and strategies targeting necroptosis in stroke, and finally propose some issues in the treatment of stroke by targeting necroptosis

Intravenous thrombolysis for ischemic stroke in the Veneto region: the gap between eligibility and reality.

Intravenous thrombolysis (IVT) is the treatment of choice for most patients with acute ischemic stroke. According to the recently updated guidelines, IVT should be administered in absence of absolute exclusion criteria. We aimed to assess the proportion of ischemic strokes potentially eligible and actually treated with IVT, and to explore the reasons for not administering IVT. We prospectively collected and analyzed data from 1184 consecutive ischemic stroke patients admitted to the 22 Stroke Units (SUs) of the Veneto region from September 18th to December 10th 2017. Patients were treated with IVT according to the current Italian guidelines. For untreated patients, the reasons for not administering IVT were reported by each center in a predefined model including absolute and/or relative exclusion criteria and other possible reasons. Out of 841 (71%) patients who presented within 4.5h of stroke onset, 704 (59%) had no other absolute exclusion criteria and were therefore potentially eligible for IVT according to the current guidelines. However, only 323 (27%) patients were eventually treated with IVT. Among 861 (73%) untreated patients, 480 had at least one absolute exclusion criterion, 283 only relative exclusion criteria, 56 only other reasons, and 42 a combination of relative exclusion criteria and other reasons. Our study showed that only 46% (323/704) of the potentially eligible patients were actually treated with IVT in the SUs of the Veneto region. All healthcare professionals involved in the acute stroke pathway should make an effort to bridge this gap between eligibility and reality.

Evidence and perspective for the role of the NLRP3 inflammasome signaling pathway in ischemic stroke and its therapeutic potential (Review).

Ischemic stroke is one of the main causes of death and disablement globally. The NLR family pyrin domain containing3 (NLRP3) inflammasome is established as a sensor of detecting cellular damage and modulating inflammatory responses to injury during the progress of ischemic stroke. Inhibiting or blocking the NLRP3 inflammasome at different stages, including expression, assembly, and secretion, may have great promise to improve the neurological deficits during ischemic stroke. The current review provides a comprehensive summary of the current understanding in the literature of the molecular structure, expression, and assembly of the NLRP3 inflammasome, and highlights its potential as a novel therapeutic target for ischemic stroke.

The Neuroprotective Roles of Sonic Hedgehog Signaling Pathway in Ischemic Stroke.

Ischemic stroke is characterized by high morbidity, mortality and disability rate worldwide. Because of its complexity in pathogenesis and lack of effective therapeutic strategies and drugs, great breakthrough has not yet been made in the treatment of cerebral ischemic stroke. Therefore, to explore a more effective and safer therapeutic strategy for cerebral ischemic stroke has been the focus of numerous researchers. Neuroprotective effects of sonic hedgehog (Shh) signaling pathway in ischemic stroke have been reported in recent studies, but have not been fully elucidated. In our review, we elaborate the roles of Shh signaling in ischemic stroke from different aspects, including oxidative stress, excitotoxicity, neuroinflammation, apoptosis, angiogenesis, neuroplasticity, neurogenesis, astrogliosis and oligodendrogenesis. Meanwhile, Shh signaling based therapeutic approaches for cerebral ischemic stroke are also included in our review. We hope it will benefit the readers to better understand the roles of Shh signaling pathway in cerebral ischemic stroke and provide more comprehensive insights for basic research and novel strategies for the clinical treatment of cerebral ischemic stroke.