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Sample records for acute stroke unenhanced

  1. Automated segmentation of brain ventricles in unenhanced CT of patients with ischemic stroke

    NASA Astrophysics Data System (ADS)

    Qian, Xiaohua; Wang, Jiahui; Li, Qiang

    2013-02-01

    We are developing an automated method for detection and quantification of ischemic stroke in computed tomography (CT). Ischemic stroke often connects to brain ventricle, therefore, ventricular segmentation is an important and difficult task when stroke is present, and is the topic of this study. We first corrected inclination angle of brain by aligning midline of brain with the vertical centerline of a slice. We then estimated the intensity range of the ventricles by use of the k-means method. Two segmentation of the ventricle were obtained by use of thresholding technique. One segmentation contains ventricle and nearby stroke. The other mainly contains ventricle. Therefore, the stroke regions can be extracted and removed using image difference technique. An adaptive template-matching algorithm was employed to identify objects in the fore-mentioned segmentation. The largest connected component was identified and considered as the ventricle. We applied our method to 25 unenhanced CT scans with stroke. Our method achieved average Dice index, sensitivity, and specificity of 95.1%, 97.0%, and 99.8% for the entire ventricular regions. The experimental results demonstrated that the proposed method has great potential in detection and quantification of stroke and other neurologic diseases.

  2. Imaging acute ischemic stroke.

    PubMed

    González, R Gilberto; Schwamm, Lee H

    2016-01-01

    Acute ischemic stroke is common and often treatable, but treatment requires reliable information on the state of the brain that may be provided by modern neuroimaging. Critical information includes: the presence of hemorrhage; the site of arterial occlusion; the size of the early infarct "core"; and the size of underperfused, potentially threatened brain parenchyma, commonly referred to as the "penumbra." In this chapter we review the major determinants of outcomes in ischemic stroke patients, and the clinical value of various advanced computed tomography and magnetic resonance imaging methods that may provide key physiologic information in these patients. The focus is on major strokes due to occlusions of large arteries of the anterior circulation, the most common cause of a severe stroke syndrome. The current evidence-based approach to imaging the acute stroke patient at the Massachusetts General Hospital is presented, which is applicable for all stroke types. We conclude with new information on time and stroke evolution that imaging has revealed, and how it may open the possibilities of treating many more patients. PMID:27432672

  3. Acute Ischemic Stroke Intervention.

    PubMed

    Khandelwal, Priyank; Yavagal, Dileep R; Sacco, Ralph L

    2016-06-01

    Acute ischemic stroke (AIS) is the leading cause of disability worldwide and among the leading causes of mortality. Although intravenous tissue plasminogen activator (IV-rtPA) was approved nearly 2 decades ago for treatment of AIS, only a minority of patients receive it due to a narrow time window for administration and several contraindications to its use. Endovascular approaches to recanalization in AIS developed in the 1980s, and recently, 5 major randomized trials showed an overwhelming superior benefit of combining endovascular mechanical thrombectomy with IV-rtPA over IV-rtPA alone. In this paper, we discuss the evolution of catheter-based treatment from first-generation thrombectomy devices to the game-changing stent retrievers, results from recent trials, and the evolving stroke systems of care to provide timely access to acute stroke intervention to patients in the United States. PMID:27256835

  4. [Cerebrolysin for acute ischemic stroke].

    PubMed

    iganshina, L E; Abakumova, T R

    2013-01-01

    The review discusses existing evidence of benefits and risks of cerebrolysin--a mixture of low-molecular-weight peptides and amino acids derived from pigs' brain tissue with proposed neuroprotective and neurotrophic properties, for acute ischemic stroke. The review presents results of systematic search and analysis of randomised clinical trials comparing cerebrolysin with placebo in patients with acute ischemic stroke. Only one trial was selected as meeting quality criteria. No difference in death and adverse events between cerebrolysin and placebo was established. The authors conclude about insufficiency of evidence to evaluate the effect of cerebrolysin on survival and dependency in people with acute ischemic stroke. PMID:23805635

  5. [Therapy of acute ischemic stroke].

    PubMed

    Sobesky, J

    2009-11-01

    New diagnostic and therapeutic developments have led to an innovative approach to stroke therapy. The slogan "time is brain" emphasizes that stroke is a medical emergency comparable to myocardial infarction. The stroke unit conception is an evidence based therapy for all stroke patients and improves outcome significantly. The monitoring of vital signs and the management of stroke specific complications are highly effective. Early secondary prophylaxis reduces the risk of recurrence. The effect of CT based thrombolysis within the time window of 4,5 h has been substantiated by current data. Stroke MRI holds the promise for an improved therapy by patient stratification and by opening the time window. Interventional recanalisation, vascular interventions and hemicraniectomy complement the therapeutic options in the acute phase of stroke. PMID:19838656

  6. Unenhanced CT for the evaluation of acute ureteric colic: the essential pictorial guide.

    PubMed

    Kennish, Steven J; Wah, Tze M; Irving, Henry C

    2010-07-01

    Acute ureteric colic is a common emergency, often dealt with by the emergency physician or general practitioner and referred on to the urologist. Unenhanced CT of the kidneys, ureters and bladder (CTKUB) is the 'gold standard' imaging investigation for establishing a diagnosis and guiding management. An appreciation of the CTKUB signs, which support or refute a diagnosis of ureteric colic, is highly valuable to the clinician when making a urological referral, and to the urologist, who must make appropriate management plans. All salient diagnostic and supportive features of ureteric colic are carefully illustrated, as are important radiological mimics, with the objectives of educating and informing the non-radiologist. Ready access to the picture archive and communication system (PACS) allows all specialists involved to interpret the radiological report with the benefit of images. A stone within the ureter may not always be readily apparent. Soft tissue rim sign around a calcific focus is an important indicator of a ureteric stone, whereas a comet tail sign suggests a phlebolith (a calcified venous thrombosis), a radiological mimic of a ureteric stone. Numerous secondary signs of ureteric obstruction may be present including hydronephrosis and perinephric stranding, and can help to confirm the diagnosis. The relative diagnostic weighting of signs is discussed, and a checklist is provided to assist with interpretation. Unexpected alternative radiological diagnoses are also illustrated, which may have significant management consequences necessitating specialist referral. PMID:20634253

  7. Recovery Potential After Acute Stroke

    PubMed Central

    Seitz, Rüdiger J.; Donnan, Geoffrey A.

    2015-01-01

    In acute stroke, the major factor for recovery is the early use of thrombolysis aimed at arterial recanalization and reperfusion of ischemic brain tissue. Subsequently, neurorehabilitative training critically improves clinical recovery due to augmention of postlesional plasticity. Neuroimaging and electrophysiology studies have revealed that the location and volume of the stroke lesion, the affection of nerve fiber tracts, as well as functional and structural changes in the perilesional tissue and in large-scale bihemispheric networks are relevant biomarkers of post-stroke recovery. However, associated disorders, such as mood disorders, epilepsy, and neurodegenerative diseases, may induce secondary cerebral changes or aggravate the functional deficits and, thereby, compromise the potential for recovery. PMID:26617568

  8. [Thrombolytic treatment of acute stroke].

    PubMed

    Amiri, H; Hacke, W; Bösel, J

    2011-11-01

    Ischemic stroke is a medical emergency and must be treated as quickly as possible according to the "time-is-brain" concept. At present, intravenous administration of recombinant tissue plasminogen activator (rt-PA) within the first 4.5 h from stroke onset is the only effective treatment but is currently still only approved within the first 3 h from onset of symptoms (0.9 mg/kg body weight, maximum dose 90 mg, 10% of the cumulative dose as bolus, remaining 90% subsequently infused within 60 min). The therapeutic effect of magnetic resonance imaging (MRI) based thrombolytic therapy beyond the 4.5 h time window remains to be proven. Proximal occlusions of the middle cerebral artery can be treated successfully within the first 6 h from stroke onset by catheter-based intra-arterial administration of plasminogen activator leading to a significant improvement of outcome. Acute basilar artery occlusion should be treated in specialized centres using intra-arterial application of urokinase, rt-PA or mechanical recanalization but intravenous thrombolysis beyond the 3 h window is an acceptable alternative. PMID:21922224

  9. Prehospital care of the acute stroke patient.

    PubMed

    Rajajee, Venkatakrishna; Saver, Jeffrey

    2005-06-01

    Emergency medical services (EMS) is the first medical contact for most acute stroke patients, thereby playing a pivotal role in the identification and treatment of acute cerebrovascular brain injury. The benefit of thrombolysis and interventional therapies for acute ischemic stroke is highly time dependent, making rapid and effective EMS response of critical importance. In addition, the general public has suboptimal knowledge about stroke warning signs and the importance of activating the EMS system. In the past, the ability of EMS dispatchers to recognize stroke calls has been documented to be poor. Reliable stroke identification in the field enables appropriate treatment to be initiated in the field and potentially inappropriate treatment avoided; the receiving hospital to be prenotified of a stroke patient's imminent arrival, rapid transport to be initiated; and stroke patients to be diverted to stroke-capable receiving hospitals. In this article we discuss research studies and educational programs aimed at improving stroke recognition by EMS dispatchers, prehospital personnel, and emergency department (ED) physicians and how this has impacted stroke treatment. In addition public educational programs and importance of community awareness of stroke symptoms will be discussed. For example, general public's utilization of 911 system for stroke victims has been limited in the past. However, it has been repeatedly shown that utilization of the 911 system is associated with accelerated arrival times to the ED, crucial to timely treatment of stroke patients. Finally, improved stroke recognition in the field has led investigators to study in the field treatment of stroke patients with neuroprotective agents. The potential impact of this on future of stroke treatment will be discussed. PMID:16194754

  10. Benchmarks for acute stroke care delivery

    PubMed Central

    Hall, Ruth E.; Khan, Ferhana; Bayley, Mark T.; Asllani, Eriola; Lindsay, Patrice; Hill, Michael D.; O'Callaghan, Christina; Silver, Frank L.; Kapral, Moira K.

    2013-01-01

    Objective Despite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators. Design Nine key acute stroke quality indicators were selected from the Canadian Stroke Best Practice Performance Measures Manual. Participants A population-based retrospective sample of patients discharged from 142 hospitals in Ontario, Canada, between 1 April 2008 and 31 March 2009 (N = 3191) was used to calculate hospital rates of performance and benchmarks. Intervention The Achievable Benchmark of Care (ABC™) methodology was used to create benchmarks based on the performance of the upper 15% of patients in the top-performing hospitals. Main Outcome Measures Benchmarks were calculated for rates of neuroimaging, carotid imaging, stroke unit admission, dysphasia screening and administration of stroke-related medications. Results The following benchmarks were derived: neuroimaging within 24 h, 98%; admission to a stroke unit, 77%; thrombolysis among patients arriving within 2.5 h, 59%; carotid imaging, 93%; dysphagia screening, 88%; antithrombotic therapy, 98%; anticoagulation for atrial fibrillation, 94%; antihypertensive therapy, 92% and lipid-lowering therapy, 77%. ABC™ acute stroke care benchmarks achieve or exceed the consensus-based targets required by Accreditation Canada, with the exception of dysphagia screening. Conclusions Benchmarks for nine hospital-based acute stroke care quality indicators have been established. These can be used in the development of standards for quality improvement initiatives. PMID:24141011

  11. Evolving Treatments for Acute Ischemic Stroke.

    PubMed

    Zerna, Charlotte; Hegedus, Janka; Hill, Michael D

    2016-04-29

    The purpose of this article is to review advances in stroke treatment in the hyperacute period. With recent evolutions of technology in the fields of imaging, thrombectomy devices, and emergency room workflow management, as well as improvement in statistical methods and study design, there have been ground breaking changes in the treatment of acute ischemic stroke. We describe how stroke presents as a clinical syndrome and how imaging as the most important biomarker will help differentiate between stroke subtypes and treatment eligibility. The evolution of hyperacute treatment has led to the current standard of care: intravenous thrombolysis with tissue-type plasminogen activator and endovascular treatment for proximal vessel occlusion in the anterior cerebral circulation. All patients with acute ischemic stroke are in need of hyperacute secondary prevention because the risk of recurrence is highest closest to the index event. The dominant themes of modern stroke care are the use of neurovascular imaging and speed of diagnosis and treatment. PMID:27126651

  12. MR Perfusion Imaging in Acute Ischemic Stroke

    PubMed Central

    Copen, William A.; Schaefer, Pamela W.; Wu, Ona

    2011-01-01

    MR perfusion imaging offers the potential for measuring brain perfusion in acute stroke patients, at a time when treatment decisions based upon these measurements may affect outcomes dramatically. Rapid advancements in both acute stroke therapy and perfusion imaging techniques have resulted in continuing redefinition of the role that perfusion imaging should play in patient management. This review first discusses the basic pathophysiology of acute stroke, with specific attention to alterations in the various perfusion-related parameters that can be studied by MR perfusion imaging. Although these parameters are sometimes treated as somewhat interchangeable, they reveal greatly different information about brain perfusion. Therefore, subsequent discussion of the utility of different kinds of perfusion images focuses on the differences between them, as well as important artifacts that can complicate their interpretation. Finally, research on the continually evolving role of MR perfusion imaging in acute stroke care is summarized. PMID:21640299

  13. Physiologic imaging in acute stroke: Patient selection

    PubMed Central

    Morgan, Clinton D; Stephens, Marcus; Zuckerman, Scott L; Waitara, Magarya S; Morone, Peter J; Dewan, Michael C

    2015-01-01

    Treatment of acute stroke is changing, as endovascular intervention becomes an important adjunct to tissue plasminogen activator. An increasing number of sophisticated physiologic imaging techniques have unique advantages and applications in the evaluation, diagnosis, and treatment-decision making of acute ischemic stroke. In this review, we first highlight the strengths, weaknesses, and possible indications for various stroke imaging techniques. How acute imaging findings in each modality have been used to predict functional outcome is discussed. Furthermore, there is an increasing emphasis on using these state-of-the-art imaging modalities to offer maximal patient benefit through IV therapy, endovascular thrombolytics, and clot retrieval. We review the burgeoning literature in the determination of stroke treatment based on acute, physiologic imaging findings. PMID:26063695

  14. Magnetic Resonance Imaging of Acute Stroke.

    PubMed

    Nael, Kambiz; Kubal, Wayne

    2016-05-01

    Neuroimaging plays a critical role in the management of patients with acute stroke syndrome, with diagnostic, therapeutic, and prognostic implications. A multiparametric magnetic resonance (MR) imaging protocol in the emergency setting can address both primary goals of neuroimaging (ie, detection of infarction and exclusion of hemorrhage) and secondary goals of neuroimaging (ie, identifying the site of arterial occlusion, tissue characterization for defining infarct core and penumbra, and determining stroke cause/mechanism). MR imaging provides accurate diagnosis of acute ischemic stroke (AIS) and can differentiate AIS from other potential differential diagnoses. PMID:27150320

  15. Accuracy of Unenhanced MR Imaging in the Detection of Acute Appendicitis: Single-Institution Clinical Performance Review.

    PubMed

    Petkovska, Iva; Martin, Diego R; Covington, Matthew F; Urbina, Shannon; Duke, Eugene; Daye, Z John; Stolz, Lori A; Keim, Samuel M; Costello, James R; Chundru, Surya; Arif-Tiwari, Hina; Gilbertson-Dahdal, Dorothy; Gries, Lynn; Kalb, Bobby

    2016-05-01

    Purpose To determine the accuracy of unenhanced magnetic resonance (MR) imaging in the detection of acute appendicitis in patients younger than 50 years who present to the emergency department with right lower quadrant (RLQ) pain. Materials and Methods The institutional review board approved this retrospective study of 403 patients from August 1, 2012, to July 30, 2014, and waived the informed consent requirement. A cross-department strategy was instituted to use MR imaging as the primary diagnostic modality in patients aged 3-49 years who presented to the emergency department with RLQ pain. All MR examinations were performed with a 1.5- or 3.0-T system. Images were acquired without breath holding by using multiplanar half-Fourier single-shot T2-weighted imaging without and with spectral adiabatic inversion recovery fat suppression without oral or intravenous contrast material. MR imaging room time was measured for each patient. Prospective image interpretations from clinical records were reviewed to document acute appendicitis or other causes of abdominal pain. Final clinical outcomes were determined by using (a) surgical results (n = 77), (b) telephone follow-up combined with review of the patient's medical records (n = 291), or (c) consensus expert panel assessment if no follow-up data were available (n = 35). Logistic regression analysis was performed to evaluate the sensitivity and specificity of MR imaging in the detection of acute appendicitis, and corresponding 95% confidence intervals were determined. Results Of the 403 patients, 67 had MR imaging findings that were positive for acute appendicitis, and 336 had negative findings. MR imaging had a sensitivity of 97.0% (65 of 67) and a specificity of 99.4% (334 of 336). The mean total room time was 14 minutes (range, 8-62 minutes). An alternate diagnosis was offered in 173 (51.5%) of 336 patients. Conclusion MR imaging is a highly sensitive and specific test in the evaluation of patients younger than 50 years

  16. First aid in acute stroke

    PubMed Central

    Reitmayer, Michael; Raschick, Marlitt; Erbguth, Frank; Neundörfer, Bernhard; Babjar, Elisabeth

    2006-01-01

    Objective First aid training is well established to teach the public how to recognize a medical emergency and take appropriate action. Though it is now handled as a high priority emergency stroke is not among the main topics of first aid. We investigated if first aid training may be useful for enhancing stroke awareness. Methods We developed a 15–20 minute teaching session about stroke as an emergency including signs and symptoms and first hands-on measures. The session was integrated in standard first aid training of the St John Ambulance of Germany and participants were asked to fill out a questionnaire regarding their knowledge about stroke. Subjects were questioned before the stroke lesson and again at the end of the training. Results 532 participants of the training responded to the questionnaire (mean age 28.6 years, 53.6% male). There was a significant increase in proportion of subjects correctly defining what stroke is (28.4% vs. 69.9%, p < 0,001) and in the mean number of stroke symptoms listed (1.52 vs. 3.35, p < 0,001) by the participants. The number of participants unable to list at least 1 symptom decreased significantly (12.8 vs. 3.6%, p<0.001). Conclusions In our study a teaching lesson integrated in first aid training was effective in improving stroke knowledge of participants. First aid training should be used for stroke information complementary to other activities like mass media campaigns as it is effective, could reach younger people that are not primarily interested in stroke and provides connections to other health topics. PMID:16896518

  17. Flow Augmentation in Acute Ischemic Stroke.

    PubMed

    Yadollahikhales, Golnaz; Borhani-Haghighi, Afshin; Torabi-Nami, Mohammad; Edgell, Randall; Cruz-Flores, Salvador

    2016-01-01

    There is an urgent need for additional therapeutic options for acute ischemic stroke considering the major pitfalls of the options available. Herein, we briefly review the role of cerebral blood flow, collaterals, vasoreactivity, and reperfusion injury in acute ischemic stroke. Then, we reviewed pharmacological and interventional measures such as volume expansion and induced hypertension, intra-aortic balloon counterpulsation, partial aortic occlusion, extracranial-intracranial carotid bypass surgery, sphenopalatine ganglion stimulation, and transcranial laser therapy with regard to their effects on flow augmentation and neuroprotection. PMID:25475112

  18. Therapeutic hypothermia for acute ischemic stroke.

    PubMed

    Froehler, Michael T; Ovbiagele, Bruce

    2010-04-01

    Intravenous recombinant tissue plasminogen activator remains the only US FDA-approved treatment for acute ischemic stroke. However, the very limited time window for its administration restricts its usefulness. Furthermore, it is becoming increasingly clear that, given the numerous pathways via which cerebral ischemia causes cell death, the capacity to inhibit multiple mechanisms simultaneously may provide additive or synergistic beneficial clinical effects for stroke patients. Although no clinical trials have yet investigated the efficacy of therapeutic hypothermia in focal cerebral ischemia, its pleiotropic neuroprotective actions, positive results in preclinical studies, as well as proven enhancement of neurologic outcomes in survivors of cardiac arrest and newborns with hypoxic-ischemic encephalopathy, make this neuroprotective strategy highly promising. This review presents an overview of the potential role of hypothermia in the treatment of acute ischemic stroke and discusses ischemic cell death pathophysiology, neuroprotective mechanisms of hypothermia, methodologies employed for the induction of hypothermia, results from animal models of cerebral ischemia, and finally, currently available clinical trial data. Two valuable lessons learned thus far are that first, rapid induction of hypothermia is key and is best accomplished with a combination of ice-cold saline infusion and the use of endovascular cooling devices, and second, that shivering can be overcome with aggressive anti-shivering protocols including meperidine, buspirone and surface warming. We await the results of clinical trials to determine the utility of therapeutic hypothermia in acute ischemic stroke. If proven efficacious, hypothermia would be a welcome complement to established reperfusion therapies for ischemic stroke patients. PMID:20397832

  19. Radiological strategy in acute stroke in children.

    PubMed

    Paonessa, Amalia; Limbucci, Nicola; Tozzi, Elisabetta; Splendiani, Alessandra; Gallucci, Massimo

    2010-04-01

    The aim of the study was to estimate the preponderance of patterns of pediatric stroke, ischemic or hemorrhagic, their etiologies and the correct diagnostic protocol for acute management. Forty-one consecutive pediatric patients (age range 5-16 years) with an acute stroke observed in acute phase during a 10-year period, were retrospectively evaluated. Twenty-three patients underwent magnetic resonance imaging (MRI), 3 cases were studied by computed tomography (CT) without MRI, and 15 underwent both CT and MRI studies. In 9 cases, intra-arterial digital subtraction angiography (IADSA) was performed after non-invasive preliminary assessment. Seventeen hemorrhagic (41%) and 24 ischemic (59%) strokes were found. Among hemorrhagic forms, 5 cases were due to arteriovenous malformation (AVM), 7 to cavernoma, and 2 to aneurysm. Among ischemic forms, 2 were due to sickle-cell disease, 1 to hyperomocysteinemia, 1 to moyamoya syndrome, 1 to pseudoxantoma elasticum, 3 to prothrombotic state, 1 to Fabry's disease, 1 concomitant with CO intoxication, 5 to venous sinus thrombosis, and 4 to cardio-embolic state. Etiology remains unknown in 8 cases (20.5%). This study shows a moderate prevalence of ischemic over hemorrhagic strokes. Moreover, personal experience suggests that MRI is always more informative than CT and in selected cases should be the first-choice examination in the acute phase. PMID:19216043

  20. Endothelial progenitor cells in acute ischemic stroke

    PubMed Central

    Martí-Fàbregas, Joan; Crespo, Javier; Delgado-Mederos, Raquel; Martínez-Ramírez, Sergi; Peña, Esther; Marín, Rebeca; Dinia, Lavinia; Jiménez-Xarrié, Elena; Fernández-Arcos, Ana; Pérez-Pérez, Jesús; Querol, Luis; Suárez-Calvet, Marc; Badimon, Lina

    2013-01-01

    Objectives The levels of circulating endothelial progenitor cells (EPCs) in ischemic stroke have not been studied extensively and reported results are inconsistent. We aimed to investigate the time course, the prognostic relevance, and the variables associated with EPC counts in patients with ischemic stroke at different time points. Material and methods We studied prospectively 146 consecutive patients with ischemic stroke within the first 48 h from the onset of symptoms (baseline). We evaluated demographic data, classical vascular risk factors, treatment with thrombolysis and statins, stroke etiology, National Institute of Health and Stroke Scale score and outcome (favorable when Rankin scale score 0–2). Blood samples were collected at baseline, at day 7 after stroke (n = 121) and at 3 months (n = 92). The EPC were measured by flow cytometry. Results We included 146 patients with a mean age of 70.8 ± 12.2 years. The circulating EPC levels were higher on day 7 than at baseline or at 3 months (P = 0.045). Pretreatment with statins (odds ratio [OR] 3.11, P = 0.008) and stroke etiology (P = 0.032) were predictive of EPC counts in the baseline sample. EPC counts were not associated with stroke severity or functional outcome in all the patients. However, using multivariate analyses, a better functional outcome was found in patients with higher EPC counts in large-artery atherosclerosis and small-vessel disease etiologic subtypes. Conclusions After acute ischemic stroke, circulating EPC counts peaked at day 7. Pretreatment with statins increased the levels of EPC. In patients with large-artery atherosclerosis and small-vessel disease subtypes, higher counts were related to better outcome at 3 months. PMID:24363968

  1. Stroke

    MedlinePlus

    ... to a hospital quickly to begin treatment. Acute stroke therapies try to stop a stroke while it is ... rehabilitation helps individuals overcome disabilities that result from stroke damage. Drug therapy with blood thinners is the most common treatment ...

  2. Heart Failure in Acute Ischemic Stroke

    PubMed Central

    Cuadrado-Godia, Elisa; Ois, Angel; Roquer, Jaume

    2010-01-01

    Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Due to the aging of the population it has become a growing public health problem in recent decades. Diagnosis of HF is clinical and there is no diagnostic test, although some basic complementary testing should be performed in all patients. Depending on the ejection fraction (EF), the syndrome is classified as HF with low EF or HF with normal EF (HFNEF). Although prognosis in HF is poor, HFNEF seems to be more benign. HF and ischemic stroke (IS) share vascular risk factors such as age, hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation. Persons with HF have higher incidence of IS, varying from 1.7% to 10.4% per year across various cohort studies. The stroke rate increases with length of follow-up. Reduced EF, independent of severity, is associated with higher risk of stroke. Left ventricular mass and geometry are also related with stroke incidence, with concentric hypertrophy carrying the greatest risk. In HF with low EF, the stroke mechanism may be embolism, cerebral hypoperfusion or both, whereas in HFNEF the mechanism is more typically associated with chronic endothelial damage of the small vessels. Stroke in patients with HF is more severe and is associated with a higher rate of recurrence, dependency, and short term and long term mortality. Cardiac morbidity and mortality is also high in these patients. Acute stroke treatment in HF includes all the current therapeutic options to more carefully control blood pressure. For secondary prevention, optimal control of all vascular risk factors is essential. Antithrombotic therapy is mandatory, although the choice of a platelet inhibitor or anticoagulant drug depends on the cardiac disease. Trials are ongoing to evaluate anticoagulant therapy for prevention of embolism in patients with low EF who are at

  3. Cardiac papillary fibroelastoma presenting as acute stroke

    PubMed Central

    Abbasi, Atif Saleem; Da Costa, Mark; Hennessy, Terry; Kiernan, Thomas John

    2013-01-01

    We present a case of a young woman who was initially diagnosed with acute stroke with no obvious risk factors. Preliminary investigation with transthoracic echocardiography and subsequent advanced imaging with transoesophageal echocardiography suggested the diagnosis of a benign cardiac tumour on the anterior leaflet of mitral valve. The patient underwent urgent surgical resection. Histology confirmed the diagnosis of cardiac papillary fibroelastoma. She made complete clinical recovery with no recurrence of symptoms. PMID:23761612

  4. Acute Kidney Injury is More Common in Acute Haemorrhagic Stroke in Mymensingh Medical College Hospital.

    PubMed

    Ray, N C; Chowdhury, M A; Sarkar, S R

    2016-01-01

    Acute kidney injury (AKI) is a common complication after acute stroke and is an independent predictor of both early and long-term mortality after acute stroke. Acute kidney injury is associated with increased mortality in haemorrhagic stroke patients. This cross sectional observational study was conducted in Nephrology, Neuromedicine and Medicine department of Mymensingh Medical College & Hospital, Mymensingh from July 2012 to June 2014. A total of 240 patients with newly detected acute stroke confirmed by CT scan of brain were included in this study. According to this study, 15.42% of acute stroke patients developed AKI. Among the patients with haemorrhagic stroke 21.87% developed AKI while only 13.07% patients with ischaemic stroke developed AKI. So, early diagnosis and management of AKI in patients with acute stroke especially in haemorrhagic stroke is very important to reduce the morbidity and mortality of these patients. PMID:26931240

  5. Predicting Hemorrhagic Transformation of Acute Ischemic Stroke

    PubMed Central

    Marsh, Elisabeth B.; Llinas, Rafael H.; Schneider, Andrea L.C.; Hillis, Argye E.; Lawrence, Erin; Dziedzic, Peter; Gottesman, Rebecca F.

    2016-01-01

    Abstract Hemorrhagic transformation (HT) increases the morbidity and mortality of ischemic stroke. Anticoagulation is often indicated in patients with atrial fibrillation, low ejection fraction, or mechanical valves who are hospitalized with acute stroke, but increases the risk of HT. Risk quantification would be useful. Prior studies have investigated risk of systemic hemorrhage in anticoagulated patients, but none looked specifically at HT. In our previously published work, age, infarct volume, and estimated glomerular filtration rate (eGFR) significantly predicted HT. We created the hemorrhage risk stratification (HeRS) score based on regression coefficients in multivariable modeling and now determine its validity in a prospectively followed inpatient cohort. A total of 241 consecutive patients presenting to 2 academic stroke centers with acute ischemic stroke and an indication for anticoagulation over a 2.75-year period were included. Neuroimaging was evaluated for infarct volume and HT. Hemorrhages were classified as symptomatic versus asymptomatic, and by severity. HeRS scores were calculated for each patient and compared to actual hemorrhage status using receiver operating curve analysis. Area under the curve (AUC) comparing predicted odds of hemorrhage (HeRS score) to actual hemorrhage status was 0.701. Serum glucose (P < 0.001), white blood cell count (P < 0.001), and warfarin use prior to admission (P = 0.002) were also associated with HT in the validation cohort. With these variables, AUC improved to 0.854. Anticoagulation did not significantly increase HT; but with higher intensity anticoagulation, hemorrhages were more likely to be symptomatic and more severe. The HeRS score is a valid predictor of HT in patients with ischemic stroke and indication for anticoagulation. PMID:26765425

  6. Plasma betathromboglobulin and serum fragment E in acute partial stroke.

    PubMed

    de Boer, A C; Turpie, A G; Butt, R W; Duke, R J; Bloch, R F; Genton, E

    1982-02-01

    Plasma betathromboglobulin (BTG) and serum fragment E (FgE) were measured serially by radioimmunoassay for 7 d in 67 patients admitted with acute partial stroke. Twelve patients progressed within 7 d of admission. Plasma BTG was not different from normal in patients with acute partial stroke and did not increase significantly with stroke progression. Serum FgE was elevated in patients with acute partial stroke compared with normal values, and was significantly higher in patients who progressed compared with those who remained stable. The results indicate that fibrin formation may be more important in the process of stroke progression than activation of platelets. PMID:6174141

  7. Dysphagia Management in Acute and Sub-acute Stroke

    PubMed Central

    Vose, Alicia; Nonnenmacher, Jodi; Singer, Michele L.; González-Fernández, Marlís

    2014-01-01

    Swallowing dysfunction is common after stroke. More than 50% of the 665 thousand stroke survivors will experience dysphagia acutely of which approximately 80 thousand will experience persistent dysphagia at 6 months. The physiologic impairments that result in post-stroke dysphagia are varied. This review focuses primarily on well-established dysphagia treatments in the context of the physiologic impairments they treat. Traditional dysphagia therapies including volume and texture modifications, strategies such as chin tuck, head tilt, head turn, effortful swallow, supraglottic swallow, super-supraglottic swallow, Mendelsohn maneuver and exercises such as the Shaker exercise and Masako (tongue hold) maneuver are discussed. Other more recent treatment interventions are discussed in the context of the evidence available. PMID:26484001

  8. Management of Acute Hypertensive Response in Patients With Ischemic Stroke.

    PubMed

    AlSibai, Ahmad; Qureshi, Adnan I

    2016-07-01

    High blood pressure (BP) >140/90 mm Hg is seen in 75% of patients with acute ischemic stroke and in 80% of patients with acute intracerebral hemorrhages and is independently associated with poor functional outcome. While BP reduction in patients with chronic hypertension remains one of the most important factors in primary and secondary stroke prevention, the proper management strategy for acute hypertensive response within the first 72 hours of acute ischemic stroke has been a matter of debate. Recent guidelines recommend clinical trials to ascertain whether antihypertensive therapy in the acute phase of stroke is beneficial. This review summarizes the current data on acute hypertensive response or elevated BP management during the first 72 hours after an acute ischemic stroke. Based on the potential deleterious effect of lowering BP observed in some clinical trials in patients with acute ischemic stroke and because of the lack of convincing evidence to support acute BP lowering in those situations, aggressive BP reduction in patients presenting with acute ischemic stroke is currently not recommended. While the early use of angiotensin receptor antagonists may help reduce cardiovascular events, this benefit is not necessarily related to BP reduction. PMID:27366297

  9. Dilemma in the emergency setting: hypomagnesemia mimicking acute stroke

    PubMed Central

    Rico, María; Martinez-Rodriguez, Laura; Larrosa-Campo, Davinia; Calleja, Sergio

    2016-01-01

    Background Stroke mimics may account for up to 30% of all acute stroke consultations. However, in the emergency setting, accurate diagnosis is not always possible. Methods Case report and review of the literature. Results A 73-year-old woman was admitted to the emergency department with acute aphasia and right hemiparesis. The National Institute of Health Stroke Score was 21, compatible with severe stroke, so she received thrombolysis. Laboratory testing demonstrated severe hypomagnesemia. She had been taking proton pump inhibitors for years and neuroimaging did not demonstrate signs of acute ischemic disease. After correcting the metabolic alterations with intravenous and oral supplemental magnesium, the patient was discharged asymptomatic. No further episodes have been registered to date. Conclusion Hypomagnesemia might cause acute neurological symptoms that could be confused with stroke. A careful history is essential for diagnosis but suspicion of stroke mimic should not prevent tPA administration. PMID:27354832

  10. Cardiac Arrhythmias and Abnormal Electrocardiograms After Acute Stroke.

    PubMed

    Ruthirago, Doungporn; Julayanont, Parunyou; Tantrachoti, Pakpoom; Kim, Jongyeol; Nugent, Kenneth

    2016-01-01

    Cardiac arrhythmias and electrocardiogram (ECG) abnormalities occur frequently but are often underrecognized after strokes. Acute ischemic and hemorrhagic strokes in some particular area of brain can disrupt central autonomic control of the heart, precipitating cardiac arrhythmias, ECG abnormalities, myocardial injury and sometimes sudden death. Identification of high-risk patients after acute stroke is important to arrange appropriate cardiac monitoring and effective management of arrhythmias, and to prevent cardiac morbidity and mortality. More studies are needed to better clarify pathogenesis, localization of areas associated with arrhythmias and practical management of arrhythmias and abnormal ECGs after acute stroke. PMID:26802767

  11. Endovascular treatment of acute ischemic stroke.

    PubMed

    Leslie-Mazwi, Thabele; Rabinov, James; Hirsch, Joshua A

    2016-01-01

    Endovascular thrombectomy is an effective treatment for major acute ischemic stroke syndromes caused by major anterior circulation artery occlusions (commonly referred to as large vessel occlusion) and is superior to intravenous thrombolysis and medical management. Treatment should occur as quickly as is reasonably possible. All patients with moderate to severe symptoms (National Institutes of Health stroke scale >8) and a treatable occlusion should be considered. The use of neuroimaging is critical to exclude hemorrhage and large ischemic cores. Very shortly after stroke onset (<3 hours) computed tomography (CT) and CT angiography provide sufficient information to proceed; diffusion magnetic resonance imaging (MRI) is less reliable during this early stage. After 3 hours from onset diffusion MRI is the most reliable method to define ischemic core size and should be used in centers that can offer it rapidly. Recanalization is highly effective with a stentriever or using a direct aspiration technique, with the patient awake or under conscious sedation rather than general anesthesia, if it may be performed safely. After thrombectomy the patient should be admitted to an intensive care setting and inpatient rehabilitation undertaken as soon as feasible. Patient outcomes should be assessed at 3 months, preferably using the modified Rankin score. PMID:27430469

  12. Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke.

    PubMed

    Hsieh, Fang-I; Jeng, Jiann-Shing; Chern, Chang-Ming; Lee, Tsong-Hai; Tang, Sung-Chun; Tsai, Li-Kai; Liao, Hsun-Hsiang; Chang, Hang; LaBresh, Kenneth A; Lin, Hung-Jung; Chiou, Hung-Yi; Chiu, Hou-Chang; Lien, Li-Ming

    2016-01-01

    In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010-2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006-08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States. PMID:27487190

  13. Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke

    PubMed Central

    Chern, Chang-Ming; Lee, Tsong-Hai; Tang, Sung-Chun; Tsai, Li-Kai; Liao, Hsun-Hsiang; Chang, Hang; LaBresh, Kenneth A.; Lin, Hung-Jung; Chiou, Hung-Yi; Chiu, Hou-Chang; Lien, Li-Ming

    2016-01-01

    In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010–2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006–08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States. PMID:27487190

  14. Experimental acute thrombotic stroke in baboons

    SciTech Connect

    Del Zoppo, G.J.; Copeland, B.R.; Harker, L.A.; Waltz, T.A.; Zyroff, J.; Hanson, S.R.; Battenberg, E.

    1986-11-01

    To study the effects of antithrombotic therapy in experimental stroke, we have characterized a baboon model of acute cerebrovascular thrombosis. In this model an inflatable silastic balloon cuff has been implanted by transorbital approach around the right middle cerebral artery (MCA), proximal to the take-off of the lenticulostriate arteries (LSA). Inflation of the balloon for 3 hours in six animals produced a stereotypic sustained stroke syndrome characterized by contralateral hemiparesis. An infarction volume of 3.2 +/- 1.5 cm3 in the ipsilateral corpus striatum was documented by computerized tomographic (CT) scanning at 10 days following stroke induction and 3.9 +/- 1.9 cm3 (n = 4) at 14 days by morphometric neuropathologic determinations of brain specimens fixed in situ by pressure-perfusion with 10% buffered formalin. Immediate pressure-perfusion fixation following deflation of the balloon was performed in 16 additional animals given Evans blue dye intravenously prior to the 3 hour MCA balloon occlusion. Light microscopy and transmission electron microscopy consistently confirmed the presence of thrombotic material occluding microcirculatory branches of the right LSA in the region of Evans blue stain, but not those of the contralateral corpus striatum. When autologous 111In-platelets were infused intravenously in four animals from the above group prior to the transient 3 hour occlusion of the right MCA, gamma scintillation camera imaging of each perfused-fixed whole brain demonstrated the presence of a single residual focus of 111In-platelet activity involving only the Evans blue-stained right corpus striatum. Focal right hemispheric activity was equivalent to 0.55 +/- 0.49 ml of whole blood, and the occlusion score derived from histologic examination of the microcirculation of the Evans blue-stained corpus striatum averaged 34.8 +/- 2.8.

  15. The assessment of visuo-spatial neglect after acute stroke.

    PubMed Central

    Stone, S P; Wilson, B; Wroot, A; Halligan, P W; Lange, L S; Marshall, J C; Greenwood, R J

    1991-01-01

    Forty four consecutive patients with acute hemispheric stroke and forty seven elderly controls with no neurological disease were assessed for visuo-spatial neglect, using a modified neglect test battery. Neglect was found to be equally common in patients with right hemisphere and left hemisphere stroke three days after stroke (72% versus 62%). It was more severe in those with a right hemisphere stroke and resolved more frequently in those with a left hemisphere stroke. The battery was validated against an occupational therapist's assessment of neglect on self-care tasks. The inter-observer reliability was good and it was possible to monitor changes over time with the battery. Images PMID:2056321

  16. Hepatitis C and recurrent treatment-resistant acute ischemic stroke

    PubMed Central

    Tarsia, Joseph; Dunn, Casey; Aysenne, Aimee; Shah, Basil; Moore, David F.

    2013-01-01

    Since the introduction of recombinant tissue plasminogen activator and thrombolysis, acute ischemic stroke has become a treatable disorder if the patient presents within the 4.5-hour time window. Typically, sporadic stroke is caused by atherosclerotic disease involving large or small cerebral arteries or secondary to a cardioembolic source often associated with atrial fibrillation. In the over-65-year age group, more rare causes of stroke, such as antiphospholipid syndromes, are unusual; such stroke etiologies are mostly seen in a younger age group (<55 years). Here we describe acute ischemic stroke in three patients >65 years with hepatitis C–associated antiphospholipid antibodies. We suggest that screening for antiphospholipid disorders in the older patient might be warranted, with potential implications for therapeutic management and secondary stroke prevention. PMID:23543984

  17. Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke

    PubMed Central

    Arboix, Adrià

    2015-01-01

    Timely diagnosis and control of cardiovascular risk factors is a priority objective for adequate primary and secondary prevention of acute stroke. Hypertension, atrial fibrillation and diabetes mellitus are the most common risk factors for acute cerebrovascular events, although novel risk factors, such as sleep-disordered breathing, inflammatory markers or carotid intima-media thickness have been identified. However, the cardiovascular risk factors profile differs according to the different subtypes of ischemic stroke. Atrial fibrillation and ischemic heart disease are more frequent in patients with cardioembolic infarction, hypertension and diabetes in patients with lacunar stroke, and vascular peripheral disease, hypertension, diabetes, previous transient ischemic attack and chronic obstructive pulmonary disease in patients with atherothrombotic infarction. This review aims to present updated data on risk factors for acute ischemic stroke as well as to describe the usefulness of new and emerging vascular risk factors in stroke patients. PMID:25984516

  18. Review of current and emerging therapies in acute ischemic stroke.

    PubMed

    Novakovic, R; Toth, G; Purdy, P D

    2009-07-01

    The statistics for stroke in the USA reads like a familiar ad slogan cited in most papers pertaining to acute ischemic stroke (AIS). Stroke is the third leading cause of death in the USA. While stroke ranks third among all causes of death, behind diseases of the heart and cancer, it is the leading cause of serious long-term disability in the USA.(1) Approximately 795 000 people, 87% of whom are ischemic, suffer from stroke each year in the USA.(2) That means that on average, every 40 seconds someone within the USA develops a stroke. For 2009 the combined direct and indirect cost of stroke, from hospitalization and rehabilitation to institutionalization, is estimated at $68.9 billion within the USA.(2). PMID:21994100

  19. Duration of delirium in the acute stage of stroke.

    PubMed

    Dostović, Zikrija; Smajlović, Dzevdet; Sinanović, Osman; Vidović, Mirjana

    2009-03-01

    The aim of the study was to determine duration of delirium in patients with acute stroke according to sex, age, type and localization of lesion. We assessed delirium prospectively in a sample of 233 consecutive patients with an acute (< or =4 days) stroke using the Delirium Rating Scale (DRS-R-98) and Diagnostic and Statistical Manual of Mental Disorders (DSM IV). The average duration of delirium was 4 days in patients with ischemic stroke and 3 days in patients with hemorrhagic stroke. There was no statistically significant difference in delirium duration between these two patient groups. A longer duration of delirium was recorded in women and in patients older than 65. The period of delirium was longer in patients with right hemispheric lesions. Patients did not differ according to delirium duration, sex, age, type and localization of stroke. In two thirds of patients, the symptoms of delirium completely disappeared on medicamentous treatment, while in the remaining one third of patients certain symptoms of delirium persisted at discharge (p=0.003). Mortality rate was significantly higher in patients with delirium in the acute phase of stroke than in those without delirium (p=0.009). In conclusion, delirium is a temporary manifestation in two thirds of patients in the acute phase of stroke. Patient sex and age, and type and stroke localization have no influence on delirium duration. PMID:19623866

  20. Contralateral diaphragmatic palsy in acute stroke: an interesting observation.

    PubMed

    Kumar, Sudhir; Reddy, Rajesh; Prabhakar, Subhashini

    2009-01-01

    Diaphragmatic palsy in hemiparetic stroke is not well recognized. Further, its implications on stroke outcome have not been studied. Here, we report a patient with left-sided diaphragmatic palsy due to an acute right middle cerebral artery territory infarction. The diagnosis was suspected on finding an elevated dome of the diaphragm on the left side in a routine chest radiograph and was confirmed by finding decreased movements of the left hemidiaphragm on fluoroscopic examination. We hypothesize that this condition is probably under-recognized in clinical practice and its clinical importance not well known. The pathophysiological basis of diaphragmatic palsy in acute stroke and its possible clinical implications are discussed. PMID:19881177

  1. Imaging Oxygen Metabolism In Acute Stroke Using MRI

    PubMed Central

    An, Hongyu; Ford, Andria L.; Vo, Katie D.; Liu, Qingwei; Chen, Yasheng; Lee, Jin-Moo; Lin, Weili

    2014-01-01

    The ability to image the ischemic penumbra during hyper-acute stroke promises to identify patients who may benefit from treatment intervention beyond population-defined therapeutic time windows. MR blood oxygenation level dependent (BOLD) contrast imaging has been explored in ischemic stroke. This review provides an overview of several BOLD-based methods, including susceptibility weighted imaging (SWI), R2, R2*, R2′, R2* under oxygen challenge, MR_OEF and MROMI approaches to assess cerebral oxygen metabolism in ischemic stroke. We will review the underlying pathophysiological basis of the imaging approaches, followed by a brief introduction of BOLD contrast. Finally, we will discuss the applications of the BOLD approaches in patients with ischemic stroke. BOLD-based methods hold promise for imaging tissue oxygenation during acute ischemia. Further technical refinement and validation studies in stroke patients against positron emission tomography (PET) measurements are needed. PMID:24707451

  2. Wernicke's Encephalopathy Mimicking Acute Onset Stroke Diagnosed by CT Perfusion

    PubMed Central

    Advani, Rajiv; Kurz, Kathinka D.; Kurz, Martin W.

    2014-01-01

    Background. Metabolic syndromes such as Wernicke's encephalopathy may present with a sudden neurological deficit, thus mimicking acute onset stroke. Due to current emphasis on rapid admission and treatment of acute stroke patients, there is a significant risk that these stroke mimics may end up being treated with thrombolysis. Rigorous clinical and radiological skills are necessary to correctly identify such metabolic stroke mimics, in order to avoid doing any harm to these patients due to the unnecessary use of thrombolysis. Patient. A 51-year-old Caucasian male was admitted to our hospital with suspicion of an acute stroke due to sudden onset dysarthria and unilateral facial nerve paresis. Clinical examination revealed confusion and dysconjugate gaze. Computed tomography (CT) including a CT perfusion (CTP) scan revealed bilateral thalamic hyperperfusion. The use of both clinical and radiological findings led to correctly diagnosing Wernicke's encephalopathy. Conclusion. The application of CTP as a standard diagnostic tool in acute stroke patients can improve the detection of stroke mimics caused by metabolic syndromes as shown in our case report. PMID:24716022

  3. Clinical and morphological correlations in acute ischemic stroke.

    PubMed

    Slujitoru, Anca Stefania; Enache, Andreea Lorena; Pintea, Irina Lavinia; Rolea, Elisabeta; Stocheci, Cristina Mariana; Pop, O T; Predescu, Anca

    2012-01-01

    We studied the clinical and histopathological changes in twenty-seven cases of acute ischemic stroke, aged between 65 and 75 years. All deaths occurred within 30 days after stroke. The aim of our study was to establish the clinical and histological correlations in acute ischemic stroke to detect prognostic factors. Brain lesions after acute stroke were observed in all regions. Our study describes the heterogeneity of brain injury after acute ischemic stroke with the participation of all brain components and the chronology in which these lesions develop and evolve. By histological and immunohistochemical studies, we identified neuronal, glial and vascular damage. The neurons had undergone in the area of lesion a process of necrosis, ballooning or condensation process. In the ischemic penumbra, we observed the presence of red neurons. Vascular lesions were represented by the discontinuity of capillaries, always associated with a marked perivascular edema. The following clinical and morphological correlations were established: liquefactive necrosis, astrocyte gliosis, phagocytosis phenomena are the more intense the later the death of the patient; apoptosis phenomena are the more intense the faster the death of the patient; the entire cerebral microcirculation presented microscopic modifications following the ischemic strokes, regardless of the time since the lesion occurred and the histological examination was made; the major neurological complications of the ischemic stroke - the hemorrhagic transformation phenomena, cerebral edema, were microscopically objectified, regardless of the time since the lesion occurred and the histological examination was made. PMID:23303014

  4. Perfusion Angiography in Acute Ischemic Stroke.

    PubMed

    Scalzo, Fabien; Liebeskind, David S

    2016-01-01

    Visualization and quantification of blood flow are essential for the diagnosis and treatment evaluation of cerebrovascular diseases. For rapid imaging of the cerebrovasculature, digital subtraction angiography (DSA) remains the gold standard as it offers high spatial resolution. This paper lays out a methodological framework, named perfusion angiography, for the quantitative analysis and visualization of blood flow parameters from DSA images. The parameters, including cerebral blood flow (CBF) and cerebral blood volume (CBV), mean transit time (MTT), time-to-peak (TTP), and T max, are computed using a bolus tracking method based on the deconvolution of the time-density curve on a pixel-by-pixel basis. The method is tested on 66 acute ischemic stroke patients treated with thrombectomy and/or tissue plasminogen activator (tPA) and also evaluated on an estimation task with known ground truth. This novel imaging tool provides unique insights into flow mechanisms that cannot be observed directly in DSA sequences and might be used to evaluate the impact of endovascular interventions more precisely. PMID:27446232

  5. Perfusion Angiography in Acute Ischemic Stroke

    PubMed Central

    Liebeskind, David S.

    2016-01-01

    Visualization and quantification of blood flow are essential for the diagnosis and treatment evaluation of cerebrovascular diseases. For rapid imaging of the cerebrovasculature, digital subtraction angiography (DSA) remains the gold standard as it offers high spatial resolution. This paper lays out a methodological framework, named perfusion angiography, for the quantitative analysis and visualization of blood flow parameters from DSA images. The parameters, including cerebral blood flow (CBF) and cerebral blood volume (CBV), mean transit time (MTT), time-to-peak (TTP), and Tmax, are computed using a bolus tracking method based on the deconvolution of the time-density curve on a pixel-by-pixel basis. The method is tested on 66 acute ischemic stroke patients treated with thrombectomy and/or tissue plasminogen activator (tPA) and also evaluated on an estimation task with known ground truth. This novel imaging tool provides unique insights into flow mechanisms that cannot be observed directly in DSA sequences and might be used to evaluate the impact of endovascular interventions more precisely. PMID:27446232

  6. What have drugs to offer the patient with acute stroke?

    PubMed Central

    Grosset, D G

    1992-01-01

    1. Drug treatment for acute stroke is designed to salvage neuronal tissue, and to prevent complications of stroke, which are often non-neurological. This review addresses the areas of recent advance in treatment designed to reduce the size of the cerebral infarct. With the exception of cardiac-source embolism, for which anticoagulation in the acute phase is sometimes considered, prevention of recurrent events is not discussed. 2. It is to be hoped that pharmaceutical developments will improve the current bleak picture in which there are no proven treatments for ischaemic stroke or intracerebral haemorrhage. To meet this challenge will require careful, controlled evaluation of treatment early after acute stroke in large scale clinical studies. PMID:1524958

  7. Investigation of acute stroke: what is the most effective strategy?

    PubMed Central

    Dunbabin, D. W.; Sandercock, P. A.

    1991-01-01

    Techniques of investigation of acute stroke syndromes have progressed rapidly in recent years, outpacing developments in effective stroke treatment. The clinician is thus faced with a variety of tests, each with different cost implications and each altering management to a greater or lesser extent. This review will concentrate on the basic tests which should be performed for all strokes (full blood count, ESR, biochemical screen, blood glucose, cholesterol, syphilis serology, chest X-ray and electrocardiogram). Additional tests may be required in selected cases: CT scan to diagnose 'non-stroke' lesions, to exclude cerebral haemorrhage if anti-haemostatic therapy is planned, and to detect strokes which may require emergency intervention (such as cerebellar stroke with hydrocephalus); echocardiography to detect cardiac sources of emboli; and in a few cases lumbar puncture and specialized haematological tests. Other tests, which are currently research tools, may be suitable for widespread use in the future including NMR, SPECT and PET scanning. PMID:2062773

  8. Anesthesia for Endovascular Approaches to Acute Ischemic Stroke.

    PubMed

    Avitsian, Rafi; Machado, Sandra B

    2016-09-01

    Involvement of the Anesthesiologist in the early stages of care for acute ischemic stroke patient undergoing endovascular treatment is essential. Anesthetic management includes the anesthetic technique (general anesthesia vs sedation), a matter of much debate and an area in need of well-designed prospective studies. The large numbers of confounding factors make the design of such studies a difficult process. A universally agreed point in the endovascular management of acute ischemic stroke is the importance of decreasing the time to revascularization. Hemodynamic and ventilatory management and implementation of neuroprotective modalities and treatment of acute procedural complications are important components of the anesthetic plan. PMID:27521194

  9. AGE AND GENDER DIFFERENCES IN ACUTE STROKE HOSPITAL PATIENTS.

    PubMed

    Kes, Vanja Bašić; Jurašić, Miljenka-Jelena; Zavoreo, Iris; Lisak, Marijana; Jelec, Vjekoslav; Matovina, Lucija Zadro

    2016-03-01

    Stroke is the second leading cause of death and the most important cause of adult disability worldwide and in Croatia. In the past, stroke was almost exclusively considered to be a disease of the elderly; however, today the age limit has considerably lowered towards younger age. The aim of this study was to determine age and gender impact on stroke patients in a Croatian urban area during one-year survey. The study included all acute stroke patients admitted to our Department in 2004. A compiled stroke questionnaire was fulfilled during hospitalization by medical personnel on the following items: stroke risk factors including lifestyle habits (smoking and alcohol), pre-stroke physical ability evaluation, stroke evolution data, laboratory and computed tomography findings, outcome data and post-stroke disability assessment. Appropriate statistical analysis of numerical and categorical data was performed at the level of p < 0.05. Analysis was performed on 396 patients, 24 of them from the younger adult stroke group. Older stroke patients had worse disability at hospital discharge and women had worse disabilities at both stroke onset and hospital discharge, probably due to older age at stroke onset. Younger patients recovered better, while older patients had to seek secondary medical facilities more often, as expected. The most important in-hospital laboratory findings in young stroke patients were elevated lipid levels, while older patients had elevated serum glucose and C-reactive protein. Stroke onset in younger patients most often presented with sudden onset headache; additionally, onset seizure was observed more frequently than expected. Stroke risk factor analysis showed that women were more prone to hypertension, chronic heart failure and atrial fibrillation, whereas men had carotid disease more frequently, were more often smokers and had higher alcohol intake. Additionally, age analysis showed that heart conditions and smoking were more prevalent among older

  10. The effects of citicoline on acute ischemic stroke: a review.

    PubMed

    Overgaard, Karsten

    2014-08-01

    Early reopening of the occluded artery is, thus, important in ischemic stroke, and it has been calculated that 2 million neurons die every minute in an ischemic stroke if no effective therapy is given; therefore, "Time is Brain." In massive hemispheric infarction and edema, surgical decompression lowers the risk of death or severe disability defined as a modified Rankin Scale score greater than 4 in selected patients. The majority, around 80%-85% of all ischemic stroke victims, does not fulfill the criteria for revascularization therapy, and also for these patients, there is no effective acute therapy. Also there is no established effective acute treatment of spontaneous intracerebral bleeding. Therefore, an effective therapy applicable to all stroke victims is needed. The neuroprotective drug citicoline has been extensively studied in clinical trials with volunteers and more than 11,000 patients with various neurologic disorders, including acute ischemic stroke (AIS). The conclusion is that citicoline is safe to use and may have a beneficial effect in AIS patients and most beneficial in less severe stroke in older patients not treated with recombinant tissue plasminogen activator. No other neuroprotective agent had any beneficial effect in confirmative clinical trials or had any positive effect in the subgroup analysis. Citicoline is the only drug that in a number of different clinical stroke trials continuously had some neuroprotective benefit. PMID:24739589

  11. Comparison of Performance Achievement Award Recognition With Primary Stroke Center Certification for Acute Ischemic Stroke Care

    PubMed Central

    Fonarow, Gregg C.; Liang, Li; Smith, Eric E.; Reeves, Mathew J.; Saver, Jeffrey L.; Xian, Ying; Hernandez, Adrian F.; Peterson, Eric D.; Schwamm, Lee H.

    2013-01-01

    Background Hospital certification and recognition programs represent 2 independent but commonly used systems to distinguish hospitals, yet they have not been directly compared. This study assessed acute ischemic stroke quality of care measure conformity by hospitals receiving Primary Stroke Center (PSC) certification and those receiving the American Heart Association's Get With The Guidelines‐Stroke (GWTG‐Stroke) Performance Achievement Award (PAA) recognition. Methods and Results The patient and hospital characteristics as well as performance/quality measures for acute ischemic stroke from 1356 hospitals participating in the GWTG‐Stroke Program 2010–2012 were compared. Hospitals were classified as PAA+/PSC+ (hospitals n=410, patients n=169 302), PAA+/PSC− (n=415, n=129 454), PAA−/PSC+ (n=88, n=26 386), and PAA−/PSC− (n=443, n=75 565). A comprehensive set of stroke measures were compared with adjustment for patient and hospital characteristics. Patient characteristics were similar by PAA and PSC status but PAA−/PSC− hospitals were more likely to be smaller and nonteaching. Measure conformity was highest for PAA+/PSC+ and PAA+/PSC− hospitals, intermediate for PAA−/PSC+ hospitals, and lowest for PAA−/PSC− hospitals (all‐or‐none care measure 91.2%, 91.2%, 84.3%, and 76.9%, respectively). After adjustment for patient and hospital characteristics, PAA+/PSC+, PAA+/PSC−, and PAA−/PSC+ hospitals had 3.15 (95% CIs 2.86 to 3.47); 3.23 (2.93 to 3.56) and 1.72 (1.47 to 2.00), higher odds for providing all indicated stroke performance measures to patients compared with PAA−/PSC− hospitals. Conclusions While both PSC certification and GWTG‐Stroke PAA recognition identified hospitals providing higher conformity with care measures for patients hospitalized with acute ischemic stroke, PAA recognition was a more robust identifier of hospitals with better performance. PMID:24125846

  12. Potential microRNA biomarkers for acute ischemic stroke.

    PubMed

    Zeng, Ye; Liu, Jing-Xia; Yan, Zhi-Ping; Yao, Xing-Hong; Liu, Xiao-Heng

    2015-12-01

    Acute ischemic stroke is a significant cause of high morbidity and mortality in the aging population globally. However, current therapeutic strategies for acute ischemic stroke are limited. Atherosclerotic plaque is considered an independent risk factor for acute ischemic stroke. To identify biomarkers for carotid atheromatous plaque, bioinformatics analysis of the gene microarray data of plaque and intact tissue from individuals was performed. Differentially expressed genes (DEGs) were identified using the Multtest and Limma packages of R language, including 56 downregulated and 69 upregulated DEGs. Enriched microRNA (miRNA or miR) DEGs networks were generated using WebGestalt software and the STRING databases, and the miRNAs were validated using serum from acute ischemic stroke patients with reverse transcription quantitative PCR (RT‑qPCR). Four confirmed differentially expressed miRNAs (miR‑9, ‑22, ‑23 and ‑125) were associated with 28 upregulated DEGs, and 7 miRNAs (miR‑9, ‑30, ‑33, ‑124, ‑181, ‑218 and ‑330) were associated with 25 downregulated DEGs. Gene ontology (GO) function suggested that the confirmed miRNA‑targeted DEGs predominantly associated with signal transduction, the circulatory system, biological adhesion, striated muscle contraction, wound healing and the immune system. The confirmed miRNA‑targeted genes identified serve as potential therapeutic targets for acute ischemic stroke. PMID:26459744

  13. Safe intravenous thrombolysis in acute stroke despite treatment with rivaroxaban.

    PubMed

    Bornkamm, Katharina; Harloff, Andreas

    2014-11-01

    Data regarding intravenous thrombolysis in stroke patients receiving new oral anticoagulant drugs (nOAC) is sparse. In the near future, however, an increasing number of patients with atrial fibrillation will suffer recurrent stroke despite treatment with nOAC. This will cause a significant therapeutic dilemma as thrombolysis is contraindicated under such circumstances. We describe an 81-year-old patient presenting with acute ischemic stroke who was successfully treated with intravenous thrombolysis despite ongoing treatment with rivaroxaban. Our case report indicates that thrombolysis under nOAC may be safe under certain conditions and emphasizes the importance of establishing and performing specific anticoagulation tests for nOAC. PMID:24938385

  14. Factoring in Factor VIII With Acute Ischemic Stroke

    PubMed Central

    Siegler, James E.; Samai, Alyana; Albright, Karen C.; Boehme, Amelia K.; Martin-Schild, Sheryl

    2016-01-01

    There is growing research interest into the etiologies of cryptogenic stroke, in particular as it relates to hypercoagulable states. An elevation in serum levels of the procoagulant factor VIII is recognized as one such culprit of occult cerebral infarctions. It is the objective of the present review to summarize the molecular role of factor VIII in thrombogenesis and its clinical use in the diagnosis and prognosis of acute ischemic stroke. We also discuss the utility of screening for serum factor VIII levels among patients at risk for, or those who have experienced, ischemic stroke. PMID:25669199

  15. No space left for intravenous thrombolysis in acute stroke: CONS.

    PubMed

    Muir, Keith

    2016-08-01

    Recent successful clinical trials of endovascular thrombectomy for large artery ischaemic stroke have established the value of this treatment modality as an adjunct to intravenous thrombolysis, not as an alternative: thrombectomy delivery was undertaken in the context of highly efficient networks for acute thrombolysis delivery and the great majority of patients received IV thrombolytic drug treatment. Even for the minority of acute stroke patients for whom thrombectomy is potentially relevant, access will be limited by geography and service infrastructure. Developments in intravenous thrombolysis in the near future will likely produce safer and more effective intravenous treatments. Intravenous thrombolysis will remain the first line of treatment for the great majority of acute stroke patients. PMID:27084182

  16. Imaging of occlusive thrombi in acute ischemic stroke

    PubMed Central

    Gasparian, GG; Sanossian, N; Shiroishi, MS; Liebeskind, DS

    2015-01-01

    Thrombi, or clots, often occlude proximal segments of the cerebral arterial circulation in acute ischemic stroke. Thromboembolic occlusion or thrombi superimposed on atherosclerotic plaque are the principal focus of acute stroke therapies such as thrombolysis or thrombectomy. We review the imaging characteristics of thrombi on multimodal CT and MRI, angiography and ultrasonography, summarizing recent studies that facilitate therapeutic decision-making from these noninvasive studies. Information about the location, size and imaging characteristics can be ascertained using these techniques. Imaging findings in relation to occlusive thrombus have been correlated with clot pathology, response to therapeutic interventions, and clinical outcome. Diagnostic evaluation of occlusive thrombi on noninvasive studies now constitutes an integral component of acute stroke management. PMID:25545291

  17. Current management of acute ischemic stroke. Part 2: Antithrombotics, neuroprotectives, and stroke units.

    PubMed Central

    Herd, A. M.

    2001-01-01

    OBJECTIVE: To help family physicians who care for patients with acute stroke or who are involved in planning service delivery or resource allocation to understand recent developments in acute stroke care. QUALITY OF EVIDENCE: A MEDLINE search indicated that most data were derived from well designed, randomized, double-blind, placebo-controlled trials, including all the largest international studies and large systematic reviews. MAIN MESSAGE: Routine anticoagulation is not recommended except for circumstances such as cardioembolic stroke or deep vein thrombosis prophylaxis. Antiplatelet therapy with low-dose acetylsalicylic acid (or another antiplatelet agent if ASA is contraindicated) should be initiated within 48 hours of stroke onset, although benefit is modest. Dedicated care for stroke patients reduces morbidity and mortality and can be cost effective. Recent research into defibrinogenating and neuroprotective agents suggests some benefit, although none are currently licensed for use. Combination therapy might be the answer. CONCLUSION: Management of acute stroke is an emerging discipline; many potential therapies are still experimental. PMID:11570305

  18. Effect and Safety of Rosuvastatin in Acute Ischemic Stroke

    PubMed Central

    Heo, Ji Hoe; Song, Dongbeom; Nam, Hyo Suk; Kim, Eung Yeop; Kim, Young Dae; Lee, Kyung-Yul; Lee, Ki-Jeong; Yoo, Joonsang; Kim, Youn Nam; Lee, Byung Chul; Yoon, Byung-Woo; Kim, Jong S.

    2016-01-01

    Background and Purpose The benefit of statins in acute stroke remains uncertain. Statins may prevent stroke recurrence during the acute stage of stroke via pleiotropic effects. However, statins may increase the risk of intracerebral hemorrhage. We investigated the effect and safety of rosuvastatin in acute stroke patients. Methods This randomized, double-blind, multi-center trial compared rosuvastatin 20 mg and placebo in statin-naïve stroke patients who underwent diffusion-weighted imaging (DWI) within 48 hours after symptom onset. The primary outcome was occurrence of new ischemic lesions on DWI at 5 or 14 days. Results This trial was stopped early after randomization of 316 patients due to slow enrollment. Among 289 patients with at least one follow-up imaging, the frequency of new ischemic lesions on DWI was not different between groups (rosuvastatin: 27/137, 19.7% vs. placebo: 36/152, 23.6%) (relative risk 0.83, 95% confidence interval 0.53–1.30). Infarct volume growth at 5 days (log-transformed volume change, rosuvastatin: 0.2±1.0 mm3 vs. placebo: 0.3±1.3 mm3; P=0.784) was not different, either. However, hemorrhagic infarction or parenchymal/subarachnoid hemorrhage on gradient-recalled echo magnetic resonance imaging occurred less frequently in the rosuvastatin group (6/137, 4.4%) than the placebo group (22/152, 14.5%, P=0.007). Among 314 patients with at least one dose of study medication, progression or clinical recurrence of stroke tended to occur less frequently in the rosuvastatin group (1/155, 0.6% vs. 7/159, 4.4%, P=0.067). Adverse events did not differ between groups. Conclusions The efficacy of rosuvastatin in reducing recurrence in acute stroke was inconclusive. However, statin use was safe and reduced hemorrhagic transformation. PMID:26846760

  19. From preoperative evaluation to stroke center: Management of postoperative acute ischemic stroke.

    PubMed

    Boyer, Thomas; Sigaut, Stéphanie; Puybasset, Louis; Deltour, Sandrine; Clarençon, Frédéric; Degos, Vincent

    2016-08-01

    Perioperative acute ischaemic stroke is a rare complication with potentially catastrophic outcomes. It has been shown that paying attention to perioperative neurological deficits and acute ischaemic stroke prevention proves to be beneficial in avoiding these catastrophic outcomes and may lead to determining early therapeutic interventions. This article reviews the perioperative management (covering diagnosis and treatment), prevention (covering surgery postponement, management with anticoagulant/antiplatelet and the growing interest in statins and beta-blockers) and intraoperative recommendations (covering anaesthetic techniques, ventilation strategies, transfusion and blood pressure management) specifically for the general surgical population. A summary of current treatments is enlightened by recently described evidence for the effectiveness of mechanical thrombectomy. PMID:27091105

  20. Alteplase Treatment in Acute Stroke: Incorporating Food and Drug Administration Prescribing Information into Existing Acute Stroke Management Guide.

    PubMed

    Demaerschalk, Bart M

    2016-08-01

    Despite strong evidence that intravenous tissue plasminogen activator (tPA) improves outcomes in acute ischemic stroke patients, its use in clinical practice remains modest. Complex eligibility criteria have been postulated as barriers to greater utilization. Further complicating this has been multiple guidelines and prescribing labels that have been published since first being approved for use in 1996. In this review, several warning and exclusion criteria for tPA in acute ischemic stroke are reviewed with the goal of providing readers a nuanced understanding of historical context and available evidence to make informed decision. PMID:27363696

  1. No space left for intravenous thrombolysis in acute stroke: PROS.

    PubMed

    Antonenko, Kateryna; Caso, Valeria

    2016-08-01

    Five recently published RCTs (MR CLEAN, EXTEND-IA, SWIFT PRIME, REVASCAT and ESCAPE) employing mechanical thrombectomy with modern stent retriever devices clearly demonstrated the superiority of endovascular treatment compared to thrombolysis alone, which is now considered standard first-line therapy for selected patients with acute severe ischemic stroke and large vessel in the anterior circulation. RCT results led to recommendations outlined in "Mechanical thrombectomy in acute ischemic stroke by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN". Moreover, endovascular procedures in the 5 RCTs to date were performed at high-volume referral centers with, in some trials, rigid requirements for the interventionalist to participate, which may have contributed substantially to the excellent results, supporting the concept of centralization of intra-arterial thrombolysis resources and expertise. Therefore, patients with suspected large-artery occlusion and deemed candidates for thrombectomy, should be treated at a Comprehensive Stroke Centre with 24/7 endovascular treatment services. There seems to be limited space left for intravenous thrombolysis alone in acute stroke patients with large-vessel occlusions as thrombectomy plus thrombolysis continues to be reported as being superior with regard to outcome. PMID:27150103

  2. Strategies to improve recovery in acute ischemic stroke patients: Iberoamerican Stroke Group Consensus.

    PubMed

    Alonso de Leciñana, M; Gutiérrez-Fernández, M; Romano, M; Cantú-Brito, C; Arauz, A; Olmos, L E; Ameriso, S F; Díez-Tejedor, E

    2014-06-01

    Stroke is not only a leading cause of death worldwide but also a main cause of disability. In developing countries, its burden is increasing as a consequence of a higher life expectancy. Whereas stroke mortality has decreased in developed countries, in Latin America, stroke mortality rates continue to rise as well as its socioeconomic dramatic consequences. Therefore, it is necessary to implement stroke care and surveillance programs to better describe the epidemiology of stroke in these countries in order to improve therapeutic strategies. Advances in the understanding of the pathogenic processes of brain ischemia have resulted in development of effective therapies during the acute phase. These include reperfusion therapies (both intravenous thrombolysis and interventional endovascular approaches) and treatment in stroke units that, through application of management protocols directed to maintain homeostasis and avoid complications, helps to exert effective brain protection that decreases further cerebral damage. Some drugs may enhance protection, and besides, there is increasing knowledge about brain plasticity and repair mechanisms that take place for longer periods beyond the acute phase. These mechanisms are responsible for recovery in certain patients and are the focus of basic and clinical research at present. This paper discusses recovery strategies that have demonstrated clinical effect, or that are promising and need further study. This rapidly evolving field needs to be carefully and critically evaluated so that investment in patient care is grounded on well-proven strategies. PMID:23802573

  3. Pseudoradial Nerve Palsy Caused by Acute Ischemic Stroke.

    PubMed

    Tahir, Hassan; Daruwalla, Vistasp; Meisel, Jeremy; Kodsi, Samir E

    2016-01-01

    Pseudoperipheral palsy has been used to characterize isolated monoparesis secondary to stroke. Isolated hand nerve palsy is a rare presentation for acute cerebral stroke. Our patient presented with clinical features of typical peripheral radial nerve palsy and a normal computed tomography scan of the head, which, without a detailed history and neurological examination, could have been easily misdiagnosed as a peripheral nerve lesion deferring further investigation for a stroke. We stress the importance of including cerebral infarction as a critical differential diagnosis in patients presenting with sensory-motor deficit in an isolated peripheral nerve pattern. A good history and physical exam can differentiate stroke from peripheral neuropathy as the cause of radial nerve palsy. PMID:27493976

  4. Pseudoradial Nerve Palsy Caused by Acute Ischemic Stroke

    PubMed Central

    Tahir, Hassan; Daruwalla, Vistasp; Meisel, Jeremy; Kodsi, Samir E.

    2016-01-01

    Pseudoperipheral palsy has been used to characterize isolated monoparesis secondary to stroke. Isolated hand nerve palsy is a rare presentation for acute cerebral stroke. Our patient presented with clinical features of typical peripheral radial nerve palsy and a normal computed tomography scan of the head, which, without a detailed history and neurological examination, could have been easily misdiagnosed as a peripheral nerve lesion deferring further investigation for a stroke. We stress the importance of including cerebral infarction as a critical differential diagnosis in patients presenting with sensory-motor deficit in an isolated peripheral nerve pattern. A good history and physical exam can differentiate stroke from peripheral neuropathy as the cause of radial nerve palsy. PMID:27493976

  5. Autonomic dysfunction in acute ischemic stroke: an underexplored therapeutic area?

    PubMed

    De Raedt, Sylvie; De Vos, Aurelie; De Keyser, Jacques

    2015-01-15

    Impaired autonomic function, characterized by a predominance of sympathetic activity, is common in patients with acute ischemic stroke. This review describes methods to measure autonomic dysfunction in stroke patients. It summarizes a potential relationship between ischemic stroke-associated autonomic dysfunction and factors that have been associated with worse outcome, including cardiac complications, blood pressure variability changes, hyperglycemia, immune depression, sleep disordered breathing, thrombotic effects, and malignant edema. Involvement of the insular cortex has been suspected to play an important role in causing sympathovagal imbalance, but its exact role and that of other brain regions remain unclear. Although sympathetic overactivity in patients with ischemic stroke appears to be a negative prognostic factor, it remains to be seen whether therapeutic strategies that reduce sympathetic activity or increase parasympathetic activity might improve outcome. PMID:25541326

  6. Intra-Arterial Treatment Methods in Acute Stroke Therapy

    PubMed Central

    Nguyen, Thanh N.; Babikian, Viken L.; Romero, Rafael; Pikula, Aleksandra; Kase, Carlos S.; Jovin, Tudor G.; Norbash, Alexander M.

    2011-01-01

    Acute revascularization is associated with improved outcomes in ischemic stroke patients. It is unclear which method of intra-arterial intervention, if any, is ideal. Promising approaches in acute stroke treatment are likely a combination of intravenous and endovascular revascularization efforts, combining early treatment initiation with direct clot manipulation and/or PTA/stenting. In this review, we will discuss available thrombolytic therapies and endovascular recanalization techniques, beginning with chemical thrombolytic agents, followed by mechanical devices, and a review of ongoing trials. Further randomized studies comparing medical therapy, intravenous and endovascular treatments are essential, and their implementation will require the wide support and enthusiasm from the neurologic, neuroradiologic, and neurosurgical stroke communities. PMID:21516256

  7. An acute stroke evaluation app: a practice improvement project.

    PubMed

    Rubin, Mark N; Fugate, Jennifer E; Barrett, Kevin M; Rabinstein, Alejandro A; Flemming, Kelly D

    2015-04-01

    A point-of-care workflow checklist in the form of an iOS (iPhone Operating System) app for use by stroke providers was introduced with the objective of standardizing acute stroke evaluation and documentation at 2 affiliated academic medical centers. Providers used the app in unselected, consecutive patients undergoing acute stroke evaluation in an emergency department or hospital setting between August 2012 and January 2013 and August 2013 and February 2014. Satisfaction surveys were prospectively collected pre- and postintervention from residents, staff neurologists, and clinical data specialists. Residents (20 preintervention and 16 postintervention), staff neurologists (6 pre and 5 post), and clinical data specialists (4 pre and 4 post) participated in this study. All 16 (100%) residents had increased satisfaction with their ability to perform an acute stroke evaluation postintervention but only 9 (56%) of 16 felt the app was more help than hindrance. Historical controls aligned with preintervention results. Staff neurologists conveyed increased satisfaction with resident presentations and decision making when compared to preintervention surveys. Stroke clinical data specialists estimated a 50% decrease in data abstraction when the app data were used in the clinical note. Concomitant effect on door-to-needle (DTN) time at 1 site, although not a primary study measure, was also evaluated. At that 1 center, the mean DTN time decreased by 16 minutes when compared to the corresponding months from the year prior. The point-of-care acute stroke workflow checklist app may assist trainees in presenting findings in a standardized manner and reduce data abstraction time. The app may help reduce DTN time, but this requires further study. PMID:25829986

  8. Magnetic resonance imaging in acute ischemic stroke treatment.

    PubMed

    Kim, Bum Joon; Kang, Hyun Goo; Kim, Hye-Jin; Ahn, Sung-Ho; Kim, Na Young; Warach, Steven; Kang, Dong-Wha

    2014-09-01

    Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis. PMID:25328872

  9. Magnetic Resonance Imaging in Acute Ischemic Stroke Treatment

    PubMed Central

    Kim, Bum Joon; Kang, Hyun Goo; Kim, Hye-Jin; Ahn, Sung-Ho; Kim, Na Young; Warach, Steven

    2014-01-01

    Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis. PMID:25328872

  10. Early embolic events complicating intravenous thrombolysis for acute ischemic stroke.

    PubMed

    Chou, Ping Song; Lin, Chien Hung; Chao, Hai Lun; Chao, A Ching

    2012-11-01

    Intravenous recombinant tissue plasminogen activator (IV rt-PA) is the only established thrombolytic therapy for acute ischemic stroke. However, secondary embolism after IV rt-PA for acute ischemic stroke is recognized as an uncommon complication, and the pathophysiology is unclear. We describe a 72-year-old man with acute infarction in the territory of left anterior cerebral artery who developed new infarction in the territory of right middle cerebral artery and acute peripheral arterial occlusion after IV rt-PA therapy. It suggested a central embolic source. Because the patient has paroxysmal atrial fibrillation (Af), the possible embolic sources may come from fragmentation of pre-existing intra-atrial clot. Although Af and the presence of cardiac thrombus are not contraindication for IV rt-PA in acute ischemic stroke, our case and review suggested that the administration of IV rt-PA to patients with known Af and intracardiac thrombus could represent a particular risk situation and should be carefully evaluated. PMID:22205004

  11. Acute vertebrobasilar ischemic stroke due to electric injury.

    PubMed

    Singh Jain, Rajendra; Kumar, Sunil; Suresh, Desai Tushar; Agarwal, Rakesh

    2015-07-01

    Electrical injuries are most commonly due to household accidents.Various factors determine the severity of electric injury, including type of current, amperage, voltage, tissue resistance, pathway of current,and duration of contact with the body. Various types of neurologic damage due to electrical injury have been described in literature. It may manifest as peripheral nerve injury, spinal cord damage, seizures, cerebellarataxia, hypoxic encephalopathy, and intracerebral hemorrhage. Acute ischemic stroke is an infrequent complication of electrical injury. Herein,we report a case of middle-aged man, who accidentally sustained high voltage electrical injury followed by acute vertebrobasilar ischemic stroke. Magnetic resonance imaging of the brain showed acute infarctin bilateral cerebellar and medial occipital regions. Computed tomographic angiogram of the brain and neck vessels was normal. Possibly,in our patient, the mechanism could be related to direct vascular injury due to electric current. PMID:25684743

  12. Human Motor Cortex Functional Changes in Acute Stroke: Gender Effects

    PubMed Central

    Di Lazzaro, Vincenzo; Pellegrino, Giovanni; Di Pino, Giovanni; Ranieri, Federico; Lotti, Fiorenza; Florio, Lucia; Capone, Fioravante

    2016-01-01

    The acute phase of stroke is accompanied by functional changes in the activity and interplay of both hemispheres. In healthy subjects, gender is known to impact the functional brain organization. We investigated whether gender influences also acute stroke functional changes. In thirty-five ischemic stroke patients, we evaluated the excitability of the affected (AH) and unaffected hemisphere (UH) by measuring resting and active motor threshold (AMT) and motor-evoked potential amplitude under baseline conditions and after intermittent theta burst stimulation (iTBS) of AH. We also computed an index of the excitability balance between the hemispheres, laterality indexes (LI), to evidence hemispheric asymmetry. AMT differed significantly between AH and UH only in the male group (p = 0.004), not in females (p > 0.200), and both LIAMT and LIRMT were significantly higher in males than in females (respectively p = 0.033 and p = 0.042). LTP-like activity induced by iTBS in AH was more frequent in females. Gender influences the functional excitability changes that take place after human stroke and the level of LTP that can be induced by repetitive stimulation. This knowledge is of high value in the attempt of individualizing to different genders any non-invasive stimulation strategy designed to foster stroke recovery. PMID:26858590

  13. Drug repurposing for immune modulation in acute ischemic stroke.

    PubMed

    Amantea, Diana; Bagetta, Giacinto

    2016-02-01

    Innate immune cells play a dualistic role in the evolution of ischemic brain damage, with classic phenotypes promoting injury, and alternatively activated M2 microglia/macrophages or N2 neutrophils providing tissue remodelling and repair. Recently, a number of drugs commonly used for other indications (i.e., azithromycin, minocycline, bexarotene, rosiglitazone, metformin) was reported to provide neuroprotection in preclinical stroke models by promoting immune polarization towards non-inflammatory, protective phenotypes. Repurposing drugs with a well-established safety profile should allow a reduction in the risk of clinical trial failure that has dominated the unsuccessful development of neuroprotective drugs in stroke during the last decades. The clinical validation of the proof of concept, followed by the assessment of safety and efficacy of immune-polarizing repurposed drugs will definitively offer new opportunities for the acute treatment of ischemic stroke. PMID:26657075

  14. Carotid Artery Stenosis with Acute Ischemic Stroke: Stenting versus Angioplasty

    PubMed Central

    Villwock, Mark R.; Padalino, David J.; Deshaies, Eric M.

    2015-01-01

    Background When a patient with carotid artery stenosis presents emergently with acute ischemic stroke, the optimum treatment plan is not clearly defined. If intervention is warranted, and open surgery is prohibitive, endovascular revascularization may be performed. The use of stents places the patient at additional risk due to their thrombogenic potential. The intent of this study was to compare outcomes following endovascular approaches (angioplasty alone vs. stent) in the setting of acute stroke. Methods We extracted a population from the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2003–2011) composed of patients with carotid artery stenosis with infarction that were admitted nonelectively and received endovascular revascularization. Patients treated with mechanical thrombectomy or thrombolysis were excluded. Categorical variables were compared between treatment groups with Chi-squared tests. Binary logistic regression was performed to evaluate mortality and iatrogenic stroke while controlling for age, case severity, and comorbidity burden. Results About 6,333 admissions met our criteria. A majority were treated via stenting (89%, n = 5,608). The angioplasty-alone group had significantly higher mortality (9.0% vs. 3.8%, p < 0.001) and iatrogenic stroke rate (3.9% vs. 1.9%, p < 0.001) than the stent group. The adjusted odds ratios of mortality and iatrogenic stroke for patients treated with angioplasty alone were 1.953 (p < 0.001) and 1.451 (p = 0.105), respectively, in comparison to patients treated with carotid stenting. Conclusion Multivariate analysis found the risk of mortality to be elevated following angioplasty alone. This may represent selection bias, but it also may indicate that symptomatic patients with stroke suffer from severe stenosis and unstable plaques that would benefit from stent placement. These results would caution angioplasty alone as an arm of a future randomized trial involving this severely burdened patient

  15. Mechanical Thrombectomy in Acute Ischemic Stroke: A Systematic Review.

    PubMed

    Lambrinos, Anna; Schaink, Alexis K; Dhalla, Irfan; Krings, Timo; Casaubon, Leanne K; Sikich, Nancy; Lum, Cheemun; Bharatha, Aditya; Pereira, Vitor Mendes; Stotts, Grant; Saposnik, Gustavo; Kelloway, Linda; Xie, Xuanqian; Hill, Michael D

    2016-07-01

    Although intravenous thrombolysis increases the probability of a good functional outcome in carefully selected patients with acute ischemic stroke, a substantial proportion of patients who receive thrombolysis do not have a good outcome. Several recent trials of mechanical thrombectomy appear to indicate that this treatment may be superior to thrombolysis. We therefore conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of new-generation mechanical thrombectomy devices with intravenous thrombolysis (if eligible) compared with intravenous thrombolysis (if eligible) in patients with acute ischemic stroke caused by a proximal intracranial occlusion. We systematically searched seven databases for randomized controlled trials published between January 2005 and March 2015 comparing stent retrievers or thromboaspiration devices with best medical therapy (with or without intravenous thrombolysis) in adults with acute ischemic stroke. We assessed risk of bias and overall quality of the included trials. We combined the data using a fixed or random effects meta-analysis, where appropriate. We identified 1579 studies; of these, we evaluated 122 full-text papers and included five randomized control trials (n=1287). Compared with patients treated medically, patients who received mechanical thrombectomy were more likely to be functionally independent as measured by a modified Rankin score of 0-2 (odds ratio, 2.39; 95% confidence interval, 1.88-3.04; I2=0%). This finding was robust to subgroup analysis. Mortality and symptomatic intracerebral hemorrhage were not significantly different between the two groups. Mechanical thrombectomy significantly improves functional independence in appropriately selected patients with acute ischemic stroke. PMID:27071728

  16. Treating the acute stroke patient as an emergency: current practices and future opportunities

    PubMed Central

    Davis, S; Lees, K; Donnan, G

    2006-01-01

    Summary Developments in acute stroke therapy have followed advances in the understanding of the evolving pathophysiology in both ischaemic stroke and intracerebral haemorrhage (ICH). In ischaemic stroke, rapid reperfusion of the ischaemic penumbra with thrombolysis within 3 h of symptom onset is of proven benefit, but few patients currently receive therapy, mainly due to the short-time window and lack of stroke expertise. In ICH, a recent study indicated that a haemostatic agent can limit ongoing bleeding and improve outcomes when administered within 4 h of stroke onset. These advances in acute stroke therapy underlie the concept that ‘time is brain’ and that urgent intervention can limit cerebral damage. Neuroprotective therapy could offer the prospect of a greater proportion of stroke patients receiving treatment, potentially before imaging and even in the ambulance setting. Virtually all stroke patients would benefit from receiving multidisciplinary care in acute stroke units. PMID:16620351

  17. The implementation of intravenous tissue plasminogen activator in acute ischaemic stroke--a scientific position statement from the National Stroke Foundation and the Stroke Society of Australasia.

    PubMed

    2009-05-01

    Intravenous tissue plasminogen activator (tPA) has been licensed in Australia for thrombolysis in selected patients with acute ischaemic stroke since 2003. The use of tPA is low but is increasing across Australia and national audits indicate efficacy and safety outcomes equivalent to international benchmarks. Implementing tPA therapy in clinical practice is, however, challenging and requires a coordinated multidisciplinary approach to acute stroke care across prehospital, emergency department and inpatient care sectors. Stroke care units are an essential ingredient underpinning safe implementation of stroke thrombolysis. Support systems such as care pathways, therapy delivery protocols, and thrombolysis-experienced multidisciplinary care teams are also important enablers. Where delivery of stroke thrombolysis is being planned, health systems need to be re-configured to provide these important elements. This consensus statement provides a review of the evidence for, and implementation of, tPA in acute ischaemic stroke with specific reference to the Australian health-care system. PMID:19545242

  18. Hunting mimics and chameleons: diagnostic difficulties in atypical acute ischaemic stroke

    PubMed Central

    Plummer, Nicholas Russell; Hari-Bhaskar, Kemparaju

    2014-01-01

    The seemingly straightforward diagnosis of acute ischaemic stroke can be complicated by the presence of conditions presenting similarly to stroke, and atypical strokes presenting with confusing and non-classical signs. We present a diagnostic quest to disentangle the effects of a number of stroke mimics from those of an underlying bilateral cerebrovascular phenomena, where with appropriate treatment of the non-stroke conditions the patient was able to make a near complete neurological recovery. PMID:24891484

  19. Retrosternal mass: An interesting allergic reaction to intravenous thrombolytic therapy for acute ischemic stroke

    PubMed Central

    Motamed, Mohammad Reza; Aghaei, Mahboubeh; Badi, Zahra

    2013-01-01

    Stroke is an important cause of disability and death worldwide, with the majority of strokes occurring in older people. Thrombolysis with recombinant tissue plasminogen activator (r-TPA) is the approved treatment for acute ischemic stroke. A major concern of physicians, who treat acute ischemic stroke with recombinant tissue plasminogen activator (r-TPA,) is the risk of intracerebral hemorrhage. However, other adverse reactions, including anaphylaxis and angioedema, can also occur. Here we report an interesting soft tissue reaction to intravenous r-TPA in an 80 year-old male who was treated for acute ischemic stroke. PMID:24250917

  20. Retrosternal mass: An interesting allergic reaction to intravenous thrombolytic therapy for acute ischemic stroke.

    PubMed

    Mehrpour, Masoud; Motamed, Mohammad Reza; Aghaei, Mahboubeh; Badi, Zahra

    2013-01-01

    Stroke is an important cause of disability and death worldwide, with the majority of strokes occurring in older people. Thrombolysis with recombinant tissue plasminogen activator (r-TPA) is the approved treatment for acute ischemic stroke. A major concern of physicians, who treat acute ischemic stroke with recombinant tissue plasminogen activator (r-TPA,) is the risk of intracerebral hemorrhage. However, other adverse reactions, including anaphylaxis and angioedema, can also occur. Here we report an interesting soft tissue reaction to intravenous r-TPA in an 80 year-old male who was treated for acute ischemic stroke. PMID:24250917

  1. Stroke

    MedlinePlus

    ... Stay Connected Home » Stroke Heath and Aging Stroke What Is a Stroke? Stroke Is an Emergency. ... IGNORE THE SIGNS OF STROKE! What Is a Stroke? A stroke happens when something changes how blood ...

  2. Endothelial Dysfunction and Procoagulant Activity in Acute Ischemic Stroke

    PubMed Central

    Blum, Arnon; Vaispapir, Vladimir; Keinan-Boker, Lital; Soboh, Soboh; Yehuda, Hila; Tamir, Snait

    2012-01-01

    Endothelium-dependent vasodilator function may be regarded as an index of inflammation. Endothelial dysfunction has been observed in stroke patients and has been related to stroke physiopathology, stroke subtypes, clinical severity, and outcome. Our aim was to measure systemic vascular function directly (using forearm flow mediated dilatation) in patients with acute ischemic stroke and to clarify whether recent acute ischemic stroke is associated with impaired vascular function. Patients who were not eligible for thrombolytic therapy because of delayed arrival were randomly recruited to the study after signing a consent form. All 43 patients were conscious and had an acute ischemic stroke. Brain CT was performed on admission, and clinical evaluation was carried out by a neurologist on admission and four days later. Vascular responsiveness was evaluated by ABI and by endothelial function measurements on admission. Levels of P-selectin were measured during the first 24 hrs and on day 4. Forty-three patients (28 men and 15 women) and 23 healthy men (control) were enrolled in the study. Patients were older (62.4±12.5 y vs 44.2±11.6 y, p=0.001), had worse endothelial dysfunction (–4.4±7.4% vs 16.6±7.6%, p=0.001), and had a higher BMI (28±6 vs 24±5, p=0.001). No gender effect was found in endothelial function (–5.1±7.8% vs –2.5±6.6%, p=0.25) and ABI (1.0±0.26 vs 1.0±0.5, p=0.29). However, men had lower BMIs compared to women (26.8±5.8 vs 31.4±5.5, p=0.01). The neurological scale decreased from 4.9±3.4 to 3.2±3.0 on day 4 (p=0.001). In men, it was 4.8±3.8 on admission, and decreased to 3.2±3.4 on day 4 (p=0.001). In women, it was 5.0±2.7, and decreased to 3.3±2.3 on day 4 (p=0.001). P-selectin levels were high on admission (68.0±55.5 pg/ml) and increased 4 days later (102.3±72.0 pg/ml) (p=0.01). Men had higher levels on admission (79.1± 66.7 pg/ml vs 48.9± 15.4 pg/ml, p=0.02) and rose on day 4 to 113.6±82.6 pg/ml (p=0.05); in women P

  3. Protein methionine oxidation augments reperfusion injury in acute ischemic stroke

    PubMed Central

    Gu, Sean X.; Blokhin, Ilya O.; Wilson, Katina M.; Dhanesha, Nirav; Doddapattar, Prakash; Grumbach, Isabella M.; Chauhan, Anil K.; Lentz, Steven R.

    2016-01-01

    Reperfusion injury can exacerbate tissue damage in ischemic stroke, but little is known about the mechanisms linking ROS to stroke severity. Here, we tested the hypothesis that protein methionine oxidation potentiates NF-κB activation and contributes to cerebral ischemia/reperfusion injury. We found that overexpression of methionine sulfoxide reductase A (MsrA), an antioxidant enzyme that reverses protein methionine oxidation, attenuated ROS-augmented NF-κB activation in endothelial cells, in part, by protecting against the oxidation of methionine residues in the regulatory domain of calcium/calmodulin-dependent protein kinase II (CaMKII). In a murine model, MsrA deficiency resulted in increased NF-κB activation and neutrophil infiltration, larger infarct volumes, and more severe neurological impairment after transient cerebral ischemia/reperfusion injury. This phenotype was prevented by inhibition of NF-κB or CaMKII. MsrA-deficient mice also exhibited enhanced leukocyte rolling and upregulation of E-selectin, an endothelial NF-κB–dependent adhesion molecule known to contribute to neurovascular inflammation in ischemic stroke. Finally, bone marrow transplantation experiments demonstrated that the neuroprotective effect was mediated by MsrA expressed in nonhematopoietic cells. These findings suggest that protein methionine oxidation in nonmyeloid cells is a key mechanism of postischemic oxidative injury mediated by NF-κB activation, leading to neutrophil recruitment and neurovascular inflammation in acute ischemic stroke. PMID:27294204

  4. The economics of treating stroke as an acute brain attack

    PubMed Central

    Bogousslavsky, Julien; Paciaroni, Maurizio

    2009-01-01

    Currently, treatments for ischemic stroke focus on restoring or improving perfusion to the ischemic area using thrombolytics. The increased hospitalization costs related to thrombolysis are offset by a decrease in rehabilitation costs, for a net cost savings to the healthcare system. However, early treatment is essential. The benefit of thrombolysis is time-dependent but only a very small proportion of patients, 2%, are presently being treated with tPA. In the United States, if the proportion of all ischemic stroke patients that receive tPA were increased to 4, 6, 8, 10, 15, or 20%, the realized cost saving would be approximately $ 15, 22, 30, 37, 55, and 74 million, respectively. Being so, efforts should be made to educate the public and paramedics regarding early stroke signs. Furthermore, additional acute stroke therapy training programs need to be established for emergency departments. Finally, hospital systems need to be re-engineered to treat patients as quickly as possible in order to optimize thrombolytic benefit as well as maximize cost-effectiveness. PMID:19775424

  5. The economics of treating stroke as an acute brain attack.

    PubMed

    Bogousslavsky, Julien; Paciaroni, Maurizio

    2009-01-01

    Currently, treatments for ischemic stroke focus on restoring or improving perfusion to the ischemic area using thrombolytics. The increased hospitalization costs related to thrombolysis are offset by a decrease in rehabilitation costs, for a net cost savings to the healthcare system. However, early treatment is essential. The benefit of thrombolysis is time-dependent but only a very small proportion of patients, 2%, are presently being treated with tPA. In the United States, if the proportion of all ischemic stroke patients that receive tPA were increased to 4, 6, 8, 10, 15, or 20%, the realized cost saving would be approximately $ 15, 22, 30, 37, 55, and 74 million, respectively. Being so, efforts should be made to educate the public and paramedics regarding early stroke signs. Furthermore, additional acute stroke therapy training programs need to be established for emergency departments. Finally, hospital systems need to be re-engineered to treat patients as quickly as possible in order to optimize thrombolytic benefit as well as maximize cost-effectiveness. PMID:19775424

  6. New pathways for evaluating potential acute stroke therapies.

    PubMed

    Fisher, Marc; Cheung, Kenneth; Howard, George; Warach, Steven

    2006-05-01

    Pharmacological therapy for acute ischemic stroke remains limited to one successful, approved treatment: tissue plasminogen activator within 3 h of stroke onset. Many neuroprotective drugs and a few other thrombolytics were evaluated in clinical trials, but none demonstrated unequivocal success and were approved by regulatory agencies. The development paradigm for such therapies needs to provide convincing evidence of efficacy and safety to obtain approval by the Food and Drug Administration (FDA). The FDA modernization act of 1997 stated that such evidence could be derived from one large phase III trial with a clinical endpoint and supportive evidence. Drugs being developed for acute ischemic stroke can potentially be approved under this act by coupling a major phase III trial with supportive evidence provided by a phase IIB trial demonstrating an effect on a relevant biomarker such as magnetic resonance imaging or computed tomography assessment of ischemic lesion growth. Statistical approaches have been developed to optimize the design of such an imaging-based phase IIB study, for example approaches that modify randomization probabilities to assign larger proportions of patients to the 'winning' strategy (i.e. 'pick the winner' strategies) with an interim assessment to reduce the sample size requirement. Demonstrating a treatment effect on a relevant imaging-based biomarker should provide supportive evidence for a new drug application, if a subsequent phase III trial with a clinical outcome demonstrates a significant treatment effect. PMID:18706045

  7. Timing of blood pressure lowering in acute ischemic stroke.

    PubMed

    Carcel, Cheryl; Anderson, Craig S

    2015-08-01

    Whether there are any benefits without harm from early lowering of blood pressure (BP) in the setting of acute ischemic stroke (AIS) has been a longstanding controversy in medicine. Whilst most studies have consistently shown associations between elevated BP, particularly systolic BP, and poor outcome, some also report that very low BP (systolic <130 mmHg) and large reductions in systolic BP are associated with poor outcomes in AIS. However, despite these associations, the observed U- or J-shaped relationship between BP and outcome in these patients may not be causally related. Patients with more severe strokes may have a more prominent autonomic response and later lower BP as their condition worsens, often pre-terminally. Fortunately, substantial progress has been made in recent years with new evidence arising from well-conducted randomized trials. This review outlines new evidence and recommendations for clinical practice over BP management in AIS. PMID:26041479

  8. Exertional heat stroke and acute liver failure: a late dysfunction.

    PubMed

    Carvalho, Ana Sofia; Rodeia, Simão C; Silvestre, Joana; Póvoa, Pedro

    2016-01-01

    Heat stroke (HS) is defined as a severe elevation of core body temperature along with central nervous system dysfunction. Exertional heat stroke (EHS) with acute liver failure (ALF) is a rare condition. The authors report the case of a 25-year-old man with a history of cognitive enhancers' intake who developed hyperthermia and neurological impairment while running an outdoor marathon. The patient was cooled and returned to normal body temperature after 6 h. He subsequently developed ALF and was transferred to the intensive care unit. Over-the-counter drug intake may have been related to heat intolerance and contributed to the event. The patient was successfully treated with conservative measures. In the presence of EHS, it is crucial to act promptly with aggressive total body cooling, in order to prevent progression of the clinical syndrome. Liver function must also be monitored, since it can be a late organ dysfunction. PMID:26969359

  9. Arterial Spin Labeling for Acute Stroke: Practical Considerations

    PubMed Central

    Zaharchuk, Greg

    2014-01-01

    Arterial spin labeling is a non-contrast method of measuring cerebral perfusion with MRI. It has several advantages over traditional contrast-based perfusion-weighted imaging, including non-invasiveness, more straightforward cerebral blood flow (CBF) quantification, and repeatability. However, because of its lower signal-to-noise ratio (SNR) per unit time and its high sensitivity to arterial transit delays, it has not been used frequently in acute stroke, where arterial delays and time-efficiency are of the essence. This is beginning to change, driven by higher SNR implementations of ASL and the increasing use of 3T scanners. Furthermore, velocity selective ASL sequences that are largely insensitive to arrival times are beginning to be applied to patients with cerebrovascular disease, and promise the ability to quantify CBF even in regions supplied by late-arriving collateral flow. Despite these advances, many practical issues must be addressed to optimize ASL for use in acute stroke studies. These include optimizing the trade-off between time, SNR, imaging resolution, and sensitivity to slow flow. Rapid and robust post-processing of image data must be made routine, such that CBF maps are available in real-time so that they can be considered when making treatment decisions. Lastly, automated software needs to be developed to delineate hypoperfused tissue volumes, with attention to the inherent differences between gray and white matter CBF. Attention to these details is critical to translate this promising research tool into mainstream clinical trials and practice in acute stroke. PMID:24323778

  10. [Telemedicine in acute stroke care--a health economics view].

    PubMed

    Günzel, F; Theiss, S; Knüppel, P; Halberstadt, S; Rose, G; Raith, M

    2010-05-01

    Specialized stroke units offer optimal treatment of patients with an acute stroke. Unfortunately, their installation is limited by an acute lack of experienced neurologists and the small number of stroke patients in sparsely populated rural areas. This problem is increasingly being solved by the use of telemedicine, so that neurological expertise is made available to basic and regular care. It has been demonstrated by national and international pilot studies that solidly based and rapid decisions can be made by telemedicine regrading the use of thrombolysis, as the most important acute treatment, but also of other interventions. So far studies have only evaluated improvement in the quality of care achieved by networking, but not of any lasting effect on any economic benefit. Complementary to a medical evaluation, the qualitative economic assessment presented here of German and American concepts of telemetric care indicate no difference in efficacy between various ways of networking. Most noteworthy, when comparing two large American and German studies, is the difference in their priorities. While the American networks achieved targeted improvements in efficacy of care that go beyond the immediate wishes of the doctors involved, this was of only secondary importance in the German studies. Also, in contrast to several American networks, the German telemetry networks have not tended to be organized for future growth. In terms of economic benefits, decentralized organized networks offer a greater potential of efficacy than purely local ones. Furthermore, the integration of inducements into the design of business models is a fundamental factor for achieving successful and lasting existence, especially within a highly competitive market. PMID:20077382

  11. Novel Thrombolytics for Acute Ischemic Stroke: Challenges and Opportunities.

    PubMed

    Logallo, Nicola; Kvistad, Christopher E; Nacu, Aliona; Thomassen, Lars

    2016-02-01

    Progress in finding a better alternative to alteplase has been slow. Tenecteplase and desmoteplase have better pharmacological profiles compared with alteplase, but definite clinical evidence of their superiority is lacking. The two major phase III studies that have tested the efficacy and safety of desmoteplase in ischemic stroke patients have shown neutral results and a promising safety profile, but the trials compared desmoteplase with placebo only in late admitted patients. Future trials should focus on testing novel thrombolytics in the early time window either as the sole acute recanalizing treatment or combined with thrombectomy. PMID:26798040

  12. Elevation of troponin I in acute ischemic stroke

    PubMed Central

    Su, Yu-Chin; Huang, Kuo-Feng; Yang, Fu-Yi

    2016-01-01

    Background. Cardiac morbidities account for 20% of deaths after ischemic stroke and is the second commonest cause of death in acute stroke population. Elevation of cardiac troponin has been regarded as a prognostic biomarker of poor outcome in patients with acute stroke. Methods. This retrospective study enrolled 871 patients with acute ischemic stroke from August 2010 to March 2015. Data included vital signs, laboratory parameters collected in the emergency department, and clinical features during hospitalization. National Institutes of Health Stroke Scale (NIHSS), Barthel index, and modified Rankin Scale (mRS) were used to assess stroke severity and outcome. Results. Elevated troponin I (TnI) > 0.01 µg/L was observed in 146 (16.8%) patients. Comparing to patients with normal TnI, patients with elevated TnI were older (median age 77.6 years vs. 73.8 years), had higher median heart rates (80 bpm vs. 78 bpm), higher median white blood cells (8.40 vs. 7.50 1,000/m3) and creatinine levels (1.40 mg/dL vs. 1.10 mg/dL), lower median hemoglobin (13.0 g/dL vs. 13.7 g/dL) and hematocrit (39% vs. 40%) levels, higher median NIHSS scores on admission (11 vs. 4) and at discharge (8 vs. 3), higher median mRS scores (4 vs3) but lower Barthel index scores (20 vs. 75) at discharge (p < 0.001). Multivariate analysis revealed that age ≥ 76 years (OR 2.25, CI [1.59–3.18]), heart rate ≥ 82 bpm (OR 1.47, CI [1.05–2.05]), evidence of clinical deterioration (OR 9.45, CI [4.27–20.94]), NIHSS score ≥ 12 on admission (OR 19.52, CI [9.59–39.73]), and abnormal TnI (OR 1.98, CI [1.18–3.33]) were associated with poor outcome. Significant factors for in-hospital mortality included male gender (OR 3.69, CI [1.45–9.44]), evidence of clinical deterioration (OR 10.78, CI [4.59–25.33]), NIHSS score ≥ 12 on admission (OR 8.08, CI [3.04–21.48]), and elevated TnI level (OR 5.59, CI [2.36–13.27]). C-statistics revealed that abnormal TnI improved the predictive power of both poor

  13. The Relation Between GABA and L-Arginine Levels With Some Stroke Risk Factors in Acute Ischemic Stroke Patients

    PubMed Central

    Hosinian, Mohsen; Qujeq, Durdi; Ahmadi Ahangar, Alijan

    2016-01-01

    Changes in extra and intracellular neurotransmitter amino acids concentration in the early stage of acute cerebral ischemia have been reported. In this the study, serum level of gamma aminobutyric acid (GABA) and L-Arginine in acute ischemic stroke patients was assessed. 60 patients with acute ischemic stroke and sixthy healthy volunteers as a control group were assessed. Serum GABA was measured with modified enzymatic method and serum L- Arginine was measured by modified Sakaguchi method. Serum GABA level in stroke cases was lower than that of the control group. There was no relationship between GABA level and age or gender. Also, no significant correlation was observed between GABA levels with ischemic stroke risk factors such as smoking, diabetes mellitus, and hypertension. Serum L- Arginine level in patients was slightly increased in comparison with control group. There was a positive relationship between serum L- Arginine level and acute ischemic stroke risk factors. Serum GABA level was reduced in patients and had no correlation with acute ischemic stroke risk factors. PMID:27478806

  14. The Relation Between GABA and L-Arginine Levels With Some Stroke Risk Factors in Acute Ischemic Stroke Patients.

    PubMed

    Hosinian, Mohsen; Qujeq, Durdi; Ahmadi Ahangar, Alijan

    2016-01-01

    Changes in extra and intracellular neurotransmitter amino acids concentration in the early stage of acute cerebral ischemia have been reported. In this the study, serum level of gamma aminobutyric acid (GABA) and L-Arginine in acute ischemic stroke patients was assessed. 60 patients with acute ischemic stroke and sixthy healthy volunteers as a control group were assessed. Serum GABA was measured with modified enzymatic method and serum L- Arginine was measured by modified Sakaguchi method. Serum GABA level in stroke cases was lower than that of the control group. There was no relationship between GABA level and age or gender. Also, no significant correlation was observed between GABA levels with ischemic stroke risk factors such as smoking, diabetes mellitus, and hypertension. Serum L- Arginine level in patients was slightly increased in comparison with control group. There was a positive relationship between serum L- Arginine level and acute ischemic stroke risk factors. Serum GABA level was reduced in patients and had no correlation with acute ischemic stroke risk factors. PMID:27478806

  15. Mechanical thrombectomy for acute ischemic stroke in pregnancy using the penumbra system.

    PubMed

    Aaron, Sanjith; Shyamkumar, N K; Alexander, Sunithi; Babu, P Suresh; Prabhakar, A T; Moses, Vinu; Murthy, T V; Alexander, Mathew

    2016-01-01

    Even though intravenous thrombolysis with tissue plasminogen activator (IV tPA) is the standard of care in acute ischemic stroke, its use in pregnancy is not clearly defined. Mechanical thrombectomy devices can be an option; however, literature on the use of such mechanical devices in stroke in pregnancy is lacking. Here we describe two cases that developed acute embolic stroke during pregnancy who were successfully treated by mechanical clot retrieval using the Penumbra system 28 (Penumbra Inc., Alameda, California, USA). To the best of our knowledge, these are the only case reports on the use of the Penumbra device in pregnant patients with acute ischemic stroke. PMID:27293343

  16. Mechanical thrombectomy for acute ischemic stroke in pregnancy using the penumbra system

    PubMed Central

    Aaron, Sanjith; Shyamkumar, N. K.; Alexander, Sunithi; Babu, P. Suresh; Prabhakar, A. T.; Moses, Vinu; Murthy, T. V.; Alexander, Mathew

    2016-01-01

    Even though intravenous thrombolysis with tissue plasminogen activator (IV tPA) is the standard of care in acute ischemic stroke, its use in pregnancy is not clearly defined. Mechanical thrombectomy devices can be an option; however, literature on the use of such mechanical devices in stroke in pregnancy is lacking. Here we describe two cases that developed acute embolic stroke during pregnancy who were successfully treated by mechanical clot retrieval using the Penumbra system 28 (Penumbra Inc., Alameda, California, USA). To the best of our knowledge, these are the only case reports on the use of the Penumbra device in pregnant patients with acute ischemic stroke. PMID:27293343

  17. Hyperbaric Oxygen Therapy in Acute Ischemic Stroke: A Review

    PubMed Central

    Ding, Zheng; Tong, Wesley C.; Lu, Xiao-Xin; Peng, Hui-Ping

    2014-01-01

    Stroke, also known as cerebrovascular disease, is a common and serious neurological disease, which is also the fourth leading cause of death in the United States so far. Hyperbaric medicine, as an emerging interdisciplinary subject, has been applied in the treatment of cerebral vascular diseases since the 1960s. Now it is widely used to treat a variety of clinical disorders, especially hypoxia-induced disorders. However, owing to the complex mechanisms of hyperbaric oxygen (HBO) treatment, the therapeutic time window and the undefined dose as well as some common clinical side effects (such as middle ear barotrauma), the widespread promotion and application of HBO was hindered, slowing down the hyperbaric medicine development. In August 2013, the US Food and Drug Administration declared artery occlusion as one of the 13 specific indications for HBO therapy. This provides opportunities, to some extent, for the further development of hyperbaric medicine. Currently, the mechanisms of HBO therapy for ischemic stroke are still not very clear. This review focuses on the potential mechanisms of HBO therapy in acute ischemic stroke as well as the time window. PMID:25337089

  18. [Peri-interventional management of acute endovascular stroke treatment].

    PubMed

    Schönenberger, S; Bösel, J

    2015-10-01

    Due to the ground breaking consistent evidence that supports the effect of endovascular stroke treatment (EST), many acute care hospitals and stroke centers will have to be prepared to provide this treatment in an optimal way within the coming years. In addition to the intervention itself, patient preparation, stabilization and monitoring during the treatment as well as the aftercare represent significant challenges and have mostly not yet been sufficiently investigated. Under these aspects, the questions of optimal sedation and airway management have received the highest attention. Based on retrospective study results it already seems to be justified, respecting certain criteria, to prefer EST with the patient under conscious sedation (CS) in comparison to general anesthesia (GA) and to only switch to GA in cases of emergency until this question has been clarified by prospective studies. This and other aspects of peri-interventional management, such as logistics, monitoring, blood pressure, ventilation settings, postprocedural steps of intensive or stroke unit care and imaging follow-up are summarized in this overview. The clinical and radiological selection of patients and thus the decision for intervention or technical aspects of the intervention itself will not be part of this article. PMID:26311331

  19. Neuroanatomical Correlates of Oral Reading in Acute Left Hemispheric Stroke

    PubMed Central

    Cloutman, Lauren L.; Newhart, Melissa; Davis, Cameron L.; Heidler-Gary, Jennifer; Hillis, Argye E.

    2010-01-01

    Oral reading is a complex skill involving the interaction of orthographic, phonological, and semantic processes. Functional imaging studies with non-impaired adult readers have identified a widely distributed network of frontal, inferior parietal, posterior temporal, and occipital brain regions involved in the task. However, while functional imaging can identify cortical regions engaged in the process under examination, it cannot identify those brain regions essential for the task. The current study aimed to identify those neuroanatomical regions critical for successful oral reading by examining the relationship between word and nonword oral reading deficits and areas of tissue dysfunction in acute stroke. We evaluated 91 patients with left hemisphere ischemic stroke with a test of oral word and nonword reading, and magnetic resonance diffusion-weighted and perfusion-weighted imaging, within 24–48 hours of stroke onset. A voxel-wise statistical map showed that impairments in word and nonword reading were associated with a distributed network of brain regions, including the inferior and middle frontal gyri, the middle temporal gyrus, the supramarginal and angular gyri, and the middle occipital gyrus. In addition, lesions associated with word deficits were found to be distributed more frontally, while nonword deficits were associated with lesions distributed more posteriorly. PMID:20889196

  20. The third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke

    PubMed Central

    Sandercock, Peter; Lindley, Richard; Wardlaw, Joanna; Dennis, Martin; Lewis, Steff; Venables, Graham; Kobayashi, Adam; Czlonkowska, Anna; Berge, Eivind; Slot, Karsten Bruins; Murray, Veronica; Peeters, Andre; Hankey, Graeme; Matz, Karl; Brainin, Michael; Ricci, Stefano; Celani, Maria Grazia; Righetti, Enrico; Cantisani, Teresa; Gubitz, Gord; Phillips, Steve; Arauz, Antonio; Prasad, Kameshwar; Correia, Manuel; Lyrer, Phillippe

    2008-01-01

    Background Intravenous recombinant tissue plasminogen activator (rt-PA) is approved for use in selected patients with ischaemic stroke within 3 hours of symptom onset. IST-3 seeks to determine whether a wider range of patients may benefit. Design International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rt-PA in acute ischaemic stroke. Suitable patients must be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracerebral haemorrhage. With 1000 patients, the trial can detect a 7% absolute difference in the primary outcome. With3500 patients, it can detect a 4.0% absolute benefit & with 6000, (mostly treated between 3 & 6 hours), it can detect a 3% benefit. Trial procedures Patients are entered into the trial by telephoning a fast, secure computerised central randomisation system or via a secure web interface. Repeat brain imaging must be performed at 24–48 hours. The scans are reviewed 'blind' by expert readers. The primary measure of outcome is the proportion of patients alive and independent (Modified Rankin 0–2) at six months (assessed via a postal questionnaire mailed directly to the patient). Secondary outcomes include: events within 7 days (death, recurrent stroke, symptomatic intracranial haemorrhage), outcome at six months (death, functional status, EuroQol). Trial registration ISRCTN25765518 PMID:18559104

  1. Statins in Acute Ischemic Stroke: A Systematic Review

    PubMed Central

    Hong, Keun-Sik; Lee, Ji Sung

    2015-01-01

    Background and Purpose Statins have pleiotropic effects of potential neuroprotection. However, because of lack of large randomized clinical trials, current guidelines do not provide specific recommendations on statin initiation in acute ischemic stroke (AIS). The current study aims to systematically review the statin effect in AIS. Methods From literature review, we identified articles exploring prestroke and immediate post-stroke statin effect on imaging surrogate markers, initial stroke severity, functional outcome, and short-term mortality in human AIS. We summarized descriptive overview. In addition, for subjects with available data from publications, we conducted meta-analysis to provide pooled estimates. Results In total, we identified 70 relevant articles including 6 meta-analyses. Surrogate imaging marker studies suggested that statin might enhance collaterals and reperfusion. Our updated meta-analysis indicated that prestroke statin use was associated with milder initial stroke severity (odds ratio [OR] [95% confidence interval], 1.24 [1.05-1.48]; P=0.013), good functional outcome (1.50 [1.29-1.75]; P<0.001), and lower mortality (0.42 [0.21-0.82]; P=0.0108). In-hospital statin use was associated with good functional outcome (1.31 [1.12-1.53]; P=0.001), and lower mortality (0.41 [0.29-0.58]; P<0.001). In contrast, statin withdrawal was associated with poor functional outcome (1.83 [1.01-3.30]; P=0.045). In patients treated with thrombolysis, statin was associated with good functional outcome (1.44 [1.10-1.89]; P=0.001), despite an increased risk of symptomatic hemorrhagic transformation (1.63 [1.04-2.56]; P=0.035). Conclusions The current study findings support the use of statin in AIS. However, the findings were mostly driven by observational studies at risk of bias, and thereby large randomized clinical trials would provide confirmatory evidence. PMID:26437994

  2. Serum activity of angiotensin converting enzyme 2 is decreased in patients with acute ischemic stroke.

    PubMed

    Bennion, Douglas M; Rosado, Christian A; Haltigan, Emily A; Regenhardt, Robert W; Sumners, Colin; Waters, Michael F

    2016-07-01

    Levels of angiotensin converting enzyme 2 (ACE2), a cardio and neuro-protective carboxypeptidase, are dynamically altered after stroke in preclinical models. We sought to characterize the previously unexplored changes in serum ACE2 activity of stroke patients and the mechanism of these changes. Serum samples were obtained from patients during acute ischemic stroke (n=39), conditions mimicking stroke (stroke-alert, n=23), or from control participants (n=20). Enzyme activity levels were analyzed by fluorometric assay and correlated with clinical variables by regression analyses. Serum ACE2 activity was significantly lower in acute ischemic stroke as compared to both control and stroke-alert patients, followed by an increase to control levels at three days. Serum ACE2 activity significantly correlated with the presence of ischemic stroke after controlling for other factors (P=0.01). Additional associations with ACE2 activity included a positive correlation with systolic blood pressure at presentation in stroke-alert (R(2)=0.24, P=0.03), while stroke levels showed no correlation (R(2)=0.01, P=0.50). ACE2 sheddase activity was unchanged between groups. These dynamic changes in serum ACE2 activity in stroke, which concur with preclinical studies, are not likely to be driven primarily by acute changes in blood pressure or sheddase activity. These findings provide new insight for developing therapies targeting this protective system in ischemic stroke. PMID:27488276

  3. Aspiration-Related Acute Respiratory Distress Syndrome in Acute Stroke Patient

    PubMed Central

    Zhao, Jiang-nan; Liu, Yao; Li, Huai-chen

    2015-01-01

    Background Aspiration of oral or gastric contents into the larynx and lower respiratory tract is a common problem in acute stroke patients, which significantly increases the incidence of acute respiratory distress syndrome (ARDS). However, little is known about the clinical characteristics of aspiration-related ARDS in acute stroke patients. Methods Over 17-month period a retrospective cohort study was done on 1495 consecutive patients with acute stroke. The data including demographic characteristics, clinical manifestations, laboratory examinations, chest imaging, and hospital discharge status were collected to analysis. Results Aspiration-related ARDS was diagnosed in 54 patients (3.6%). The most common presenting symptom was tachypnea (respiratory rate ≥25 breaths/min) in 50 cases. Computed tomography (CT) images usually demonstrated diffuse ground-glass opacities (GGOs) and inhomogeneous patchy consolidations involving the low lobes. Age, NIHSS score, GCS score, dysphagia, dysarthria, hemoglobin concentration, serum aspertate aminotransferase (AST), serum albumin, serum sodium, and admission glucose level were independently associated with aspiration-related ARDS (odds ratio (OR) 1.05, 95% confidence interval (CI) (1.04–1.07); OR 2.87, (2.68–3.63); OR 4.21, (3.57–5.09); OR 2.18, (1.23–3.86); OR 1.67, (1.31–2.14); OR 2.31, (1.11–4.84); OR 1.68, (1.01–2.80); OR 2.15, (1.19–3.90); OR 1.92, (1.10–3.36) and OR 1.14, (1.06–1.21) respectively). Conclusions Aspiration-related ARDS frequently occurs in acute stroke patient with impairment consciousness. It is advisable that performing chest CT timely may identify disease early and prompt treatment to rescue patients. PMID:25790377

  4. Usefulness of cervical magnetic resonance imaging for detecting type A acute aortic dissection with acute stroke symptoms.

    PubMed

    Matsumoto, Hiroaki; Yoshida, Yasuhisa; Hirata, Yutaka

    2016-09-01

    Type A acute aortic dissection (TAAAD) sometimes presents with acute stroke-like symptoms. When intravenous tissue plasminogen activator (IV-tPA) therapy is considered for acute ischemic stroke, TAAAD must be excluded. Painless TAAAD presenting with acute stroke may be easily missed. Two cases of painless TAAAD presenting with acute stroke in which IV-tPA therapy was considered are reported. In these cases, cervical magnetic resonance angiography (MRA) was useful for detecting TAAAD, and IV-tPA therapy was canceled. The mottled high signal ("snowstorm") in the common carotid artery on cervical MRA is specific for TAAAD. We have thus named this phenomenon the "snowstorm sign" and believe it can help diagnose TAAAD. PMID:27118510

  5. Quality of Life after Intra-arterial Therapy for Acute Ischemic Stroke

    PubMed Central

    Cortez, Melissa M.; Wilder, Michael; McFadden, Molly; Majersik, Jennifer J.

    2014-01-01

    Few data exist about health-related quality of life outcomes after intra-arterial therapy for acute ischemic stroke. We assessed stroke-specific quality of life in stroke survivors after intra-arterial therapy. Consecutive patients undergoing intra-arterial therapy for acute ischemic stroke from 2005-2010 were retrospectively identified via an institutional database. Stroke-specific quality of life (using the Stroke-Specific Quality of Life Score) and disability status (modified Rankin Scale) were prospectively assessed via mailed questionnaire. We analyzed quality of life scores by domain and summary score, with a summary score of ≥ 4 defined as a good outcome. Analysis of variance was used to model the effect of final recanalization status, stroke severity, and modified Rankin Scale on total quality of life score. ANOVA and Pearson's correlations were used to test the association between stroke severity/modified Rankin Scale and quality of life/time since stroke respectively. Of ninety-nine acute ischemic stroke patients, 61 responded yielding: 11 interim deaths, 7 incomplete surveys, and 43 complete surveys for analysis. Among responding survivors, overall quality of life score was 3.9 (SD 0.7); 77% of these reported good quality of life. Scores were higher in recanalized patients in 11 of 12 domains, but was significant only for mood. Although modified Rankin Scale was associated with stroke severity, quality of life was independent of both. Seventy-seven percent of acute ischemic stroke survivors who received intra-arterial therapy reported good quality of life. Furthermore, these data suggest that stroke-specific quality of life is an independent outcome from stroke severity and disability status. PMID:24813258

  6. Early treatment of hypertension in acute ischemic and intracerebral hemorrhagic stroke: progress achieved, challenges, and perspectives.

    PubMed

    Feldstein, Carlos A

    2014-03-01

    Hypertension is the leading risk factor for ischemic and intracerebral hemorrhagic subtypes of stroke. Additionally, high blood pressure (BP) in the acute cerebrovascular event is associated with poor outcome, and a high percentage of stroke survivors have inadequate control of hypertension. The present is a systematic review of prospective, randomized, and controlled trials carried out on safety and efficacy of antihypertensive treatment of both subtypes of acute stroke. Six trials involving 7512 patients were included, which revealed controversies on the speed and the goals of treatment. These controversies could be due at least in part, from the fact that some studies analyzed the results of antihypertensive treatment in ischemic and intracerebral hemorrhagic subtypes of acute stroke together, and from a different prevalence of past-stroke in the randomized groups. Further research is necessary to establish whether standard antihypertensive treatment provides greater benefit than simple observation in patients with ischemic acute stroke and Stage 2 hypertension of JNC 7, albeit they were not candidates for acute reperfusion. In that case, the target reduction in BP could be 10% to 15% within 24 hours. The recently published INTERACT 2 has provided evidence that patients with hemorrhagic stroke may receive intensive antihypertensive treatment safely with the goal of reducing systolic BP to levels no lower than 130 mm Hg. It is important to take into account that marked BP lowering in acute stroke increases the risk of poor outcome by worsening cerebral ischemia from deterioration of cerebral blood flow autoregulation. PMID:24220549

  7. Ancrod causes rapid thrombolysis in patients with acute stroke.

    PubMed

    Pollak, V E; Glas-Greenwalt, P; Olinger, C P; Wadhwa, N K; Myre, S A

    1990-05-01

    Clot lysis is desirable in patients with thrombi in arteries and arterioles by a safe rapidly-acting thrombolytic agent. Ancrod cleaves fibrinogen; the resulting circulating ancrod-fibrin stimulates fibrinolysis. Ancrod action and effect were studied in 20 patients with acute developing stroke in a double-blind, placebo-controlled study. Patients were randomly assigned to one of two treatment groups, and received either normal saline or ancrod 0.5 mu/kg in normal saline administered as a constant-rate intravenous infusion over 6 hours. Subsequent doses of ancrod (or saline placebo) were determined daily thereafter for a total treatment period of 7 days. Neither bleeding nor re-thrombosis occurred within the 90 day follow-up period. That ancrod acted rapidly was shown by a significant decrease in functional plasminogen activator inhibitor (PA-I) within 60 minutes, and by significant elevations of fibrin(ogen) degradation products (FDP) and D-dimer within 3 and 4 hours. The biological effect of fibrinolysis in ancrod infused patients was demonstrated by a greater improvement in stroke score when compared to those infused with saline. PMID:2186630

  8. Technologies for diagnosis and treatment of acute stroke

    SciTech Connect

    Fitch, J.P.

    1998-02-09

    From October 1994 to June 1997, a multidisciplinary team of scientists and engineers at Lawrence Livermore National Laboratory were funded through LDRD to develop and integrate technologies for diagnosis and treatment of acute stroke. The project was summarized in a Science and Technology Review article `Brain Attack` that appeared in June 1997 and again in the Center for Healthcare Technologies Report (UCRL-LR-124761). This article is the best overview of the project, epidemiology of stroke and technical progress. Most of the technical progress has been documented in conference papers and presentations and refereed journal articles. Additional technical publication can be expected as our remaining patent applications progress through the US Patent and Trademark Office. The purpose of this report is to provide an appropriate introduction and organization to the numerous publications so that interested readers can quickly find information. Because there is no documentation for the history of this project, this report provides a summary. It also provides the final status report for the LDRD funding.

  9. Classification of motor imagery performance in acute stroke

    NASA Astrophysics Data System (ADS)

    Tangwiriyasakul, Chayanin; Mocioiu, Victor; van Putten, Michel J. A. M.; Rutten, Wim L. C.

    2014-06-01

    Objective. Effective motor imagery performance, seen as strong suppression of the sensorimotor rhythm, is the key element in motor imagery therapy. Therefore, optimization of methods to classify whether the subject is performing the imagery task is a prerequisite. An optimal classification method should have high performance accuracy and use a small number of channels. We investigated the additional benefit of the common spatial pattern filtering (CSP) to a linear discriminant analysis (LDA) classifier, for different channel configurations. Methods. Ten hemispheric acute stroke patients and 11 healthy subjects were included. EEGs were recorded using 60 channels. The classifier was trained with a motor execution task. For both healthy controls and patients, analysis of recordings was initially limited to 3 and 11 electrodes recording from the motor cortex area, and later repeated using 45 electrodes. Results. No significant improvement on the addition of CSP to LDA was found (in both cases, the area under the receiving operating characteristic (AU-ROC) ≈0.70 (acceptable)). We then repeated the LDA+CSP method on recordings of 45 electrodes, since the use of imagery neuronal circuits may well extend beyond the motor area. AU-ROC rose to 0.90, but no virtual ‘most responsible’ electrode was observed. Finally, in mild-to-moderate stroke patients we could successfully use the EEG data recorded from the healthy hemisphere to train the classifier (AU-ROC ≈ 0.70). Significance. Including only the channels on the unaffected motor cortex is sufficient to train a classifier.

  10. Sonothrombolysis in the management of acute ischemic stroke.

    PubMed

    Rubiera, Marta; Alexandrov, Andrei V

    2010-01-01

    Multiple in vitro and animal models have demonstrated the efficacy of ultrasound to enhance fibrinolysis. Mechanical pressure waves produced by ultrasound energy improve the delivery and penetration of alteplase (recombinant tissue plasminogen activator [tPA]) inside the clot. In human stroke, the CLOTBUST phase II trial showed that the combination of alteplase plus 2 hours of continuous transcranial Doppler (TCD) increased recanalization rates, producing a trend toward better functional outcomes compared with alteplase alone. Other small clinical trials also showed an improvement in clot lysis when transcranial color-coded sonography was combined with alteplase. In contrast, low-frequency ultrasound increased the symptomatic intracranial hemorrhage rate in a clinical trial. Administration of microbubbles (MBs) may further enhance the effect of ultrasound on thrombolysis by lowering the ultrasound-energy threshold needed to induce acoustic cavitation. Initial clinical trials have been encouraging, and a multicenter international study, TUCSON, determined a dose of newly developed MBs that can be safely administered with alteplase and TCD. Even in the absence of alteplase, the ultrasound energy, with or without MBs, could increase intrinsic fibrinolysis. The intra-arterial administration of ultrasound with the EKOS NeuroWave catheter is another ultrasound application for acute stroke that is currently being studied in the IMS III trial. Operator-independent devices, different MB-related techniques, and other ultrasound parameters for improving and spreading sonothrombolysis are being tested. PMID:20104930

  11. Early seizures in patients with acute stroke: Frequency, predictive factors, and effect on clinical outcome

    PubMed Central

    Alberti, Andrea; Paciaroni, Maurizio; Caso, Valeria; Venti, Michele; Palmerini, Francesco; Agnelli, Giancarlo

    2008-01-01

    Background Early seizure (ES) may complicate the clinical course of patients with acute stroke. The aim of this study was to assess the rate of and the predictive factors for ES as well the effects of ES on the clinical outcome at hospital discharge in patients with first-ever stroke. Patients and methods A total of 638 consecutive patients with first-ever stroke (543 ischemic, 95 hemorrhagic), admitted to our Stroke Unit, were included in this prospective study. ES were defined as seizures occurring within 7 days from acute stroke. Patients with history of epilepsy were excluded. Results Thirty-one patients (4.8%) had ES. Seizures were significantly more common in patients with cortical involvement, severe and large stroke, and in patient with cortical hemorrhagic transformation of ischemic stroke. ES was not associated with an increase in adverse outcome (mortality and disability). After multivariate analysis, hemorrhagic transformation resulted as an independent predictive factor for ES (OR = 6.5; 95% CI: 1.95–22.61; p = 0.003). Conclusion ES occur in about 5% of patients with acute stroke. In these patients hemorrhagic transformation is a predictive factor for ES. ES does not seem to be associated with an adverse outcome at hospital discharge after acute stroke. PMID:18827922

  12. The Quest for Arterial Recanalization in Acute Ischemic Stroke-The Past, Present and the Future

    PubMed Central

    L.L.Yeo, Leonard; Sharma, Vijay K

    2013-01-01

    Ischemic stroke is one of the major causes of mortality and long-term disability. In the recent past, only very few treatment options were available and a considerable proportion of stroke survivors remained permanently disabled. However, over the last 2 decades rapid advances in acute stroke care have resulted in a corresponding improvement in mortality rates and functional outcomes. In this review, we describe the evolution of systemic thrombolytic agents and various interventional devices, their current status as well as some of the future prospects. We reviewed literature pertaining to acute ischemic stroke reperfusion treatment. We explored the current accepted treatment strategies to attain cerebral reperfusion via intravenous modalities and compare and contrast them within the boundaries of their clinical trials. Subsequently we reviewed the trials for interventional devices for acute ischemic stroke, categorizing them into thrombectomy devices, aspiration devices, clot disruption devices and thrombus entrapment devices. Finally we surveyed several of the alternative reperfusion strategies available. We also shed some light on the controversies surrounding the current strategies of treatment of acute ischemic stroke. Acute invasive interventional strategies continue to improve along with the noninvasive modalities. Both approaches appear promising. We conducted a comprehensive chronological review of the existing treatments as well as upcoming remedies for acute ischemic stroke. PMID:23864913

  13. Pharmacological therapy of acute ischaemic stroke: Achievements and problems.

    PubMed

    Moretti, Antonio; Ferrari, Federica; Villa, Roberto F

    2015-09-01

    Acute ischaemic stroke (AIS) is a leading cause of death and disability worldwide. Its incidence and prevalence increase considerably with age and numbers will grow with an ageing population. Consequently, the impact of AIS on costs is soaring. AIS is caused by the abrupt occlusion of an intracranial vessel resulting in reduced blood flow to the brain region supplied. The ischaemic core (which is irreversibly lesioned) is surrounded by the penumbra region with less severe flow reduction, lower functional impairment and potential recovery. Therefore, the fundamental treatment of AIS relies on prompt recanalisation and reperfusion of the threatened, but potentially salvageable, ischaemic penumbra. With this aim, intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) remains the current strategy. However, thrombolysis is underused, owing to various exclusion criteria that limit the number of treated patients. Other thrombolytics are under investigation. Endovascular therapy with mechanical recanalisation devices is also increasingly applied, though definite evidence of its benefit is lacking. Moreover, hypertension and hyperglycaemia are acute complications to be treated in AIS. This review analyses the current status, the problems, the perspectives and the cost-effectiveness of the pharmacological therapy for AIS. PMID:26079382

  14. A qualitative exploration of discharge destination as an outcome or a driver of acute stroke care

    PubMed Central

    2014-01-01

    Background Many patients with acute stroke do not receive recommended care in tertiary hospital settings. Allied health professionals have important roles within multidisciplinary stroke teams and influence the quality of care patients receive. Studies examining the role of allied health professionals in acute stroke management are scarce, and very little is known about the clinical decision making of these stroke clinicians. In this study we aimed to describe factors that influence the complex clinical decision making of these professionals as they prioritise acute stroke patients for recommended care. This qualitative study was part of a larger mixed methods study. Methods The qualitative methodology applied was a constructivist grounded theory approach. Fifteen allied health professionals working with acute stroke patients at three metropolitan tertiary care hospitals in South Australia were purposively sampled. Semi-structured interviews were conducted face to face using a question guide, and digital recording. Interviews were transcribed and analysed by two researchers using rigorous grounded theory processes. Results Our analysis highlighted ‘predicted discharge destination’ as a powerful driver of care decisions and clinical prioritisation for this professional group. We found that complex clinical decision making to predict discharge destination required professionals to concurrently consider patient’s pre-stroke status, the nature and severity of their stroke, the course of their recovery and multiple factors from within the healthcare system. The consequences of these decisions had potentially profound consequences for patients and sometimes led to professionals experiencing considerable uncertainty and stress. Conclusions Our qualitative enquiry provided new insights into the way allied health professionals make important clinical decisions for patients with acute stroke. This is the first known study to demonstrate that the subjective prediction

  15. History, Evolution, and Importance of Emergency Endovascular Treatment of Acute Ischemic Stroke.

    PubMed

    Holodinsky, Jessalyn K; Yu, Amy Y X; Assis, Zarina A; Al Sultan, Abdulaziz S; Menon, Bijoy K; Demchuk, Andrew M; Goyal, Mayank; Hill, Michael D

    2016-05-01

    More than 800,000 people in North America suffer a stroke each year, with ischemic stroke making up the majority of these cases. The outcomes of ischemic stroke range from complete functional and cognitive recovery to severe disability and death; outcome is strongly associated with timely reperfusion treatment. Historically, ischemic stroke has been treated with intravenous thrombolytic agents with moderate success. However, five recently published positive trials have established the efficacy of endovascular treatment in acute ischemic stroke. In this review, we will discuss the history of stroke treatments moving from various intravenous thrombolytic drugs to intra-arterial thrombolysis, early mechanical thrombectomy devices, and finally modern endovascular devices. Early endovascular therapy failures, recent successes, and implications for current ischemic stroke management and future research directions are discussed. PMID:27021771

  16. ACUTE BEHAVORIAL EFFECTS FROM EXPOSURE TO TWO-STROKE ENGINE EXHAUST

    EPA Science Inventory

    Benefits of changing from two-stroke to four-stroke engines (and other remedial requirements) can be evaluated (monetized) from the standpoint of acute behavioral effects of human exposure to exhaust from these engines. The monetization process depends upon estimates of the magn...

  17. Right Hemispatial Neglect: Frequency and Characterization Following Acute Left Hemisphere Stroke

    ERIC Educational Resources Information Center

    Kleinman, Jonathan T.; Newhart, Melissa; Davis, Cameron; Heidler-Gary, Jennifer; Gottesman, Rebecca F.; Hillis, Argye E.

    2007-01-01

    The frequency of various types of unilateral spatial neglect and associated areas of neural dysfunction after left hemisphere stroke are not well characterized. Unilateral spatial neglect (USN) in distinct spatial reference frames have been identified after acute right, but not left hemisphere stroke. We studied 47 consecutive right handed…

  18. Hemodilution increases cerebral blood flow in acute ischemic stroke

    SciTech Connect

    Vorstrup, S.; Andersen, A.; Juhler, M.; Brun, B.; Boysen, G.

    1989-07-01

    We measured cerebral blood flow in 10 consecutive, but selected, patients with acute ischemic stroke (less than 48 hours after onset) before and after hemodilution. Cerebral blood flow was measured by xenon-133 inhalation and emission tomography, and only patients with focal hypoperfusion in clinically relevant areas were included. Hemodilution was done according to the hematocrit level: for a hematocrit greater than or equal to 42%, 500 ml whole blood was drawn and replaced by the same volume of dextran 40; for a hematocrit between 37% and 42%, only 250 ml whole blood was drawn and replaced by 500 cc of dextran 40. Mean hematocrit was reduced by 16%, from 46 +/- 5% (SD) to 39 +/- 5% (SD) (p less than 0.001). Cerebral blood flow increased in both hemispheres by an average of 20.9% (p less than 0.001). Regional cerebral blood flow increased in the ischemic areas in all cases, on an average of 21.4 +/- 12.0% (SD) (p less than 0.001). In three patients, a significant redistribution of flow in favor of the hypoperfused areas was observed, and in six patients, the fractional cerebral blood flow increase in the hypoperfused areas was of the same magnitude as in the remainder of the brain. In the last patient, cerebral blood flow increased relatively less in the ischemic areas. Our findings show that cerebral blood flow increases in the ischemic areas after hemodilution therapy in stroke patients. The marked regional cerebral blood flow increase seen in some patients could imply an improved oxygen delivery to the ischemic tissue.

  19. Utility of EEG measures of brain function in patients with acute stroke.

    PubMed

    Wu, Jennifer; Srinivasan, Ramesh; Burke Quinlan, Erin; Solodkin, Ana; Small, Steven L; Cramer, Steven C

    2016-06-01

    EEG has been used to study acute stroke for decades; however, because of several limitations EEG-based measures rarely inform clinical decision-making in this setting. Recent advances in EEG hardware, recording electrodes, and EEG software could overcome these limitations. The present study examined how well dense-array (256 electrodes) EEG, acquired with a saline-lead net and analyzed with whole brain partial least squares (PLS) modeling, captured extent of acute stroke behavioral deficits and varied in relation to acute brain injury. In 24 patients admitted for acute ischemic stroke, 3 min of resting-state EEG was acquired at bedside, including in the ER and ICU. Traditional quantitative EEG measures (power in a specific lead, in any frequency band) showed a modest association with behavioral deficits [NIH Stroke Scale (NIHSS) score] in bivariate models. However, PLS models of delta or beta power across whole brain correlated strongly with NIHSS score (R(2) = 0.85-0.90) and remained robust when further analyzed with cross-validation models (R(2) = 0.72-0.73). Larger infarct volume was associated with higher delta power, bilaterally; the contralesional findings were not attributable to mass effect, indicating that EEG captures significant information about acute stroke effects not available from MRI. We conclude that 1) dense-array EEG data are feasible as a bedside measure of brain function in patients with acute stroke; 2) high-dimension EEG data are strongly correlated with acute stroke behavioral deficits and are superior to traditional single-lead metrics in this regard; and 3) EEG captures significant information about acute stroke injury not available from structural brain imaging. PMID:26936984

  20. Development, Implementation, and Evaluation of a Telemedicine Service for the Treatment of Acute Stroke Patients: TeleStroke

    PubMed Central

    2012-01-01

    Background Health care service based on telemedicine can reduce both physical and time barriers in stroke treatments. Moreover, this service connects centers specializing in stroke treatment with other centers and practitioners, thereby increasing accessibility to neurological specialist care and fibrinolytic treatment. Objective Development, implementation, and evaluation of a care service for the treatment of acute stroke patients based on telemedicine (TeleStroke) at Virgen del Rocío University Hospital. Methods The evaluation phase, conducted from October 2008 to January 2011, involved patients who presented acute stroke symptoms confirmed by the emergency physician; they were examined using TeleStroke in two hospitals, at a distance of 16 and 110 kilometers from Virgen del Rocío University Hospital. We analyzed the number of interconsultation sheets, the percentage of patients treated with fibrinolysis, and the number of times they were treated. To evaluate medical professionals’ acceptance of the TeleStroke system, we developed a web-based questionnaire using a Technology Acceptance Model. Results A total of 28 patients were evaluated through the interconsultation sheet. Out of 28 patients, 19 (68%) received fibrinolytic treatment. The most common reasons for not treating with fibrinolysis included: clinical criteria in six out of nine patients (66%) and beyond the time window in three out of nine patients (33%). The mean “onset-to-hospital” time was 69 minutes, the mean time from admission to CT image was 33 minutes, the mean “door-to-needle” time was 82 minutes, and the mean “onset-to-needle” time was 150 minutes. Out of 61 medical professionals, 34 (56%) completed a questionnaire to evaluate the acceptability of the TeleStroke system. The mean values for each item were over 6.50, indicating that respondents positively evaluated each item. This survey was assessed using the Cronbach alpha test to determine the reliability of the

  1. Plasma C-Reactive Protein and Clinical Outcomes after Acute Ischemic Stroke: A Prospective Observational Study

    PubMed Central

    Matsuo, Ryu; Ago, Tetsuro; Hata, Jun; Wakisaka, Yoshinobu; Kuroda, Junya; Kuwashiro, Takahiro; Kitazono, Takanari; Kamouchi, Masahiro

    2016-01-01

    Background and Purpose Although plasma C-reactive protein (CRP) is elevated in response to inflammation caused by brain infarction, the association of CRP with clinical outcomes after acute ischemic stroke remains uncertain. This study examined whether plasma high-sensitivity CRP (hsCRP) levels at onset were associated with clinical outcomes after acute ischemic stroke independent of conventional risk factors and acute infections after stroke. Methods We prospectively included 3653 patients with first-ever ischemic stroke who had been functionally independent and were hospitalized within 24 h of onset. Plasma hsCRP levels were measured on admission and categorized into quartiles. The association between hsCRP levels and clinical outcomes, including neurological improvement, neurological deterioration, and poor functional outcome (modified Rankin scale ≥3 at 3 months), were investigated using a logistic regression analysis. Results Higher hsCRP levels were significantly associated with unfavorable outcomes after adjusting for age, sex, baseline National Institutes of Health Stroke Scale score, stroke subtype, conventional risk factors, intravenous thrombolysis and endovascular therapy, and acute infections during hospitalization (multivariate-adjusted odds ratios [95% confidence interval] in the highest quartile versus the lowest quartile as a reference: 0.80 [0.65–0.97] for neurological improvement, 1.72 [1.26–2.34] for neurological deterioration, and 2.03 [1.55–2.67] for a poor functional outcome). These associations were unchanged after excluding patients with infectious diseases occurring during hospitalization, or those with stroke recurrence or death. These trends were similar irrespective of stroke subtypes or baseline stroke severity, but more marked in patients aged <70 years (Pheterogeneity = 0.001). Conclusions High plasma hsCRP is independently associated with unfavorable clinical outcomes after acute ischemic stroke. PMID:27258004

  2. Effect of a 72 Hour Stroke Care Bundle on Early Outcomes after Acute Stroke: A Non Randomised Controlled Study

    PubMed Central

    Nakibuuka, Jane; Sajatovic, Martha; Nankabirwa, Joaniter; Ssendikadiwa, Charles; Kalema, Nelson; Kwizera, Arthur; Byakika-Tusiime, Jayne; Furlan, Anthony J.; Kayima, James; Ddumba, Edward; Katabira, Elly

    2016-01-01

    Background Integrated care pathways (ICP) in stroke management are increasingly being implemented to improve outcomes of acute stroke patients. We evaluated the effect of implementing a 72 hour stroke care bundle on early outcomes among patients admitted within seven days post stroke to the national referral hospital in Uganda. Methods In a one year non-randomised controlled study, 127 stroke patients who had ‘usual care’ (control group) were compared to 127 stroke patients who received selected elements from an ICP (intervention group). Patients were consecutively enrolled (controls first, intervention group second) into each group over 5 month periods and followed to 30-days post stroke. Incidence outcomes (mortality and functional ability) were compared using chi square test and adjusted for potential confounders. Kaplan Meier survival estimates and log rank test for comparison were used for time to death analysis for all strokes and by stroke severity categories. Secondary outcomes were in-hospital mortality, median survival time and median length of hospital stay. Results Mortality within 7 days was higher in the intervention group compared to controls (RR 13.1, 95% CI 3.3–52.9). There was no difference in 30-day mortality between the two groups (RR 1.2, 95% CI 0.5–2.6). There was better 30-day survival in patients with severe stroke in the intervention group compared to controls (P = 0.018). The median survival time was 30 days (IQR 29–30 days) in the control group and 30 days (IQR 7–30 days) in the intervention group. In the intervention group, 41patients (32.3%) died in hospital compared to 23 (18.1%) in controls (P < 0.001). The median length of hospital stay was 8 days (IQR 5–12 days) in the controls and 4 days (IQR 2–7 days) in the intervention group. There was no difference in functional outcomes between the groups (RR 0.9, 95% CI 0.4–2.2). Conclusions While implementing elements of a stroke-focused ICP in a Ugandan national referral

  3. Acute stroke revealing Takayasu's arteritis in a patient with Crohn's disease.

    PubMed

    Lavie, Gil; Zalmanovich, Anat; Golan, Yitzhak; Jonas Kimchi, Tali; Barenboim, Erez

    2016-08-01

    A 36-year-old Caucasian male with Crohn's disease exhibited acute ischaemic stroke as the first manifestation of Takayasu's arteritis. Stroke as the first clinical manifestation of Takayasu's arteritis has been rarely reported. Though rare in Western countries, Takayasu's arteritis should be considered as a possibility in young patients presenting with stroke. Both Takayasu's arteritis and Crohn's disease may increase the risk of ischaemic stroke. Furthermore, their coexistence is much higher than that expected by chance and suggest a pathophysiological link between these diseases. PMID:27075786

  4. Endovascular Interventions in Acute Ischemic Stroke: Recent Evidence, Current Challenges, and Future Prospects.

    PubMed

    Appireddy, Ramana; Zerna, Charlotte; Menon, Bijoy K; Goyal, Mayank

    2016-07-01

    After many years of clinical research, endovascular thrombectomy has been conclusively proven to be an effective treatment in acute ischemic stroke. The evidence is compelling; however, it is generated in high volume stroke centers with stroke expertise. Challenges remain ahead on translating and implementing this evidence in routine clinical care across the world. The current evidence has opened up avenues for further research and innovation in this field. In this review, we will discuss the evolution of evidence on endovascular thrombectomy followed by a discussion of challenges and future prospects in this exciting field of stroke care. PMID:27221502

  5. Unsuccessful tissue plasminogen activator treatment of acute stroke caused by a calcific embolus.

    PubMed

    Halloran, John I; Bekavac, Ivo

    2004-10-01

    Intravenous (IV) administration of tissue plasminogen activator (tPA) given to patients during acute cerebral ischemia according to National Institute of Neurological Disorders and Stroke (NINDS) guidelines improves clinical outcome by 11% to 14%. The success of IV tPA stroke therapy is dependent on several previously reported factors. The authors suggest that the presence of calcification within an embolus may represent an additional important factor. This report describes a patient with an acute stroke secondary to a spontaneous calcific cerebral embolus who had a negative outcome despite receiving proper thrombolytic therapy. PMID:15358964

  6. The effects of telemedicine on racial and ethnic disparities in access to acute stroke care

    PubMed Central

    Lyerly, Michael J; Wu, Tzu-Ching; Mullen, Michael T; Albright, Karen C; Wolff, Catherine; Boehme, Amelia K; Branas, Charles C; Grotta, James C; Savitz, Sean I; Carr, Brendan G

    2016-01-01

    Racial and ethnic disparities have been previously reported in acute stroke care. We sought to determine the effect of telemedicine (TM) on access to acute stroke care for racial and ethnic minorities in the state of Texas. Data were collected from the US Census Bureau, The Joint Commission and the American Hospital Association. Access for racial and ethnic minorities was determined by summing the population that could reach a primary stroke centre (PSC) or telemedicine spoke within specified time intervals using validated models. TM extended access to stroke expertise by 1.5 million residents. The odds of providing 60-minute access via TM were similar in Blacks and Whites (prevalence odds ratios (POR) 1.000, 95% CI 1.000–1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000–1.001). The odds of providing access via TM were also similar for Hispanics and non-Hispanics (POR 1.000, 95% CI 1.000–1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000–1.000). We found that telemedicine increased access to acute stroke care for 1.5 million Texans. While racial and ethnic disparities exist in other components of stroke care, we did not find evidence of disparities in access to the acute stroke expertise afforded by telemedicine. PMID:26116854

  7. Remote ischemic conditioning for acute ischemic stroke: dawn in the darkness.

    PubMed

    Pan, Jingrui; Li, Xiangpen; Peng, Ying

    2016-07-01

    Stroke is a leading cause of disability with high morbidity and mortality worldwide. Of all strokes, 87% are ischemic. The only approved treatments for acute ischemic stroke are intravenous thrombolysis with alteplase within 4.5 h and thrombectomy within 8 h after symptom onset, which can be applied to just a few patients. During the past decades, ischemic preconditioning has been widely studied to confirm its neuroprotection against subsequent ischemia/reperfusion injury in the brain, including preconditioning in situ or in a remote organ (such as a limb) before onset of brain ischemia, the latter of which is termed as remote ischemic preconditioning. Because acute stroke is unpredicted, ischemic preconditioning is actually not suitable for clinical application. So remote ischemic conditioning performed during or after the ischemic duration of the brain was then designed to study its neuroprotection alone or in combination with alteplase in animals and patients, which is named as remote ischemic perconditioning or remote ischemic postconditioning. As expected, animal experiments and clinical trials both showed exciting results, indicating that an evolution in the treatment for acute ischemic stroke may not be far away. However, some problems or disputes still exist. This review summarizes the research progress and unresolved issues of remote ischemic conditioning (pre-, per-, and post-conditioning) in treating acute ischemic stroke, with the hope of advancing our understanding of this promising neuroprotective strategy for ischemic stroke in the near future. PMID:26812782

  8. The Influence of Acute Hyperglycemia in an Animal Model of Lacunar Stroke That Is Induced by Artificial Particle Embolization

    PubMed Central

    Tsai, Ming-Jun; Lin, Ming-Wei; Huang, Yaw-Bin; Kuo, Yu-Min; Tsai, Yi-Hung

    2016-01-01

    Animal and clinical studies have revealed that hyperglycemia during ischemic stroke increases the stroke's severity and the infarct size in clinical and animal studies. However, no conclusive evidence demonstrates that acute hyperglycemia worsens post-stroke outcomes and increases infarct size in lacunar stroke. In this study, we developed a rat model of lacunar stroke that was induced via the injection of artificial embolic particles during full consciousness. We then used this model to compare the acute influence of hyperglycemia in lacunar stroke and diffuse infarction, by evaluating neurologic behavior and the rate, size, and location of the infarction. The time course of the neurologic deficits was clearly recorded from immediately after induction to 24 h post-stroke in both types of stroke. We found that acute hyperglycemia aggravated the neurologic deficit in diffuse infarction at 24 h after stroke, and also aggravated the cerebral infarct. Furthermore, the infarct volumes of the basal ganglion, thalamus, hippocampus, and cerebellum but not the cortex were positively correlated with serum glucose levels. In contrast, acute hyperglycemia reduced the infarct volume and neurologic symptoms in lacunar stroke within 4 min after stroke induction, and this effect persisted for up to 24 h post-stroke. In conclusion, acute hyperglycemia aggravated the neurologic outcomes in diffuse infarction, although it significantly reduced the size of the cerebral infarct and improved the neurologic deficits in lacunar stroke. PMID:27226775

  9. Building a "brain attack" team to administer thrombolytic therapy for acute ischemic stroke

    PubMed Central

    Hill, M D; Barber, P A; Demchuk, A M; Sevick, R J; Newcommon, N J; Green, T; Buchan, A M

    2000-01-01

    Before tissue plasminogen activator (tPA) was licensed for use in Canada, in February 1999, the Calgary Regional Stroke Program spearheaded the development and organization of local resources to use thrombolytic therapy in patients who had experienced acute ischemic stroke. In 1996 special permission was obtained from the Calgary Regional Health Authority to use intravenously administered tPA for acute ischemic stroke, and ethical and scientific review boards approved the protocols. After 3 years our efforts have resulted in improved patient outcomes, shorter times from symptom onset to treatment and acceptable adverse event rates. Areas for continued improvement include the door-to-needle time and broader education of the public about the symptoms of acute ischemic stroke. PMID:10862236

  10. Effects of Centralizing Acute Stroke Services on Stroke Care Provision in Two Large Metropolitan Areas in England

    PubMed Central

    Morris, Stephen; Hoffman, Alex; Hunter, Rachael M.; Boaden, Ruth; McKevitt, Christopher; Perry, Catherine; Pursani, Nanik; Rudd, Anthony G.; Turner, Simon J.; Tyrrell, Pippa J.; Wolfe, Charles D.A.; Fulop, Naomi J.

    2015-01-01

    Background and Purpose— In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients’ homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London’s stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. Methods— Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. Results— Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3–66.2); London=72.1% (71.4–72.8); comparator=55.5% (54.8–56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. Conclusions— Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical

  11. Stroke

    MedlinePlus

    ... the blockages that lead to ischemic strokes. A hemorrhagic stroke occurs if an artery in the brain leaks ... risms) are examples of conditions that can cause hemorrhagic strokes. (Aneurysms are balloon-like bulges in an artery ...

  12. Noninvasive ventilatory correction as an adjunct to an experimental systemic reperfusion therapy in acute ischemic stroke.

    PubMed

    Barlinn, Kristian; Balucani, Clotilde; Palazzo, Paola; Zhao, Limin; Sisson, April; Alexandrov, Andrei V

    2010-01-01

    Background. Obstructive sleep apnea (OSA) is a common condition in patients with acute ischemic stroke and associated with early clinical deterioration and poor functional outcome. However, noninvasive ventilatory correction is hardly considered as a complementary treatment option during the treatment phase of acute ischemic stroke. Summary of Case. A 55-year-old woman with an acute middle cerebral artery (MCA) occlusion received intravenous tissue plasminogen activator (tPA) and enrolled into a thrombolytic research study. During tPA infusion, she became drowsy, developed apnea episodes, desaturated and neurologically deteriorated without recanalization, re-occlusion or intracerebral hemorrhage. Urgent noninvasive ventilatory correction with biphasic positive airway pressure (BiPAP) reversed neurological fluctuation. Her MCA completely recanalized 24 hours later. Conclusions. Noninvasive ventilatory correction should be considered more aggressively as a complementary treatment option in selected acute stroke patients. Early initiation of BiPAP can stabilize cerebral hemodynamics and may unmask the true potential of other therapies. PMID:21052540

  13. Incremental Value of Left Atrial Global Longitudinal Strain for Prediction of Post Stroke Atrial Fibrillation in Patients with Acute Ischemic Stroke

    PubMed Central

    Kim, Darae; Cho, In Jeong; Kim, Young Dae; Nam, Hyo Suk; Chang, Hyuk-Jae; Hong, Geu-Ru; Ha, Jong-Won; Heo, Ji Hoe; Chung, Namsik

    2016-01-01

    Background Atrial fibrillation (AF) is a well-established risk factor for stroke. Interestingly, ischemic stroke increases risk of incident AF in patients without prior diagnosed AF. For better risk stratification for post-stroke AF, we studied left atrial (LA) size and mechanical function using two-dimensional (2D) speckle tracking imaging in patients with acute ischemic stroke. Methods A total of 227 patients (132 males, age 67 ± 12) with acute ischemic stroke without a history of AF underwent 2D transthoracic echocardiography and speckle tracking imaging for the assessment of LA volume index and global LA longitudinal strain (LALS). From clinical variables, the CHA2DS2-VASc score and National Institute of Health Stroke Scale (NIHSS) were calculated in each patient. Post-stroke AF was defined as newly diagnosed AF during the course after ischemic stroke. Results Post-stroke AF occurred in 25 patients (11%). Patients with post-stroke AF were older and showed a higher tendency of CHA2DS2-VASc score, significantly higher log NIHSS, larger LA volume index and lower global LALS than those without. In multivariate analysis, global LALS was an independent predictor for post-stroke AF (hazard ratio 0.90, 95% confidence interval 0.83.0.97, p < 0.01) after controlling for confounding factors. Furthermore, global LALS provided incremental predictive value for post-stroke AF over the CHA2DS2-VASc score, NIHSS, and LA volume index. The global LALS < 14.5% better distinguished post-stroke AF (area under the curve 0.837, sensitivity 60%, specificity 95%, p < 0.01) than CHA2DS2-VASc score. Conclusion Global LALS as a marker of LA mechanical function has incremental predictive value for post-stroke AF in patients with acute ischemic stroke. PMID:27081440

  14. Incidence and Risk Factors for Acute Kidney Injury Following Mannitol Infusion in Patients With Acute Stroke: A Retrospective Cohort Study.

    PubMed

    Lin, Shin-Yi; Tang, Sung-Chun; Tsai, Li-Kai; Yeh, Shin-Joe; Shen, Li-Jiuan; Wu, Fe-Lin Lin; Jeng, Jiann-Shing

    2015-11-01

    Mannitol, an osmotic diuretic, is commonly used to treat patients with acute brain edema, but its use also increases the risk of developing acute kidney injury (AKI). In this study, we investigated the incidence and risk factors of mannitol-related AKI in acute stroke patients.A total of 432 patients (ischemic stroke 62.3%) >20 years of age who were admitted to the neurocritical care center in a tertiary hospital and received mannitol treatment were enrolled in this study. Clinical parameters including the scores of National Institutes of Health Stroke Scale (NIHSS) at admission, vascular risk factors, laboratory data, and concurrent nephrotoxic medications were registered. Acute kidney injury was defined as an absolute elevation in the serum creatinine (Scr) level of ≥0.3 mg/dL from the baseline or a ≥50% increase in Scr.The incidence of mannitol-related AKI was 6.5% (95% confidence interval, 4.5%-9.3%) in acute stroke patients, 6.3% in patients with ischemic stroke, and 6.7% in patients with intracerebral hemorrhage. Multivariate analysis revealed that diabetes, lower estimated glomerular filtration rate at baseline, higher initial NIHSS score, and concurrent use of diuretics increased the risk of mannitol-related AKI. When present, the combination of these elements displayed an area under the receiver operating characteristic curve of 0.839 (95% confidence interval, 0.770-0.909). In conclusion, mannitol-related AKI is not uncommon in the treatment of acute stroke patients, especially in those with vulnerable risk factors. PMID:26632702

  15. [Ischemic stroke as reaction to an acute stressful event].

    PubMed

    Ibrahimagić, Omer C; Sinanović, Osman; Cickusić, Amra; Smajlović, Dzevdet

    2005-01-01

    The period following ischemic stroke can be considered as a reaction to a stressful event. Changes in cortisol secretion are one of the indicators of stress reaction. The aim of the study was to determine morning serum levels of cortisol in stroke patients within 48 hours and 15 days of ischemic stroke onset. Study group included 40 patients, 20 of them were females, mean age 65.3 +/- 10.3 years. The patients did not receive any corticosteroid agents or spironolactone, and did not suffer from Cushing's or Addison's syndrome. Ischemic stroke was verified by computed tomography of the brain. The fluorometric method with DELFIA Cortisol immunoassay was used to determine morning serum cortisol levels. Reference values of the measured hormone were 201-681 nmol/l. The mean level of serum cortisol within 48 hours of stroke was 560.9 +/- 318.9 nmol/l, and on day 15 it was 426.2 +/- 159.3 nmol/l, i.e. significantly lower (p < 0.02). On the first measurement, the level of serum cortisol was elevated in 32%, and on the second measurement in only 7.5% patients, which was also significantly lower (p < 0.001). It was concluded that the stress reaction in ischemic stroke patients was more pronounced within the first 48 hours of stroke onset. Judging from the morning cortisol levels, the reaction to stress was considerably less pronounced 15 days after stroke onset. PMID:15875466

  16. Early High-dosage Atorvastatin Treatment Improved Serum Immune-inflammatory Markers and Functional Outcome in Acute Ischemic Strokes Classified as Large Artery Atherosclerotic Stroke

    PubMed Central

    Tuttolomondo, Antonino; Di Raimondo, Domenico; Pecoraro, Rosaria; Maida, Carlo; Arnao, Valentina; Corte, Vittoriano Della; Simonetta, Irene; Corpora, Francesca; Di Bona, Danilo; Maugeri, Rosario; Iacopino, Domenico Gerardo; Pinto, Antonio

    2016-01-01

    Abstract Statins have beneficial effects on cerebral circulation and brain parenchyma during ischemic stroke and reperfusion. The primary hypothesis of this randomized parallel trial was that treatment with 80 mg/day of atorvastatin administered early at admission after acute atherosclerotic ischemic stroke could reduce serum levels of markers of immune-inflammatory activation of the acute phase and that this immune-inflammatory modulation could have a possible effect on prognosis of ischemic stroke evaluated by some outcome indicators. We enrolled 42 patients with acute ischemic stroke classified as large arteries atherosclerosis stroke (LAAS) randomly assigned in a randomized parallel trial to the following groups: Group A, 22 patients treated with atorvastatin 80 mg (once-daily) from admission day until discharge; Group B, 20 patients not treated with atorvastatin 80 mg until discharge, and after discharge, treatment with atorvastatin has been started. At 72 hours and at 7 days after acute ischemic stroke, subjects of group A showed significantly lower plasma levels of tumor necrosis factor-α, interleukin (IL)-6, vascular cell adhesion molecule-1, whereas no significant difference with regard to plasma levels of IL-10, E-Selectin, and P-Selectin was observed between the 2 groups. At 72 hours and 7 days after admission, stroke patients treated with atorvastatin 80 mg in comparison with stroke subjects not treated with atorvastatin showed a significantly lower mean National Institutes of Health Stroke Scale and modified Rankin scores. Our findings provide the first evidence that atorvastatin acutely administered immediately after an atherosclerotic ischemic stroke exerts a lowering effect on immune-inflammatory activation of the acute phase of stroke and that its early use is associated to a better functional and prognostic profile. PMID:27043681

  17. Acute Stroke Care at Rural Hospitals in Idaho: Challenges in Expediting Stroke Care

    ERIC Educational Resources Information Center

    Gebhardt, James G.; Norris, Thomas E.

    2006-01-01

    Context: Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. Purpose: To provide a snapshot of…

  18. Assessment of Serum UCH-L1 and GFAP in Acute Stroke Patients

    PubMed Central

    Ren, Changhong; Kobeissy, Firas; Alawieh, Ali; Li, Na; Li, Ning; Zibara, Kazem; Zoltewicz, Susie; Guingab-Cagmat, Joy; Larner, Stephen F.; Ding, Yuchuan; Hayes, Ronald L.; Ji, Xunming; Mondello, Stefania

    2016-01-01

    A rapid and reliable diagnostic test to distinguish ischemic from hemorrhagic stroke in patients presenting with stroke-like symptoms is essential to optimize management and triage for thrombolytic therapy. The present study measured serum concentrations of ubiquitin C-terminal hydrolase (UCH-L1) and glial fibrillary astrocytic protein (GFAP) in acute stroke patients and healthy controls and investigated their relation to stroke severity and patient characteristics. We also assessed the diagnostic performance of these markers for the differentiation of intracerebral hemorrhage (ICH) from ischemic stroke (IS). Both UCH-L1 and GFAP concentrations were significantly greater in ICH patients than in controls (p < 0.0001). However, exclusively GFAP differed in ICH compared with IS (p < 0.0001). GFAP yielded an AUC of 0.86 for differentiating between ICH and IS within 4.5hrs of symptom onset with a sensitivity of 61% and a specificity of 96% using a cut-off of 0.34ng/ml. Higher GFAP levels were associated with stroke severity and history of prior stroke. Our results demonstrate that blood UCH-L1 and GFAP are increased early after stroke and distinct biomarker-specific release profiles are associated with stroke characteristics and type. We also confirmed the potential of GFAP as a tool for early rule-in of ICH, while UCH-L1 was not clinically useful. PMID:27074724

  19. Motor recovery monitoring using acceleration measurements in post acute stroke patients

    PubMed Central

    2013-01-01

    Background Stroke is one of the major causes of morbidity and mortality. Its recovery and treatment depends on close clinical monitoring by a clinician especially during the first few hours after the onset of stroke. Patients who do not exhibit early motor recovery post thrombolysis may benefit from more aggressive treatment. Method A novel approach for monitoring stroke during the first few hours after the onset of stroke using a wireless accelerometer based motor activity monitoring system is developed. It monitors the motor activity by measuring the acceleration of the arms in three axes. In the presented proof of concept study, the measured acceleration data is transferred wirelessly using iMote2 platform to the base station that is equipped with an online algorithm capable of calculating an index equivalent to the National Institute of Health Stroke Score (NIHSS) motor index. The system is developed by collecting data from 15 patients. Results We have successfully demonstrated an end-to-end stroke monitoring system reporting an accuracy of calculating stroke index of more than 80%, highest Cohen’s overall agreement of 0.91 (with excellent κ coefficient of 0.76). Conclusion A wireless accelerometer based ‘hot stroke’ monitoring system is developed to monitor the motor recovery in acute-stroke patients. It has been shown to monitor stroke patients continuously, which has not been possible so far with high reliability. PMID:23590690

  20. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke

    PubMed Central

    Rabinstein, Alejandro A.

    2015-01-01

    Most of the contraindications to the administration of intravenous (IV) recombinant tissue plasminogen activator (rtPA) originated as exclusion criteria in major stroke trials. These were derived from expert consensus for the National Institute of Neurological Disorders and Stroke (NINDS) trial. Despite the fact that the safety and efficacy of IV rtPA has been repeatedly confirmed in large international observational studies over the past 20 years, most patients with acute ischemic stroke disappointingly still do not receive thrombolytic treatment. Some of the original exclusion criteria have proven to be unnecessarily restrictive in real-world clinical practice. It has been suggested that application of relaxed exclusion criteria might increase the IV thrombolysis rate up to 20% with comparable outcomes to thrombolysis with more conventional criteria. We review the absolute and relative contraindications to IV rtPA for acute ischemic stroke, discussing the underlying rationale and evidence supporting these exclusion criteria. PMID:26288669

  1. Thrombolytics in acute ischaemic stroke: a guide to patient selection and optimum use.

    PubMed

    Adams, H P

    2000-02-01

    Intravenously administered alteplase (recombinant tissue plasminogen activator; rtPA) is the only medical treatment that has been approved for the management of acute ischaemic stroke. Although rtPA has demonstrated efficacy in improving outcomes of patients with a wide range of neurological impairments, it cannot be given with impunity. Thrombolytic therapy is associated with a considerable risk of intracranial bleeding that is likely to be catastrophic. Careful selection of patients to treat and intensive ancillary care are the keys for successful administration of rtPA. An algorithm for selection is based on the interval from the onset of stroke, history of recent medical illnesses or use of medications, findings of the medical and neurological examinations and the results of laboratory and brain imaging studies. Because rtPA must be given within 3 hours of onset of stroke, most patients cannot be treated. Thus, additional therapies are needed for treatment of patients with acute ischaemic stroke. PMID:18034518

  2. Acute Stroke: Current Evidence-based Recommendations for Prehospital Care

    PubMed Central

    Glober, Nancy K.; Sporer, Karl A.; Guluma, Kama Z.; Serra, John P.; Barger, Joe A.; Brown, John F.; Gilbert, Gregory H.; Koenig, Kristi L.; Rudnick, Eric M.; Salvucci, Angelo A.

    2016-01-01

    Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols. PMID:26973735

  3. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study.

    PubMed Central

    Weir, C. J.; Murray, G. D.; Dyker, A. G.; Lees, K. R.

    1997-01-01

    OBJECTIVE: To determine whether raised plasma glucose concentration independently influences outcome after acute stroke or is a stress response reflecting increased stroke severity. DESIGN: Long-term follow up study of patients admitted to an acute stroke unit. SETTING: Western Infirmary, Glasgow. SUBJECTS: 811 patients with acute stroke confirmed by computed tomography. Analysis was restricted to the 750 non-diabetic patients. MAIN OUTCOME MEASURES: Survival time and placement three months after stroke. RESULTS: 645 patients (86%) had ischaemic stroke and 105 patients (14%) haemorrhagic stroke. Cox's proportional hazards modelling with stratification according to Oxfordshire Community Stroke Project categories identified increased age (relative hazard 1.36 per decade; 95% confidence interval 1.21 to 1.53), haemorrhagic stroke (relative hazard 1.67; 1.22 to 2.28), time to resolution of symptoms > 72 hours (relative hazard 2.15; 1.15 to 4.05), and hyperglycaemia (relative hazard 1.87; 1.43 to 2.45) as predictors of mortality. The effect of glucose concentration on survival was greatest in the first month. CONCLUSIONS: Plasma glucose concentration above 8 mmol/l after acute stroke predicts a poor prognosis after correcting for age, stroke severity, and stroke subtype. Raised plasma glucose concentration is therefore unlikely to be solely a stress response and should arguably be treated actively. A randomised trial is warranted. PMID:9158464

  4. Gender differences in patients with acute ischemic stroke.

    PubMed

    Caso, Valeria; Paciaroni, Maurizio; Agnelli, Giancarlo; Corea, Francesco; Ageno, Walter; Alberti, Andrea; Lanari, Alessia; Micheli, Sara; Bertolani, Luca; Venti, Michele; Palmerini, Francesco; Billeci, Antonia M R; Comi, Giancarlo; Previdi, Paolo; Silvestrelli, Giorgio

    2010-01-01

    Stroke has a greater effect on women than men owing to the fact that women have more stroke events and are less likely to recover. Age-specific stroke rates are higher in men; however, because of women's longer life expectancy and the much higher incidence of stroke at older ages, women have more stroke events than men overall. The aims of this prospective study in consecutive patients were to assess whether there are gender differences in stroke risk factors, treatment or outcome. Consecutive patients with ischemic stroke were included in this prospective study at four study centers. Disability was assessed using a modified Rankin Scale score (>or=3 indicating disabling stroke) in both genders at 90 days. Outcomes and risk factors in both genders were compared using the chi(2) test. Multiple logistic regression analysis was used to identify any independent predictors of outcome. A total of 1136 patients were included in this study; of these, 494 (46%) were female. Women were statistically older compared with men: 76.02 (+/- 12.93) and 72.68 (+/- 13.27) median years of age, respectively. At admission, females had higher NIH Stroke Scale scores compared with males (9.4 [+/- 6.94] vs 7.6 [+/- 6.28] for men; p = 0.0018). Furthermore, females tended to have more cardioembolic strokes (153 [30%] vs 147 [23%] for men; p = 0.004). Males had lacunar and atherosclerotic strokes more often (146 [29%] vs 249 [39%] for men; p = 0.002, and 68 [13%] vs 123 [19%] for men; p = 0.01, respectively). The mean modified Rankin Scale score at 3 months was also significantly different between genders, at 2.5 (+/- 2.05) for women and 2.1 (+/- 2.02) for men (p = 0.003). However, at multivariate analysis, female gender was not an indicator for negative outcome. It was concluded that female gender was not an independent factor for negative outcome. In addition, both genders demonstrated different stroke pathophysiologies. These findings should be taken into account when diagnostic workup and

  5. Sex differences in patients with acute ischemic stroke in Tuzla region, Bosnia and Herzegovina.

    PubMed

    Salihović, Denisa; Smajlović, Dzevdet; Sinanović, Osman; Kojić, Biljana

    2010-05-01

    Although many aspects of stroke are similar at both sexes, however, there are some differences and characteristics as well. The aim of this study was to analyze sex differences in patients with acute ischemic stroke (IS) regarding to risk factors, subtypes, stroke severity and outcome. From January 1st 2001 to December 31st 2005 at the Department of Neurology Tuzla 2833 patients were admitted with acute ischemic stroke (IS). We were analyzed risk factors, subtypes, stroke severity (Scandinavian Stroke Scale), and thirty-day outcome. There were 1484 (52.3%) female, and they were older than male (67.8 +/- 10.6 vs. 65.7 +/- 10.5, p<0.0001). Hypertension (78% vs. 67%, p<0.0001), heart diseases (50% vs. 45%, p=0.009), atrial fibrillation (22% vs. 14%, p<0.0001) and diabetes mellitus (33% vs. 21%, p<0.0001) were frequently in female, while smoking (45% vs. 14%) and alcohol overuse (18% vs. 0,6%) in male (p<0.0001). Atherothrombotic type of ischemic stroke was frequently in male (37.4% vs. 31.6%, p=0.0013) and cardioembolic in female (21.7% vs. 15.5%, p<0.0001). At admission female had lower SS (SS 31.0 +/- 15 vs. 34.0 +/- 15, p<0.0001). Thirty-day mortality was significantly higher in female (23.3% vs. 18.4%, p=0.0015), and favourable outcome within one month (Rankin Scale stroke is higher in female who are older than male. There are some sex differences according to the distribution of risk factors and subtypes of ischemic stroke. Stroke severity at admission, thirty-day mortality, and disability are higher in female. PMID:20507291

  6. Intrinsic factors influencing help-seeking behaviour in an acute stroke situation.

    PubMed

    Zock, Elles; Kerkhoff, Henk; Kleyweg, Ruud Peter; van de Beek, Diederik

    2016-09-01

    The proportion of stroke patients eligible for intravenous or intra-arterial treatment is still limited because many patients do not seek medical help immediately after stroke onset. The aim of our study was to explore which intrinsic factors and considerations influence help-seeking behaviour of relatively healthy participants, confronted with stroke situations. Semi-structured interviews were conducted with 25 non-stroke participants aged 50 years or older. We presented 5 clinical stroke situations as if experienced by the participants themselves. Recognition and interpretation of symptoms were evaluated and various factors influencing help-seeking behaviour were explored in-depth. We used the thematic synthesis method for data analysis. Five themes influencing help-seeking behaviour in a stroke situation were identified: influence of knowledge, views about seriousness, ideas about illness and health, attitudes towards others and beliefs about the emergency medical system. A correct recognition of stroke symptoms or a correct interpretation of the stroke situations did not automatically result in seeking medical help. Interestingly, similar factors could lead to different types of actions between participants. Many intrinsic, as well as social and environmental factors are of influence on help-seeking behaviour in an acute stroke situation. All these factors seem to play a complex role in help-seeking behaviour with considerable inter-individual variations. Accomplishing more patients eligible for acute stroke treatment, future research should focus on better understanding of all factors at various levels grounded in a theory of help-seeking behaviour. PMID:26732617

  7. What is still missing in acute-phase treatment of stroke: a prospective observational study.

    PubMed

    Mazzucco, Sara; Turri, Giulia; Mirandola, Rina; Bovi, Paolo; Bisoffi, Giulia

    2013-04-01

    Early recognition of stroke symptoms and activation of emergency medical service (EMS) positively affects prognosis after a stroke. To assess stroke awareness among stroke patients and medical personnel in the catchment area of Verona Hospital and how it affects stroke care, we prospectively studied timing of acute stroke care in relation to patients' characteristics. Patients admitted to Medical Departments of Verona University Hospital between January 1st and December 31st 2009 with a diagnosis of TIA or stroke were enrolled. Outcome measures were: time between (i) symptoms onset and hospital arrival, (ii) hospital arrival and brain CT scan, blood examination, ECG and neurological evaluation. The following patient/event characteristics were also collected: means of hospital arrival, sex, age, degree of disability, type of event (first or recurrent) and acute-phase treatment. Of 578 patients providing complete information, 60 % arrived to the emergency department with the EMS (EMS+ group), while 40 % arrived on their own (EMS-). EMS+ group was older than EMS- (mean age 76.2, SD 13.2, vs. 72.3, SD 13, respectively), displayed more severe symptoms (mRS 4 vs. 2) and shorter time interval between symptoms onset and hospital arrival, hospital arrival and CT scan, ECG, laboratory tests and neurological evaluation (p < 0.0001); 22 % of the EMS+ patients were stroke recurrences versus 29 % of the EMS- (p = 0.058); 85 % of thrombolised patients were EMS+. We conclude that there is a lack of awareness of stroke symptoms and risks of recurrence even among patients who already had a stroke and among medical personnel. PMID:22466805

  8. Diagnostic Potential of the NMDA Receptor Peptide Assay for Acute Ischemic Stroke

    PubMed Central

    Dambinova, Svetlana A.; Bettermann, Kerstin; Glynn, Theodore; Tews, Matthew; Olson, David; Weissman, Joseph D.; Sowell, Richard L.

    2012-01-01

    Background The acute assessment of patients with suspected ischemic stroke remains challenging. The use of brain biomarker assays may improve the early diagnosis of ischemic stroke. The main goal of the study was to evaluate whether the NR2 peptide, a product of the proteolytic degradation of N-methyl-D-aspartate (NMDA) receptors, can differentiate acute ischemic stroke (IS) from stroke mimics and persons with vascular risk factors/healthy controls. A possible correlation between biomarker values and lesion sizes was investigated as the secondary objective. Methods and Findings A total of 192 patients with suspected stroke who presented within 72 h of symptom onset were prospectively enrolled. The final diagnosis was determined based on clinical observations and radiological findings. Additionally gender- and age-matched healthy controls (n = 52) and persons with controlled vascular risk factors (n = 48) were recruited to compare NR2 peptide levels. Blinded plasma was assayed by rapid magnetic particles (MP) ELISA for NR2 peptide within 30 min and results for different groups compared using univariate and multivariate statistical analyses. There was a clinical diagnosis of IS in 101 of 192 (53%) and non-stroke in 91 (47%) subjects. The non-stroke group included presented with acute stroke symptoms who had no stroke (n = 71) and stroke mimics (n = 20). The highest NR2 peptide elevations where found in patients with IS that peaked at 12 h following symptom onset. When the biomarker cut off was set at 1.0 ug/L, this resulted in a sensitivity of 92% and a specificity of 96% to detect IS. A moderate correlation (rs = 0.73) between NR2 peptide values and acute ischemic cortical lesions (<200 mL) was found. Conclusions This study suggests that the NR2 peptide may be a brain specific biomarker to diagnose acute IS and may allow the differentiation of IS from stroke mimics and controls. Additional larger scale clinical validation studies are required

  9. Matrix Metalloproteinases and Blood-Brain Barrier Disruption in Acute Ischemic Stroke

    PubMed Central

    Lakhan, Shaheen E.; Kirchgessner, Annette; Tepper, Deborah; Leonard, Aidan

    2013-01-01

    Ischemic stroke continues to be one of the most challenging diseases in translational neurology. Tissue plasminogen activator (tPA) remains the only approved treatment for acute ischemic stroke, but its use is limited to the first hours after stroke onset due to an increased risk of hemorrhagic transformation over time resulting in enhanced brain injury. In this review we discuss the role of matrix metalloproteinases (MMPs) in blood-brain barrier (BBB) disruption as a consequence of ischemic stroke. MMP-9 in particular appears to play an important role in tPA-associated hemorrhagic complications. Reactive oxygen species can enhance the effects of tPA on MMP activation through the loss of caveolin-1 (cav-1), a protein encoded in the cav-1 gene that serves as a critical determinant of BBB permeability. This review provides an overview of MMPs’ role in BBB breakdown during acute ischemic stroke. The possible role of MMPs in combination treatment of acute ischemic stroke is also examined. PMID:23565108

  10. Current knowledge on the neuroprotective and neuroregenerative properties of citicoline in acute ischemic stroke.

    PubMed

    Martynov, Mikhail Yu; Gusev, Eugeny I

    2015-01-01

    Ischemic stroke is one of the leading causes of long-lasting disability and death. Two main strategies have been proposed for the treatment of ischemic stroke: restoration of blood flow by thrombolysis or mechanical thrombus extraction during the first few hours of ischemic stroke, which is one of the most effective treatments and leads to a better functional and clinical outcome. The other direction of treatment, which is potentially applicable to most of the patients with ischemic stroke, is neuroprotection. Initially, neuroprotection was mainly targeted at protecting gray matter, but during the past few years there has been a transition from a neuron-oriented approach toward salvaging the whole neurovascular unit using multimodal drugs. Citicoline is a multimodal drug that exhibits neuroprotective and neuroregenerative effects in a variety of experimental and clinical disorders of the central nervous system, including acute and chronic cerebral ischemia, intracerebral hemorrhage, and global cerebral hypoxia. Citicoline has a prolonged therapeutic window and is active at various temporal and biochemical stages of the ischemic cascade. In acute ischemic stroke, citicoline provides neuroprotection by attenuating glutamate exitotoxicity, oxidative stress, apoptosis, and blood-brain barrier dysfunction. In the subacute and chronic phases of ischemic stroke, citicoline exhibits neuroregenerative effects and activates neurogenesis, synaptogenesis, and angiogenesis and enhances neurotransmitter metabolism. Acute and long-term treatment with citicoline is safe and in most clinical studies is effective and improves functional outcome. PMID:27186142

  11. Current knowledge on the neuroprotective and neuroregenerative properties of citicoline in acute ischemic stroke

    PubMed Central

    Martynov, Mikhail Yu; Gusev, Eugeny I

    2015-01-01

    Ischemic stroke is one of the leading causes of long-lasting disability and death. Two main strategies have been proposed for the treatment of ischemic stroke: restoration of blood flow by thrombolysis or mechanical thrombus extraction during the first few hours of ischemic stroke, which is one of the most effective treatments and leads to a better functional and clinical outcome. The other direction of treatment, which is potentially applicable to most of the patients with ischemic stroke, is neuroprotection. Initially, neuroprotection was mainly targeted at protecting gray matter, but during the past few years there has been a transition from a neuron-oriented approach toward salvaging the whole neurovascular unit using multimodal drugs. Citicoline is a multimodal drug that exhibits neuroprotective and neuroregenerative effects in a variety of experimental and clinical disorders of the central nervous system, including acute and chronic cerebral ischemia, intracerebral hemorrhage, and global cerebral hypoxia. Citicoline has a prolonged therapeutic window and is active at various temporal and biochemical stages of the ischemic cascade. In acute ischemic stroke, citicoline provides neuroprotection by attenuating glutamate exitotoxicity, oxidative stress, apoptosis, and blood–brain barrier dysfunction. In the subacute and chronic phases of ischemic stroke, citicoline exhibits neuroregenerative effects and activates neurogenesis, synaptogenesis, and angiogenesis and enhances neurotransmitter metabolism. Acute and long-term treatment with citicoline is safe and in most clinical studies is effective and improves functional outcome. PMID:27186142

  12. The unexpected force of acute stroke leading to patients' sudden death as described by nurses.

    PubMed

    Rejnö, Åsa; Danielson, Ella; von Post, Iréne

    2013-03-01

    Stroke occurs suddenly and unexpectedly and its consequences can mean the difference between life and death. Research into stroke is extensive but largely focused on patients who survive. The aim of the study was to describe how nurses experience the patient's death and dying, when patients are afflicted by acute stroke and whose lives cannot be saved. The study had a descriptive design with a hermeneutical approach. Interviews were carried out with ten nurses in stroke units at three hospitals. Data were interpreted using hermeneutic textual interpretation based on Gadamer's philosophy. The study shows that sudden death, when unexpected forces intervene in the lives of patients afflicted by acute stroke, was described by the main theme sudden death - the unexpected force and the following three sub-themes: death comes unexpectedly and without warning to the patient; the relatives are at the mercy of the unexpected and the nurses find themselves in demanding situations. The new understanding emphasizes that the unexpected and demanding situations the nurses are put in can be understood as ethical dilemmas and value conflicts because they are not free to give their time to preserving the dying patient's dignity and are not able to give the good care they wish to. A more flexible organization could support the nurses in making use of the creative forces in the unexpected event which an acute stroke that leads to death constitutes. PMID:22612457

  13. Developing drug strategies for the neuroprotective treatment of acute ischemic stroke.

    PubMed

    Tuttolomondo, Antonino; Pecoraro, Rosaria; Arnao, Valentina; Maugeri, Rosario; Iacopino, Domenico Gerardo; Pinto, Antonio

    2015-01-01

    Developing new treatment strategies for acute ischemic stroke in the last twenty years has offered some important successes, but also several failures. Most trials of neuroprotective therapies have been uniformly negative to date. Recent research has reported how excitatory amino acids act as the major excitatory neurotransmitters in the cerebral cortex and hippocampus. Furthermore, other therapeutic targets such as free radical scavenger strategies and the anti-inflammatory neuroprotective strategy have been evaluated with conflicting data in animal models and human subjects with acute ischemic stroke. Whereas promising combinations of neuroprotection and neurorecovery, such as citicoline, albumin and cerebrolysin have been tested with findings worthy of further evaluation in larger randomized clinical trials. Understanding the complexities of the ischemic cascade is essential to developing pharmacological targets for acute ischemic stroke in neuroprotective or flow restoration therapeutic strategies. PMID:26469760

  14. Predicting discharge mortality after acute ischemic stroke using balanced data.

    PubMed

    Ho, King Chung; Speier, William; El-Saden, Suzie; Liebeskind, David S; Saver, Jeffery L; Bui, Alex A T; Arnold, Corey W

    2014-01-01

    Several models have been developed to predict stroke outcomes (e.g., stroke mortality, patient dependence, etc.) in recent decades. However, there is little discussion regarding the problem of between-class imbalance in stroke datasets, which leads to prediction bias and decreased performance. In this paper, we demonstrate the use of the Synthetic Minority Over-sampling Technique to overcome such problems. We also compare state of the art machine learning methods and construct a six-variable support vector machine (SVM) model to predict stroke mortality at discharge. Finally, we discuss how the identification of a reduced feature set allowed us to identify additional cases in our research database for validation testing. Our classifier achieved a c-statistic of 0.865 on the cross-validated dataset, demonstrating good classification performance using a reduced set of variables. PMID:25954451

  15. Subclinical carpal tunnel syndrome in patients with acute stroke

    PubMed Central

    Dahmardeh, Maryam; Dabiri, Soroosh

    2012-01-01

    Background Stroke is the first cause of morbidity all around the world. Entrapment neuropathies are a known complication of stroke. The objective of this study is to assess the frequency of subclinical carpal tunnel syndrome in the healthy and paretic hands of stroke patients. Methods The authors performed nerve conduction study in the first three days after admission in 39 stroke patients without subclinical carpal tunnel syndrome and 30 days after admission. Electrophysiological studies were done in both paretic and non-paretic hands. Both ulnar and median nerves were studied. Results After one month we found subclinical carpal tunnel syndrome in 16 paretic hands and 13 healthy hands. We did not find any difference in the frequency of carpal tunnel syndrome in two sides. Conclusion The authors suggest that simultaneous different mechanisms may act in inducing carpal tunnel syndrome in both hands of hemiparetic patients. PMID:24250872

  16. The Effect of Pulsatility Index on Infarct Volume in Acute Lacunar Stroke

    PubMed Central

    Kim, Yoon; Lee, Hanbin; An, Se-A; Yim, Byeongsoo; Kim, Jonguk; Kim, Ok Joon; Kim, Won Chan; Kim, Hyun Sook; Oh, Seung Hun

    2016-01-01

    Purpose Lacunar stroke, in the context of small vessel disease, is a type of cerebral infarction caused by occlusion of a penetrating artery. Pulsatility index (PI) is an easily measurable parameter in Transcranial Doppler ultrasound (TCD) study. PI reflects distal cerebral vascular resistance and has been interpreted as a surrogate marker of small vessel disease. We hypothesized that an increased PI, a marker of small vessel disease, might be associated with a larger infarct volume in acute lacunar stroke. Materials and Methods This study included 64 patients with acute lacunar stroke who underwent TCD and brain MRI. We evaluated the association between the mean PI value of bilateral middle cerebral arteries and infarct volume on diffusion-weighted MRI using univariate and multivariate linear regression. Results The mean infarct volume and PI were 482.18±406.40 mm3 and 0.86±0.18, respectively. On univariate linear regression, there was a significant positive association between PI and infarct volume (p=0.001). In the multivariate model, a single standard deviation increase of PI (per 0.18) was associated with an increase of 139.05 mm3 in infarct volume (95% confidence interval, 21.25 to 256.85; p=0.022). Conclusion We demonstrated that PI was an independent determinant of infarct volume in acute lacunar stroke. The PI value measured in acute stroke may be a surrogate marker of the extent of ischemic injury. PMID:27189290

  17. Acute ischemic non-embolic stroke and serum level of uric acid

    PubMed Central

    Sheykholeslami, Nazanin Zia; Gadari, Faranak; Ahmady, Jafar

    2012-01-01

    Background Impact of high level of uric acid on stroke is still controversial. We conducted this study to investigate the relationship between acute ischemic non-embolic stroke and serum levels of uric acid. Methods This was a case-control study on patients with acute ischemic non-embolic stroke in Rafsanjan, Iran. The control group consisted of normal persons who were similar to the case group in terms of age and gender. Serum level of uric acid in the first 24 hours of admission was measured with photometry method. Results In a total of 130 patients (59 mens), hyperuricemia was seen in 13.0% of subjects in the control group and 10.7% of subjects in the case group. Nine patients in case group and 7 patients in control group with hyperuricemia were women. No significant relationship was found between acute ischemic non-embolic stroke and serum level of uric acid. Conclusion There was no relationship between uric acid and acute ischemic non-embolic stroke. PMID:24250850

  18. Abnormal EEG Complexity and Functional Connectivity of Brain in Patients with Acute Thalamic Ischemic Stroke

    PubMed Central

    Liu, Shuang; Guo, Jie; Meng, Jiayuan; Wang, Zhijun; Yao, Yang; Yang, Jiajia; Qi, Hongzhi; Ming, Dong

    2016-01-01

    Ischemic thalamus stroke has become a serious cardiovascular and cerebral disease in recent years. To date the existing researches mostly concentrated on the power spectral density (PSD) in several frequency bands. In this paper, we investigated the nonlinear features of EEG and brain functional connectivity in patients with acute thalamic ischemic stroke and healthy subjects. Electroencephalography (EEG) in resting condition with eyes closed was recorded for 12 stroke patients and 11 healthy subjects as control group. Lempel-Ziv complexity (LZC), Sample Entropy (SampEn), and brain network using partial directed coherence (PDC) were calculated for feature extraction. Results showed that patients had increased mean LZC and SampEn than the controls, which implied the stroke group has higher EEG complexity. For the brain network, the stroke group displayed a trend of weaker cortical connectivity, which suggests a functional impairment of information transmission in cortical connections in stroke patients. These findings suggest that nonlinear analysis and brain network could provide essential information for better understanding the brain dysfunction in the stroke and assisting monitoring or prognostication of stroke evolution. PMID:27403202

  19. Music as Medicine: The Therapeutic Potential of Music for Acute Stroke Patients.

    PubMed

    Supnet, Charlene; Crow, April; Stutzman, Sonja; Olson, DaiWai

    2016-04-01

    Nurses caring for patients with acute stroke are likely to administer both music and medication with therapeutic intent. The administration of medication is based on accumulated scientific evidence and tailored to the needs of each patient. However, the therapeutic use of music is generally based on good intentions and anecdotal evidence. This review summarizes and examines the current literature regarding the effectiveness of music in the treatment of critically ill patients and the use of music in neurologically injured patients. The rationale for hypothesis-driven research to explore therapeutic music intervention in acute stroke is compelling. PMID:27037347

  20. CT Angiography and Presentation NIH stroke Scale in Predicting TIA in Patients Presenting with Acute Stroke Symptoms.

    PubMed

    Karaman, Bedriye; Selph, James; Burdine, Joselyn; Graham, Cole Blease; Sen, Souvik

    2013-11-01

    Patient candidacy for acute stroke intervention, is currently assessed using brain computed tomography angiography (CTA) evidence of significant stenosis/occlusion (SSO) with a high National Institutes of Health Stroke Scale (NIHSS) (>6). This study examined the association between CTA without significant stenosis/occlusion (NSSO) and lower NIHSS (≤ 6) with transient ischemic attack (TIA) and other good clinical outcomes at discharge. Patients presenting <8 hours from stroke symptom onset, had an NIHSS assessment and brain CTA performed at presentation. Good clinical outcomes were defined as: discharge diagnosis of TIA, modified Rankin Score [mRS] ≤ 1, and home as the discharge disposition. Eighty-five patients received both an NIHSS at presentation and a CTA at 4.2 ± 2.2 hours from stroke symptom onset. Patients with NSSO on CTA as well as those with NIHSS≤6 had better outcomes at discharge (p<0.001). NIHSS ≤ 6 were more likely than NSSO (p=0.01) to have a discharge diagnosis of TIA (p<0.001). NSSO on CTA and NIHSS ≤ 6 also correlated with fewer deaths (p<0.001). Multivariable analyses showed NSSO on CTA (Adjusted OR: 5.8 95% CI: 1.2-27.0, p=0.03) independently predicted the discharge diagnosis of TIA. Addition of NIHSS ≤ 6 to NSSO on CTA proved to be a stronger independent predictor of TIA (Adjusted OR 18.7 95% CI: 3.5-98.9, p=0.001). PMID:24851234

  1. CT Angiography and Presentation NIH stroke Scale in Predicting TIA in Patients Presenting with Acute Stroke Symptoms

    PubMed Central

    Karaman, Bedriye; Selph, James; Burdine, Joselyn; Graham, Cole Blease; Sen, Souvik

    2014-01-01

    Patient candidacy for acute stroke intervention, is currently assessed using brain computed tomography angiography (CTA) evidence of significant stenosis/occlusion (SSO) with a high National Institutes of Health Stroke Scale (NIHSS) (>6). This study examined the association between CTA without significant stenosis/occlusion (NSSO) and lower NIHSS (≤ 6) with transient ischemic attack (TIA) and other good clinical outcomes at discharge. Patients presenting <8 hours from stroke symptom onset, had an NIHSS assessment and brain CTA performed at presentation. Good clinical outcomes were defined as: discharge diagnosis of TIA, modified Rankin Score [mRS] ≤ 1, and home as the discharge disposition. Eighty-five patients received both an NIHSS at presentation and a CTA at 4.2 ± 2.2 hours from stroke symptom onset. Patients with NSSO on CTA as well as those with NIHSS≤6 had better outcomes at discharge (p<0.001). NIHSS ≤ 6 were more likely than NSSO (p=0.01) to have a discharge diagnosis of TIA (p<0.001). NSSO on CTA and NIHSS ≤ 6 also correlated with fewer deaths (p<0.001). Multivariable analyses showed NSSO on CTA (Adjusted OR: 5.8 95% CI: 1.2-27.0, p=0.03) independently predicted the discharge diagnosis of TIA. Addition of NIHSS ≤ 6 to NSSO on CTA proved to be a stronger independent predictor of TIA (Adjusted OR 18.7 95% CI: 3.5-98.9, p=0.001). PMID:24851234

  2. Proton magnetic resonance spectroscopy as a diagnostic biomarker in mild cognitive impairment following stroke in acute phase.

    PubMed

    Meng, Ningqin; Shi, Shengliang; Su, Ying

    2016-05-25

    To investigate proton magnetic resonance spectroscopy (HMRS) as a diagnostic biomarker to identify mild cognitive impairment (MCI) following stroke in the acute phase. A total of 72 stroke patients were recruited in the acute phase of stroke from the Department of Neurology, including 36 stroke patients with MCI and 36 stroke patients without MCI. All patients underwent brain MRI/MRS examination on a 3.0 T scanner and a neuropsychological test in the acute phase of stroke. Single-voxel HMRS was performed to obtain hippocampal metabolism intensities and brain infarcts were assessed on MRI. Group difference in metabolite ratios was analyzed using a T-test. Spearman rank correlation was used to study the correlation between metabolite ratios and Montreal Cognitive Assessment scores. The hippocampal n-acetylaspartate/creatine (NAA/Cr) ratio was found to be significantly lower in stroke patients with MCI compared with stroke patients without MCI (P<0.02). However, we found no differences in the metabolite ratios between hippocampus ipsilateral to infarctions and the contralateral side (P>0.05) in stroke patients with MCI. Furthermore, a correlation was found between hippocampal NAA/Cr ratios and Montreal Cognitive Assessment scores in stroke patients with MCI (P<0.01). HMRS could be a biomarker to identify MCI following stroke in the acute phase by capturing neurodegenerative changes. PMID:26981713

  3. Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit.

    PubMed

    Chen, L; Lee, W; Chambers, B R; Dewey, H M

    2011-05-01

    Acute vestibular syndrome may be due to vestibular neuritis (VN) or posterior circulation strokes. Bedside ocular motor testing performed by experts is superior to early MRI in excluding strokes. We sought to demonstrate that differentiation of strokes from VN in our stroke unit is reliable. During a prospective study at a tertiary hospital over 1 year, patients with AVS were evaluated in the emergency department (ED) and underwent admission with targeted examination: gait, gaze-holding, horizontal head impulse test (hHIT), testing for skew deviation (SD) and vertical smooth pursuit (vSP). Neuroimaging included CT, transcranial Doppler (TCD) and MRI with MR angiogram (MRA). VN was diagnosed with normal diffusion-weighted images (DWI) and absence of neurological deficits on follow-up. Acute strokes were confirmed with DWI. A total of 24 patients with AVS were enrolled and divided in two groups. In the pure vestibular group (n = 20), all VN (n = 10/10) had positive hHIT and unidirectional nystagmus, but 1 patient had SD and abnormal vertical smooth pursuit (SP). In all the strokes (n = 10/10), one of the following signs suggestive of central lesion was present: negative hHIT, central-type nystagmus, SD or abnormal vSP. Finding one of these was 100% sensitive and 90% specific for stroke. In the cochleovestibular group (n = 4) all had normal DWI, but 3 patients had central ocular motor signs (abnormal vertical SP and SD). Whilst the study is small, classification of AVS in our stroke unit is reliable. The sensitivity and specificity of bedside ocular motor testing are comparable to those previously reported by expert neuro-otologists. Acute cochleovestibular loss and normal DWI may signify a labyrinthine infarct but differentiating between different causes of inner ear dysfunction is not possible with bedside testing. PMID:21153732

  4. Effect of upper airway obstruction in acute stroke on functional outcome at 6 months

    PubMed Central

    Turkington, P; Allgar, V; Bamford, J; Wanklyn, P; Elliott, M

    2004-01-01

    Background: The aim of this study was to determine whether upper airway obstruction occurring within the first 24 hours of stroke onset has an effect on outcome following stroke at 6 months. Traditional definitions used for obstructive sleep apnoea (OSA) are arbitrary and may not apply in the acute stroke setting, so a further aim of the study was to redefine respiratory events and to assess their impact on outcome. Methods: 120 patients with acute stroke underwent a sleep study within 24 hours of onset to determine the severity of upper airway obstruction (respiratory disturbance index, RDI-total study). Stroke severity (Scandinavian Stroke Scale, SSS) and disability (Barthel score) were also recorded. Each patient was subsequently followed up at 6 months to determine morbidity and mortality. Results: Death was independently associated with SSS (OR (95% CI) 0.92 (0.88 to 0.95), p<0.00001) and RDI-total study (OR (95% CI) 1.07 (1.03 to 1.12), p<0.01). The Barthel index was independently predicted by SSS (p = 0.0001; r = 0.259; 95% CI 0.191 to 0.327) and minimum oxygen saturation during the night (p = 0.037; r = 0.16; 95% CI 0.006 to 0.184). The mean length of the respiratory event most significantly associated with death at 6 months was 15 seconds (sensitivity 0.625, specificity 0.525) using ROC curve analysis. Conclusion: The severity of upper airway obstruction appears to be associated with a worse functional outcome following stroke, increasing the likelihood of death and dependency. Longer respiratory events appear to have a greater effect. These data suggest that long term outcome might be improved by reducing upper airway obstruction in acute stroke. PMID:15115859

  5. Lack of international consensus on ethical aspects of acute stroke trials.

    PubMed

    Leira, Enrique C; Kaldjian, Lauris C; Ludwig, Bryan R; Torner, James C; Olalde, Heena M; Hacke, Werner; Adams, Harold P

    2012-04-01

    Acute stroke trials are becoming increasingly multinational. Working toward a shared ethical standard for acute stroke research necessitates evaluating the degree of consensus among international researchers. We surveyed all 275 coinvestigators and coordinators who participated in the AbESTT II study (evaluating abciximab vs placebo) about their experience with their local institutional review board (IRB) or equivalent, as well as, about their personal beliefs regarding the ethical aspects of acute stroke trials. A total of 90 coinvestigators from 15 different countries responded to our survey. Among the IRBs represented by the responding coinvestigators, only 18% allowed surrogate consent to be obtained over the phone. Although 52% allowed the participation of subjects with aphasia, only 5% allowed the participation of subjects with neglect/hemi-inattention. The National Institutes of Health Stroke Scale score was deemed adequate to establish decisional capacity based on language by 62% of the coinvestigators and 36% of the IRBs. A belief that IRB regulations cause unnecessary delays and fear in relatives/patients was reported by 67% of coinvestigators, and the belief that granting an exemption from informed consent under specific circumstances is appropriate was reported by 41%. There appears to be considerable international diversity in the ethical priorities and informed consent standards among different IRBs and investigators in stroke research. The stroke community should make an attempt to standardize the consent process used in research. Given the critical nature of the time to treatment in stroke care, these standards should be integrated into current frameworks of clinical care and research. The absence of an ethical consensus can become a barrier to advancing stroke treatment internationally. PMID:20719537

  6. Stroke

    MedlinePlus

    ... emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds ... blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused ...

  7. Acute care in stroke: the importance of early intervention to achieve better brain protection.

    PubMed

    Díez-Tejedor, E; Fuentes, B

    2004-01-01

    It is known that 'time is brain', and only early therapies in acute stroke have been effective, like thrombolysis within the first 3 h, and useful neuroprotective drugs are searched for that probably would be effective only with their very early administration. General care (respiratory and cardiac care, fluid and metabolic management, especially blood glucose and blood pressure control, early treatment of hyperthermia, and prevention and treatment of neurological and systemic complications) in acute stroke patients is essential and must already start in the prehospital setting and continue at the patient's arrival to hospital in the emergency room and in the stroke unit. A review of published studies analyzing the influence of general care on stroke outcome and the personal experience from observational studies was performed. Glucose levels >8 mmol/l have been found to be predictive of a poor prognosis after correcting for age, stroke severity, and stroke subtype. Although a clinical trial of glucose-insulin-potassium infusions is ongoing, increased plasma glucose levels should be treated. Moreover, insulin therapy in critically ill patients, including stroke patients, is safe and determines lower mortality and complication rates. Both high and low blood pressure levels have been related to a poor prognosis in acute stroke, although the target levels have not been defined yet in clinical trials. The body temperature has been shown to have a negative effect on stroke outcome, and its control and early treatment of hyperthermia are important. Hypoxemia also worsens the stroke prognosis, and oxygen therapy in case of <92% O(2) saturation is recommended. Besides, blood pressure stabilization avoiding falls of the diastolic pressure and the lowering of glycemia and temperature have been related to a better prognosis in stroke units patients, and homeostasis maintenance is associated with a better outcome. General care has become an emergent and first-line brain

  8. Excessive α-tocopherol exacerbates microglial activation and brain injury caused by acute ischemic stroke

    PubMed Central

    Khanna, Savita; Heigel, Mallory; Weist, Jessica; Gnyawali, Surya; Teplitsky, Seth; Roy, Sashwati; Sen, Chandan K.; Rink, Cameron

    2015-01-01

    The vitamin E family includes both tocopherols and tocotrienols, where α-tocopherol (αTOC) is the most bioavailable form. Clinical trials testing the therapeutic efficacy of high-dose αTOC against stroke have largely failed or reported negative outcomes when a “more is better” approach to supplementation (>400 IU/d) was used. This work addresses mechanisms by which supraphysiologic αTOC may contribute to stroke-induced brain injury. Ischemic stroke injury and the neuroinflammatory response were studied in tocopherol transfer protein-deficient mice maintained on a diet containing αTOC vitamin E at the equivalent human dose of 1680 IU/d. Ischemic stroke-induced brain injury was exacerbated in the presence of supraphysiologic brain αTOC levels. At 48 h after stroke, S100B and RAGE expression was increased in stroke-affected cortex of mice with elevated brain αTOC levels. Such increases were concomitant with aggravated microglial activation and neuroinflammatory signaling. A poststroke increase in markers of oxidative injury and neurodegeneration in the presence of elevated brain αTOC establish that at supraphysiologic levels, αTOC potentiates neuroinflammatory responses to acute ischemic stroke. Exacerbation of microglial activation by excessive αTOC likely depends on its unique cell signaling regulatory properties independent of antioxidant function. Against the background of clinical failure for high-dose αTOC, outcomes of this work identify risk for exacerbating stroke-induced brain injury as a result of supplementing diet with excessive levels of αTOC.—Khanna, S., Heigel,M., Weist, J., Gnyawali, S., Teplitsky, S., Roy, S., Sen, C. K., Rink, C. Excessive α-tocopherol exacerbates microglial activation and brain injury caused by acute ischemic stroke. PMID:25411436

  9. The Multidisciplinary Swallowing Team Approach Decreases Pneumonia Onset in Acute Stroke Patients

    PubMed Central

    Aoki, Shiro; Hirayama, Junko; Nakamori, Masahiro; Yoshikawa, Mineka; Nezu, Tomohisa; Kubo, Satoshi; Nagano, Yuka; Nagao, Akiko; Yamane, Naoya; Nishikawa, Yuichi; Takamoto, Megumi; Ueno, Hiroki; Ochi, Kazuhide; Maruyama, Hirofumi; Yamamoto, Hiromi; Matsumoto, Masayasu

    2016-01-01

    Dysphagia occurs in acute stroke patients at high rates, and many of them develop aspiration pneumonia. Team approaches with the cooperation of various professionals have the power to improve the quality of medical care, utilizing the specialized knowledge and skills of each professional. In our hospital, a multidisciplinary participatory swallowing team was organized. The aim of this study was to clarify the influence of a team approach on dysphagia by comparing the rates of pneumonia in acute stroke patients prior to and post team organization. All consecutive acute stroke patients who were admitted to our hospital between April 2009 and March 2014 were registered. We analyzed the difference in the rate of pneumonia onset between the periods before team organization (prior period) and after team organization (post period). Univariate and multivariate analyses were performed using a Cox proportional hazards model to determine the predictors of pneumonia. We recruited 132 acute stroke patients from the prior period and 173 patients from the post period. Pneumonia onset was less frequent in the post period compared with the prior period (6.9% vs. 15.9%, respectively; p = 0.01). Based on a multivariate analysis using a Cox proportional hazards model, it was determined that a swallowing team approach was related to pneumonia onset independent from the National Institutes of Health Stroke Scale score on admission (adjusted hazard ratio 0.41, 95% confidence interval 0.19–0.84, p = 0.02). The multidisciplinary participatory swallowing team effectively decreased the pneumonia onset in acute stroke patients. PMID:27138162

  10. Minimising time to treatment: targeted strategies to minimise time to thrombolysis for acute ischaemic stroke.

    PubMed

    Tai, Y J; Yan, B

    2013-11-01

    Time to thrombolysis is a critical determinant of favourable outcomes in acute ischaemic stroke. It is not infrequent that patient outcomes are compromised due to out-of-hospital and in-hospital time delays. On the other hand, time delays could be minimised through the identification of barriers and the implementation of targeted solutions. This review outlines the different strategies in minimising treatment delays and offers recommendations. Literature search in PubMed, Medline and EBSCO Host was conducted to identify studies that are relevant to reduction of time to treatment from January 1995 to December 2012. Strategies to reduce time to thrombolysis are categorised into pre-hospital strategies, in-hospital strategies and post-treatment decision strategies. Proposed pre-hospital strategies include public education on stroke symptoms awareness, prioritising stroke by emergency medical services, increasing ease of access to medical records, pre-hospital notification, and mobile computed tomography scanning. In-hospital strategies include a streamlined code stroke system, computed tomography scanner co-location with emergency department, 24/7 availability of stroke physicians, point-of-care laboratory testing and access to expert neuroimaging interpretation. Post-decision strategies include increasing availability of intravenous thrombolysis and simplification of informed consent procurement. Time to thrombolysis delays is multifactorial. Effective reduction of time delays for acute ischaemic stroke requires the correct identification of and targeted strategies to overcome time barriers. PMID:23734983

  11. Acupuncture for acute stroke: study protocol for a multicenter, randomized, controlled trial

    PubMed Central

    2014-01-01

    Background Acupuncture has been widely used as a treatment for stroke in China for more than 3,000 years. However, previous research has not yet shown that acupuncture is effective as a stroke treatment. We report a protocol for a multicenter, randomized, controlled, and outcome assessor-blind trial to evaluate the efficacy and safety of acupuncture on acute ischemic stroke. Methods/Design In a prospective trial involving three hospitals in the Zhejiang Province (China) 250 patients with a recent (less than 1 week previous) episode of ischemic stroke will be included. Patients will be randomized into two groups: an acupuncture group given scalp acupuncture and electroacupuncture, and a control group given no acupuncture. Eighteen treatment sessions will be performed over a three-week period. The primary outcome will be measured by changes in the National Institutes of Health Stroke Scale score at the one, three, and four-week follow-up. Secondary outcome measures will be: 1) the Fugl-Meyer assessment scale for motor function; 2) the mini-mental state examination and Montreal cognitive assessment for cognitive function; 3) the video-fluoroscopic swallowing study for swallowing ability; and 4) the incidence of adverse events. Discussion This trial is expected to clarify whether or not acupuncture is effective for acute stroke. It will also show if acupuncture can improve motor, cognitive, or swallowing function. Trial registration Chinese Clinical Trial Registry ChiCTR-TRC-12001971. PMID:24908241

  12. Post-stroke apathy and hypersomnia lead to worse outcomes from acute rehabilitation

    PubMed Central

    Harris, Ari L.; Elder, Jessica; Schiff, Nicholas D.; Victor, Jonathan D.; Goldfine, Andrew M.

    2014-01-01

    Apathy and hypersomnia occur after stroke and, by definition, reduce participation in rehabilitation, but their effect on outcome from acute rehabilitation is not known. We performed a retrospective review of 213 patients admitted to a stroke-specialized acute rehabilitation unit in the United States. All patients had ischemic or hemorrhagic stroke, and no dementia or dependence on others pre-stroke. We diagnosed apathy and hypersomnia using standardized documentation by treating therapists. We used multiple regression analysis to control for overall impairment (combination of strength, cognitive and sensory measures), age, time since stroke, and stroke type (ischemic or hemorrhagic). 44 (21%) of patients had persistent apathy, and 12 (5.6%) had persistent hypersomnia. Both groups were more impaired in cognition, sustained attention, and more likely to be treated for depression. Patients with apathy were 2.4 times more likely to go to a nursing home, and had discharge FIM scores 12 points below the mean. Patients with hypersomnia were 10 times more likely to go to a nursing home, and had discharge FIM scores 16 points below the mean. These findings indicate that studies to prospectively define these clinical factors and potential confounds using standardized tools are indicated, and if confirmed, justify studies to identify these patients early and develop targeted interventions. PMID:24323716

  13. Prehospital Use of Magnesium Sulfate as Neuroprotection in Acute Stroke

    PubMed Central

    Saver, Jeffrey L.; Starkman, Sidney; Eckstein, Marc; Stratton, Samuel J.; Pratt, Franklin D.; Hamilton, Scott; Conwit, Robin; Liebeskind, David S.; Sung, Gene; Kramer, Ian; Moreau, Gary; Goldweber, Robert; Sanossian, Nerses

    2016-01-01

    BACKGROUND Magnesium sulfate is neuroprotective in preclinical models of stroke and has shown signals of potential efficacy with an acceptable safety profile when delivered early after stroke onset in humans. Delayed initiation of neuroprotective agents has hindered earlier phase 3 trials of neuroprotective agents. METHODS We randomly assigned patients with suspected stroke to receive either intravenous magnesium sulfate or placebo, beginning within 2 hours after symptom onset. A loading dose was initiated by paramedics before the patient arrived at the hospital, and a 24-hour maintenance infusion was started on the patient’s arrival at the hospital. The primary outcome was the degree of disability at 90 days, as measured by scores on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability). RESULTS Among the 1700 enrolled patients (857 in the magnesium group and 843 in the placebo group), the mean (±SD) age was 69±13 years, 42.6% were women, and the mean pretreatment score on the Los Angeles Motor Scale of stroke severity (range, 0 to 10, with higher scores indicating greater motor deficits) was 3.7±1.3. The final diagnosis of the qualifying event was cerebral ischemia in 73.3% of patients, intracranial hemorrhage in 22.8%, and a stroke-mimicking condition in 3.9%. The median interval between the time the patient was last known to be free of stroke symptoms and the start of the study-drug infusion was 45 minutes (interquartile range, 35 to 62), and 74.3% of patients received the study-drug infusion within the first hour after symptom onset. There was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the magnesium group and those in the placebo group (P = 0.28 by the Cochran–Mantel–Haenszel test); mean scores at 90 days did not differ between the magnesium group and the placebo group (2.7 in each group, P = 1.00). No significant between

  14. Early phase combined therapeutic management of acute ischaemic stroke.

    PubMed

    Bassi, P; Lattuada, P; Tonietti, S

    2005-05-01

    An adequate treatment of ischaemic stroke in the early phase (28-48 h) is the most important factor for a better outcome. Thrombolysis with rTPA (within 3 h) and oral ASA 300 mg/days are the first therapeutic misures. Continuous monitoring of cardiological and haemodinamic parameters allows early detection of cardiac disturbances. Treatment of hypertension, low haematic oxigenation, hyperglicaemia, seizures and hypertermia is basic to improve outcome. Pharmacological therapy is only one of the components of effective multidisciplinary integrated management of ischaemic stroke; we remind also the precocity of rehabilitation procedures and an accurate psychological assessment. PMID:15883687

  15. Screening for dysphagia and aspiration in acute stroke: a systematic review.

    PubMed

    Perry, L; Love, C P

    2001-01-01

    Stroke is a common problem, producing a variety of neurological problems that affect eating. Dysphagia is a particular concern because of its potential for airway obstruction, malnutrition, and aspiration pneumonia. With chest infection reported in up to 32% of stroke patients, this is a major clinical issue. The following research questions are raised: (1) What are the incidence and outcomes of dysphagia and aspiration in acute stroke? (2) What screening interventions are available to detect dysphagia in patients with acute stroke and what effect have they on patient outcomes? A systematic review was carried out using methods and quality criteria of the NHS Centre for Reviews and Dissemination (1996), focusing on studies of adults with acute stroke. Data were extracted, collated, and presented descriptively. Two hundred forty-eight articles were retrieved with 26 meeting inclusion and quality criteria. Clinical dysphagia is common, associated with a range of deleterious outcomes and clearly linked to development of chest infection. Interpretation of aspiration on videofluoroscopy is not as straightforward but probably also confers additional risk. Further work is required on the relationship between aspiration and pneumonia, and pneumonia prevention. This will include exploration of the effects of screening, and the further development and validation of screening methods. While studies indicate current "best practice," in this important area of patient care further work is urgently required. PMID:11213249

  16. Multiparametric, Longitudinal Optical Coherence Tomography Imaging Reveals Acute Injury and Chronic Recovery in Experimental Ischemic Stroke

    PubMed Central

    Srinivasan, Vivek J.; Mandeville, Emiri T.; Can, Anil; Blasi, Francesco; Climov, Mihail; Daneshmand, Ali; Lee, Jeong Hyun; Yu, Esther; Radhakrishnan, Harsha; Lo, Eng H.; Sakadžić, Sava; Eikermann-Haerter, Katharina; Ayata, Cenk

    2013-01-01

    Progress in experimental stroke and translational medicine could be accelerated by high-resolution in vivo imaging of disease progression in the mouse cortex. Here, we introduce optical microscopic methods that monitor brain injury progression using intrinsic optical scattering properties of cortical tissue. A multi-parametric Optical Coherence Tomography (OCT) platform for longitudinal imaging of ischemic stroke in mice, through thinned-skull, reinforced cranial window surgical preparations, is described. In the acute stages, the spatiotemporal interplay between hemodynamics and cell viability, a key determinant of pathogenesis, was imaged. In acute stroke, microscopic biomarkers for eventual infarction, including capillary non-perfusion, cerebral blood flow deficiency, altered cellular scattering, and impaired autoregulation of cerebral blood flow, were quantified and correlated with histology. Additionally, longitudinal microscopy revealed remodeling and flow recovery after one week of chronic stroke. Intrinsic scattering properties serve as reporters of acute cellular and vascular injury and recovery in experimental stroke. Multi-parametric OCT represents a robust in vivo imaging platform to comprehensively investigate these properties. PMID:23940761

  17. Validity of Diagnostic Codes for Acute Stroke in Administrative Databases: A Systematic Review

    PubMed Central

    McCormick, Natalie; Bhole, Vidula; Lacaille, Diane; Avina-Zubieta, J. Antonio

    2015-01-01

    Objective To conduct a systematic review of studies reporting on the validity of International Classification of Diseases (ICD) codes for identifying stroke in administrative data. Methods MEDLINE and EMBASE were searched (inception to February 2015) for studies: (a) Using administrative data to identify stroke; or (b) Evaluating the validity of stroke codes in administrative data; and (c) Reporting validation statistics (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), or Kappa scores) for stroke, or data sufficient for their calculation. Additional articles were located by hand search (up to February 2015) of original papers. Studies solely evaluating codes for transient ischaemic attack were excluded. Data were extracted by two independent reviewers; article quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. Results Seventy-seven studies published from 1976–2015 were included. The sensitivity of ICD-9 430-438/ICD-10 I60-I69 for any cerebrovascular disease was ≥ 82% in most [≥ 50%] studies, and specificity and NPV were both ≥ 95%. The PPV of these codes for any cerebrovascular disease was ≥ 81% in most studies, while the PPV specifically for acute stroke was ≤ 68%. In at least 50% of studies, PPVs were ≥ 93% for subarachnoid haemorrhage (ICD-9 430/ICD-10 I60), 89% for intracerebral haemorrhage (ICD-9 431/ICD-10 I61), and 82% for ischaemic stroke (ICD-9 434/ICD-10 I63 or ICD-9 434&436). For in-hospital deaths, sensitivity was 55%. For cerebrovascular disease or acute stroke as a cause-of-death on death certificates, sensitivity was ≤ 71% in most studies while PPV was ≥ 87%. Conclusions While most cases of prevalent cerebrovascular disease can be detected using 430-438/I60-I69 collectively, acute stroke must be defined using more specific codes. Most in-hospital deaths and death certificates with stroke as a cause-of-death correspond to true stroke deaths. Linking vital

  18. Intravenous thrombolysis in a patient with left atrial myxoma with acute ischemic stroke

    PubMed Central

    Kulkarni, Girish Baburao; Yadav, Ravi; Mustare, Veerendrakumar; Modi, Sailesh

    2014-01-01

    Intravenous thrombolysis (IVT) is an accepted therapy in patients with acute ischemic stroke presenting within 3-4.5 hours of symptom onset. Selection of the patient for thrombolysis depends on the careful assessment for the risk of post thrombolysis symptomatic haemorrhage (6.2-8.9%) which may be fatal. Atrial myxomas which are the commonest tumors of the heart are associated with stroke due to tumor/clot embolism. There are very few case reports of IVT and its outcome in patients with atrial myxoma with stroke. Some have reported successful thrombolysis, while others have reported intracerebral bleeding. In this report we describe our experience of IVT in atrial myxoma patient with ischemic stroke and review the relevant literature. PMID:25506173

  19. Mechanical thrombectomy in pediatric acute ischemic stroke: Clinical outcomes and literature review.

    PubMed

    Madaelil, Thomas P; Kansagra, Akash P; Cross, DeWitte T; Moran, Christopher J; Derdeyn, Colin P

    2016-08-01

    There are limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke. PMID:26945589

  20. Targets of vascular protection in acute ischemic stroke differ in type 2 diabetes.

    PubMed

    Kelly-Cobbs, Aisha I; Prakash, Roshini; Li, Weiguo; Pillai, Bindu; Hafez, Sherif; Coucha, Maha; Johnson, Maribeth H; Ogbi, Safia N; Fagan, Susan C; Ergul, Adviye

    2013-03-15

    Hemorrhagic transformation is an important complication of acute ischemic stroke, particularly in diabetic patients receiving thrombolytic treatment with tissue plasminogen activator, the only approved drug for the treatment of acute ischemic stroke. The objective of the present study was to determine the effects of acute manipulation of potential targets for vascular protection [i.e., NF-κB, peroxynitrite, and matrix metalloproteinases (MMPs)] on vascular injury and functional outcome in a diabetic model of cerebral ischemia. Ischemia was induced by middle cerebral artery occlusion in control and type 2 diabetic Goto-Kakizaki rats. Treatment groups received a single dose of the peroxynitrite decomposition catalyst 5,10,15,20-tetrakis(4-sulfonatophenyl)prophyrinato iron (III), the nonspecific NF-κB inhibitor curcumin, or the broad-spectrum MMP inhibitor minocycline at reperfusion. Poststroke infarct volume, edema, hemorrhage, neurological deficits, and MMP-9 activity were evaluated. All acute treatments reduced MMP-9 and hemorrhagic transformation in diabetic groups. In addition, acute curcumin and minocycline therapy reduced edema in these animals. Improved neurological function was observed in varying degrees with treatment, as indicated by beam-walk performance, modified Bederson scores, and grip strength; however, infarct size was similar to untreated diabetic animals. In control animals, all treatments reduced MMP-9 activity, yet bleeding was not improved. Neuroprotection was only conferred by curcumin and minocycline. Uncovering the underlying mechanisms contributing to the success of acute therapy in diabetes will advance tailored stroke therapies. PMID:23335797

  1. Analysis of the risk factors for the short-term prognosis of acute ischemic stroke

    PubMed Central

    Liang, Jin; Liu, Wenbo; Sun, Jianping; Gu, Xinyi; Ma, Qiang; Tong, Weijun

    2015-01-01

    This study investigated the risk factors for the short-term prognosis of acute ischemic stroke to provide a scientific evidence for improving prevention and treatment. A total of 2557 cases of acute ischemic stroke were included in the study. We collected the data on demographic characteristics, life style-related risk factors, clinical feature, and other clinical characteristics for all the participants. The outcomes were assessed using the modified Rankin scale (mRs) on day 14 or at discharge. According to the mRs score, the subjects were divided into three groups, namely, the control group (0≤ mRs ≤2), the disability group (3≤ mRs ≤5), and the death group (mRs = 6). The general conditions of these three groups were compared. An mRs score of 3≤ mRs ≤6 belonged to the composite outcome group. Logistic regression was also applied to analyze the risk factors of short-term prognosis. Monovariant logistic regression showed that age, on-set admission, hospital stays, temperature, heart rate, stroke subtype, hypertension, hyperglycemia, history of heart disease, history of atrial fibrillation, history of cerebral stroke, drinking, count of WBC, count of mononuclear leucocyte, and rate of neutrophile granulocyte were statically significant. To further control the confounding factors, multivariant logistic regression analysis was carried out. The result showed that age, on-set admission, hospital stays, temperature, heart rate, hyperglycemia, history of atrial fibrillation, and cerebral stroke history were related to the short-term prognosis. Age, on-set admission, hospital stays, temperature, heart rate, hyperglycemia, history of atrial fibrillation, and cerebral stroke history were the risk factors of the short-term prognosis of acute ischemic stroke. PMID:26885162

  2. Determinants of Quality of Life in the Acute Stage Following Stroke

    PubMed Central

    Jeong, Bo-Ok; Kang, Hee-Ju; Bae, Kyung-Yeol; Kim, Sung-Wan; Shin, Il-Seon; Kim, Joon-Tae; Park, Man-Seok; Cho, Ki-Hyun; Yoon, Jin-Sang

    2012-01-01

    Objective This study aimed to investigate the factors influence the quality of life (QOL) of survivors of an acute stroke. Methods For 422 stroke patients, assessments were made within two weeks of the index event. QOL was measured using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF), which has four domains related to physical factors, psychological factors, social relationships, and environmental context. Associations of each four WHOQOL-BREF domain score with socio-demographic characteristics (age, sex, education, marital status, religion, and occupation), stroke severity (National Institutes of Health Stroke Scale), physical disability (Barthel Index), cognitive function (Mini-Mental Status Examination: MMSE), grip strength, and psychological distress (Hospital Anxiety and Depression Scale depression and anxiety subscale: HADS-D and HADS-A) were investigated using the linear regression models. Results Higher physical domain scores were independently associated with higher MMSE scores, stronger hand-grip strength, and lower HADS-D and HADS-A scores; higher psychological domain scores were independently associated with higher educational level, higher MMSE scores, and lower HADS-D and HADS-A scores; higher social relationships domain scores were independently associated with lower HADS-D and HADS-A scores; and higher environmental domain scores were independently associated with higher educational level, higher MMSE scores, and lower HADS-D scores. Conclusion Psychological distress and impaired cognitive function were independently associated with lower QOL in patients with acute stroke. However, stroke severity, physical disability and other socio-demographic factors were less significantly associated with QOL. These findings underscore the importance of psychological interventions for improving QOL during the acute phase following stroke. PMID:22707962

  3. Modeling the Cost Effectiveness of Neuroimaging-Based Treatment of Acute Wake-Up Stroke

    PubMed Central

    Pandya, Ankur; Eggman, Ashley A.; Kamel, Hooman; Gupta, Ajay; Schackman, Bruce R.; Sanelli, Pina C.

    2016-01-01

    Background Thrombolytic treatment (tissue-type plasminogen activator [tPA]) is only recommended for acute ischemic stroke patients with stroke onset time <4.5 hours. tPA is not recommended when stroke onset time is unknown. Diffusion-weighted MRI (DWI) and fluid attenuated inversion recovery (FLAIR) MRI mismatch information has been found to approximate stroke onset time with some accuracy. Therefore, we developed a micro-simulation model to project health outcomes and costs of MRI-based treatment decisions versus no treatment for acute wake-up stroke patients. Methods and Findings The model assigned simulated patients a true stroke onset time from a specified probability distribution. DWI-FLAIR mismatch estimated stroke onset <4.5 hours with sensitivity and specificity of 0.62 and 0.78, respectively. Modified Rankin Scale (mRS) scores reflected tPA treatment effectiveness accounting for patients’ true stroke onset time. Discounted lifetime costs and benefits (quality-adjusted life years [QALYs]) were projected for each strategy. Incremental cost-effectiveness ratios (ICERs) were calculated for the MRI-based strategy in base-case and sensitivity analyses. With no treatment, 45.1% of simulated patients experienced a good stroke outcome (mRS score 0–1). Under the MRI-based strategy, in which 17.0% of all patients received tPA despite stroke onset times >4.5 hours, 46.3% experienced a good stroke outcome. Lifetime discounted QALYs and costs were 5.312 and $88,247 for the no treatment strategy and 5.342 and $90,869 for the MRI-based strategy, resulting in an ICER of $88,000/QALY. Results were sensitive to variations in patient- and provider-specific factors such as sleep duration, hospital travel and door-to-needle times, as well as onset probability distribution, MRI specificity, and mRS utility values. Conclusions Our model-based findings suggest that an MRI-based treatment strategy for this population could be cost-effective and quantifies the impact that

  4. “Missing clot” during mechanical thrombectomy in acute stroke using Solitaire stent retrieval system

    PubMed Central

    Huded, Vikram; Nambiar, Vivek; De Souza, Romnesh; Bohra, Vikram; Ramankutty, Ritesh

    2016-01-01

    Stent retrieval system is an established treatment modality in acute ischemic stroke with large vessel occlusion. Here, we describe a complication which occurred during mechanical thrombectomy in three cases where the clot dislodged during retrieval. There was a possibility of the clot getting reinjected into the artery with possible dire consequences. PMID:27293350

  5. Acute recovery of oral word production following stroke: Patterns of performance as predictors of recovery

    PubMed Central

    Cloutman, Lauren; Newhart, Melissa; Davis, Cameron; Heidler-Gary, Jennifer; Hillis, Argye E.

    2010-01-01

    Background Impairments in oral word production are common at the onset of stroke. The identification of factors that predict early recovery has important implications for identifying those at greater risk of continued impaired functioning, and the management of the patient’s care following discharge. Aims To identify patterns of performance that are predictors of acute recovery of oral word production abilities following stroke; to identify any association between early and more chronic recovery. Method and procedures Acute stroke patients were administered oral word production tasks within 1–2 days of hospital admission, with repeat testing by 7 days; a subset of patients had repeat testing between three weeks to one year later. Performance was examined for error rate and type to identify potential predictors of early recovery. Outcome and results The proportion of circumlocution and no response errors at initial testing were associated with the magnitude of recovery of language functioning within the first week following stroke. Patient characteristics of age and gender were found to have no influence on the degree of early recovery observed. None of the examined factors predicted late recovery. The degree of early recovery was not associated with the degree of later recovery. Conclusions The current study identified patterns of task performance that increase our understanding of how oral word production recovers following acute stroke. The finding that the degree of early recovery does not predict the degree of later recovery is consistent with the hypothesis that early and late recovery are due to different mechanisms (restored blood flow in acute stroke, and reorganization in later recovery). PMID:19996511

  6. High Homocysteine and Blood Pressure Related to Poor Outcome of Acute Ischemia Stroke in Chinese Population

    PubMed Central

    Liu, Changjiang; Zhao, Liang; Zhou, Mo; Sun, Wenjie; Xu, Tan; Tong, Weijun

    2014-01-01

    Objectives To assess the association between plasma homocysteine (Hcy), blood pressure (BP) and poor outcome at hospital discharge among acute ischemic stroke patients, and if high Hcy increases the risk of poor outcome based on high BP status in a northern Chinese population. Methods Between June 1, 2009 and May 31, 2013, a total of 3695 acute ischemic stroke patients were recruited from three hospitals in northern Chinese cities. Demographic characteristics, lifestyle risk factors, medical history, and other clinical characteristics were recorded for all subjects. Poor outcome was defined as a discharge modified Rankin Scale (mRS) score ≥3 or death. The association between homocysteine concentration, admission blood pressure, and risk of poor outcome following acute ischemic stroke was analyzed by using multivariate non-conditional logistic regression models. Results Compared with those in the lowest quartile of Hcy concentration in a multivariate-adjusted model, those in the highest quartile of Hcy concentration had increased risk of poor outcome after acute ischemic stroke, (OR = 1.33, P<0.05). The dose-response relationship between Hcy concentration and risk of poor outcome was statistically significant (p-value for trend  = 0.027). High BP was significantly associated with poor outcome following acute ischemic stroke (adjusted OR = 1.44, 95%CI, 1.19–1.74). Compared with non-high BP with nhHcy, in a multivariate-adjusted model, the ORs (95% CI) of non-high BP with hHcy, high BP with nhHcy, and high BP with hHcy to poor outcome were 1.14 (0.85–1.53), 1.37 (1.03–1.84) and 1.70 (1.29–2.34), respectively. Conclusion The present study suggested that high plasma Hcy and blood pressure were independent risk factors for prognosis of acute ischemic stroke, and hHcy may further increase the risk of poor outcome among patients with high blood pressure. Additionally, the results indicate that high Hcy with high BP may cause increased susceptibility

  7. Elevated Cardiac Troponin in Acute Stroke without Acute Coronary Syndrome Predicts Long-Term Adverse Cardiovascular Outcomes

    PubMed Central

    Bhatt, Reema; Bove, Alfred A.

    2014-01-01

    Background. Elevated cardiac troponin in acute stroke in absence of acute coronary syndrome (ACS) has unclear long-term outcomes. Methods. Retrospective analysis of 566 patients admitted to Temple University Hospital from 2008 to 2010 for acute stroke was performed. Patients were included if cardiac troponin I was measured and had no evidence of ACS and an echocardiogram was performed. Of 200 patients who met the criteria, baseline characteristics, electrocardiograms, and major adverse cardiovascular events (MACE) were reviewed. Patients were characterized into two groups with normal and elevated troponins. Primary end point was nonfatal myocardial infarction during follow-up period after discharge. The secondary end points were MACE and death from any cause. Results. For 200 patients, 17 patients had positive troponins. Baseline characteristics were as follows: age 63.1 ± 13.8, 64% African Americans, 78% with hypertension, and 22% with previous CVA. During mean follow-up of 20.1 months, 7 patients (41.2%) in elevated troponin and 6 (3.3%) patients in normal troponin group had nonfatal myocardial infarction (P = 0.0001). MACE (41.2% versus 14.2%, P = 0.01) and death from any cause (41.2% versus 14.5%, P = 0.017) were significant in the positive troponin group. Conclusions. Elevated cardiac troponin in patients with acute stroke and no evidence of ACS is strong predictor of long-term cardiac outcomes. PMID:25530906

  8. Acute ischemic stroke in a child due to basilar artery occlusion treated successfully with a stent retriever.

    PubMed

    Savastano, Luis; Gemmete, Joseph J; Pandey, Aditya S; Roark, Christopher; Chaudhary, Neeraj

    2016-08-01

    Ischemic strokes in childhood are rare. Thrombolytic therapy with intravenous (IV) tissue plasminogen activator (tPA) has been the main intervention for the management of pediatric stroke patients, but safety data are lacking and efficacy has been questioned. Recently, successful endovascular treatments for acute ischemic stroke in children have been reported with increasing frequency, suggesting that mechanical thrombectomy can be a safe and effective treatment. We present the case of a 22-month-old child with acute ischemic stroke due to basilar artery occlusion that was successfully treated with a stent retriever. PMID:26156170

  9. Ginsenoside Rd Is Efficacious Against Acute Ischemic Stroke by Suppressing Microglial Proteasome-Mediated Inflammation.

    PubMed

    Zhang, Guangyun; Xia, Feng; Zhang, Yunxia; Zhang, Xiao; Cao, Yuhong; Wang, Ling; Liu, Xuedong; Zhao, Gang; Shi, Ming

    2016-05-01

    A great deal of attention has been paid to neuroprotective therapies for cerebral ischemic stroke. Our two recent clinical trials showed that ginsenoside Rd (Rd), a kind of monomeric compound extracted from Chinese herbs, Panax ginseng and Panax notoginseng, was safe and efficacious for the treatment of ischemic stroke. In this study, we conducted a pooled analysis of the data from 199 patients with acute ischemic stroke in the first trial and 390 in the second to reanalyze the efficacy and safety of Rd. Moreover, animal stroke models were carried out to explore the possible molecular mechanisms underlying Rd neuroprotection. The pooled analysis showed that compared with placebo group, Rd could improve patients' disability as assessed by modified Rankin Scale (mRS) score on day 90 post-stroke and reduce neurologic deficits on day 15 or day 90 post-stroke as assessed by NIH Stroke Scale (NIHSS) and Barthel Index (BI) scores. For neuroprotective mechanisms, administration of Rd 4 h after stroke could inhibit ischemia-induced microglial activation, decrease the expression levels of various proinflammatory cytokines, and suppress nuclear factor of kappa light polypeptide gene enhancer in B cells inhibitor, alpha (IκBα) phosphorylation and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) nuclear translocation. An in vitro proteasome activity assay revealed a significant inhibitory effect of Rd on proteasome activity in microglia. Interestingly, Rd was showed to have less side effects than glucocorticoid. Therefore, our study demonstrated that Rd could safely improve the outcome of patients with ischemic stroke, and this therapeutic effect may result from its capability of suppressing microglial proteasome activity and sequential inflammation. PMID:26081140

  10. Carotid interventions (CEA and CAS) in acute stroke patients: which procedure on which patient.

    PubMed

    Darling, Ralph C; Warner, Courtney; Yeh, Chin C; Shah, Melissa D; Hnath, Jeffrey C; Shah, Dhiraj M

    2016-02-01

    Treatment of carotid bifurcation disease in patients presenting with acute stroke has been a controversial issue over the past four decades. Classically, patients were asked to wait four to six weeks before intervention was entertained in order for the brain to stabilize and the risks of intervention to be minimized. Unfortunately, up to 20% of patients will have a secondary event after their index event and the window of opportunity to save potentially salvageable ischemic tissue will be missed. Early reports had demonstrated poor results with intervention. However, more recently, institutions such as ours have demonstrated excellent results with early intervention in patients who present with stable mild to moderate stroke with an NIH stroke scale less than 15 and preferably less than 10, present with stroke and ipsilateral carotid artery lesion of 50% or greater. Also more recently, we have been aggressively treating patients with larger ulcerative plaques even if the stenosis approaches 50%. In our and others experiences, patients who are treated at institutions that have comprehensive stroke centers (CSCs) where they have a multidisciplinary system that consists of vascular surgeons, neuro interventionalists, stroke neurologists, specifically trained stroke nursing staff and a neuro intensive ICU have had optimal results. Early assessment, diagnosis of stroke with recognition of cause of embolization is mandatory but patient selection is extremely important; finding those patients who will benefit the most from urgent intervention. Most studies have demonstrated the benefit of carotid endarterectomy in these patients. More recent studies have demonstrated acceptable results with carotid stenting, especially in smaller lesions, those less than 1.2 centimeters. Early intervention should be avoided in most patients who are obtunded or with an NIH stroke scale greater than 15 or who do not have any "brain at risk" to salvage. These patients may be better served by

  11. Occult infarct with acute hemorrhagic stroke in juvenile diabetic ketoacidosis.

    PubMed

    Lin, Jainn-Jim; Lin, Kuang-Lin; Wang, Huei-Shyong; Wong, Alex Mun-Ching; Hsia, Shao-Hsuan

    2008-01-01

    Diabetes ketoacidosis (DKA) is one of the common complications of type I insulin-dependent diabetes mellitus. Neurological deterioration during an episode of DKA is usually assumed to be caused by cerebral edema and cerebral vascular accidents. However, hemorrhagic stroke is a very rare complication of juvenile DKA. We describe a girl who had newly diagnosed insulin-dependent diabetes mellitus with juvenile DKA developed intracerebral hemorrhage. PMID:17629647

  12. Intranasal Insulin and Insulin-Like Growth Factor 1 as Neuroprotectants in Acute Ischemic Stroke.

    PubMed

    Lioutas, Vasileios-Arsenios; Alfaro-Martinez, Freddy; Bedoya, Francisco; Chung, Chen-Chih; Pimentel, Daniela A; Novak, Vera

    2015-08-01

    Treatment options for stroke remain limited. Neuroprotective therapies, in particular, have invariably failed to yield the expected benefit in stroke patients, despite robust theoretical and mechanistic background and promising animal data. Insulin and insulin-like growth factor 1 (IGF-1) play a pivotal role in critical brain functions, such as energy homeostasis, neuronal growth, and differentiation. They may exhibit neuroprotective properties in acute ischemic stroke based upon their vasodilatory, anti-inflammatory and antithrombotic effects, as well as improvements of functional connectivity, neuronal metabolism, neurotransmitter regulation, and remyelination. Intranasally administered insulin has demonstrated a benefit for prevention of cognitive decline in older people, and IGF-1 has shown potential benefit to improve functional outcomes in animal models of acute ischemic stroke. The intranasal route presents a feasible, tolerable, safe, and particularly effective administration route, bypassing the blood-brain barrier and maximizing distribution to the central nervous system (CNS), without the disadvantages of systemic side effects and first-pass metabolism. This review summarizes the neuroprotective potential of intranasally administered insulin and IGF-1 in stroke patients. We present the theoretical background and pathophysiologic mechanisms, animal and human studies of intranasal insulin and IGF-1, and the safety and feasibility of intranasal route for medication administration to the CNS. PMID:26040423

  13. Predictors of poor hospital discharge outcome in acute stroke due to atrial fibrillation.

    PubMed

    Tian, Melissa J; Tayal, Ashis H; Schlenk, Elizabeth A

    2015-02-01

    Atrial fibrillation (AF) is a frequent cause of acute ischemic stroke that results in severe neurological disability and death despite treatment with intravenous thrombolysis (intravenous recombinant tissue plasminogen activator [rtPA]). We performed a retrospective review of a single-center registry of patients treated with intravenous rtPA for stroke. The purposes of this study were to compare intravenous rtPA treated patients with stroke with and without AF to examine independent predictors of poor hospital discharge outcome (in-hospital death or hospital discharge to a skilled nursing facility, long-term acute care facility, or hospice care). A univariate analysis was performed on 144 patients receiving intravenous rtPA for stroke secondary to AF and 190 patients without AF. Characteristics that were significantly different between the two groups were age, initial National Institutes of Health Stroke Scale score, length of hospital stay, gender, hypertension, hyperlipidemia, smoking status, presence of large cerebral infarct, and hospital discharge outcome. Bivariate logistic regression analysis indicated that patients with stroke secondary to AF with a poor hospital discharge outcome had a greater likelihood of older age, higher initial National Institutes of Health Stroke Scale scores, longer length of hospital stay, intubation, and presence of large cerebral infarct compared with those with good hospital discharge outcome (discharged to home or inpatient rehabilitation or signed oneself out against medical advice). A multivariate logistic regression analysis showed that older age, longer length of hospital stay, and presence of large cerebral infarct were independent predictors of poor hospital discharge outcome. These predictors can guide nursing interventions, aid the multidisciplinary treating team with treatment decisions, and suggest future directions for research. PMID:25503541

  14. Mechanical Revascularization for Acute Ischemic Stroke: A Single-Center, Retrospective Analysis

    SciTech Connect

    Jeromel, Miran Milosevic, Z. V. Kocijancic, I. J. Lovric, D.; Svigelj, V. Zvan, B.

    2013-04-15

    BackgroundEndovascular mechanical revascularization (thrombectomy) is an increasingly used method for intracranial large vessel recanalization in acute stroke. The purpose of the study was to analyze the recanalization rate, clinical outcome, and complication rate in our stroke patients treated with mechanical revascularization. A total of 57 patients with large vessel stroke (within 3 h for anterior and 12 h for posterior circulation) were treated with mechanical revascularization at a single center during 24 months. The primary goal of endovascular treatment using different mechanical devices was recanalization of the occluded vessel. Recanalization rate (reported as thrombolysis in cerebral infarction [TICI] score), clinical outcome (reported as National Institutes of Health Stroke Scale [NIHSS] score and modified Rankin scale [mRS] score), as well as periprocedural complications were analyzed. The mean age of the patients was 63.1 {+-} 12.9 years, with baseline median NIHSS score of 14 (interquartile range, 9.5-19). Successful recanalization (TICI 2b or 3) was achieved in 41 (72 %) patients. Twenty patients (35 %) presented with favorable outcome (mRS {<=}2) 30 days after stroke. Overall, significant neurological improvement ({>=}4 NIHSS point reduction) occurred in 36 (63 %) patients. A clinically significant procedure-related adverse events (vessel disruption, peri/postprocedural intracranial bleeding) defined with decline in NIHSS of {>=}4 or death occurred in three (5 %) patients. The study showed a high recanalization rate with improved clinical outcome and a low rate of periprocedural complications in our stroke patients treated with mechanical revascularization. Therefore, we could conclude that endovascular revascularization (primary or in combination with a bridging thrombolysis) was an effective and safe procedure for intracranial large vessel recanalization in acute stroke.

  15. The Impact of Acute Phase Domain-Specific Cognitive Function on Post-stroke Functional Recovery

    PubMed Central

    Park, Jihong; Lee, Gangpyo; Lee, Shi-Uk

    2016-01-01

    Objective To assess whether the cognitive function in the acute stage evaluated by domain-specific neuropsychological assessments would be an independent predictor of functional outcome after stroke. Methods Forty patients underwent 4 domain-specific neuropsychological examinations about 3 weeks after the onset of stroke. The tests included the Boston Naming Test (BNT), the construction recall test (CRT), the construction praxis test (CPT), and the verbal fluency test (VFT). The Korean version of Modified Barthel Index (K-MBI) at 3 months and the modified Rankin Scale (mRS) at 6 months were investigated as functional outcome after stroke. Functional improvement was assessed using the change in K-MBI during the first 3 months and subjects were dichotomized into 'good status' and 'poor status' according to mRS at 6 months. The domain-specific cognitive function along with other possible predictors for functional outcome was examined using regression analysis. Results The z-score of CPT (p=0.044) and CRT (p<0.001) were independent predictors for functional improvement measured by the change in K-MBI during the first 3 months after stroke. The z-score of CPT (p=0.049) and CRT (p=0.048) were also independent predictors of functional status at post-stroke 6 months assessed by mRS. Conclusion Impairment in visuospatial construction and memory within one month after stroke can be an independent prognostic factor of functional outcome. Domain-specific neuropsychological assessments could be considered in patients with stroke in the acute phase to predict long-term functional outcome. PMID:27152270

  16. Copolymer-1 promotes neurogenesis and improves functional recovery after acute ischemic stroke in rats.

    PubMed

    Cruz, Yolanda; Lorea, Jonathan; Mestre, Humberto; Kim-Lee, Jennifer Hyuna; Herrera, Judith; Mellado, Raúl; Gálvez, Vanesa; Cuellar, Leopoldo; Musri, Carolina; Ibarra, Antonio

    2015-01-01

    Stroke triggers a systemic inflammatory response that exacerbates the initial injury. Immunizing with peptides derived from CNS proteins can stimulate protective autoimmunity (PA). The most renowned of these peptides is copolymer-1 (Cop-1) also known as glatiramer acetate. This peptide has been approved for use in the treatment of multiple sclerosis. Cop-1-specific T cells cross the blood-brain barrier and secrete neurotrophins and anti-inflammatory cytokines that could stimulate proliferation of neural precursor cells and recruit them to the injury site; making it an ideal therapy for acute ischemic stroke. The aim of this work was to evaluate the effect of Cop-1 on neurogenesis and neurological recovery during the acute phase (7 days) and the chronic phase of stroke (60 days) in a rat model of transient middle cerebral artery occlusion (tMCAo). BDNF and NT-3 were quantified and infarct volumes were measured. We demonstrated that Cop-1 improves neurological deficit, enhances neurogenesis (at 7 and 60 days) in the SVZ, SGZ, and cerebral cortex through an increase in NT-3 production. It also decreased infarct volume even at the chronic phase of tMCAo. The present manuscript fortifies the support for the use of Cop-1 in acute ischemic stroke. PMID:25821957

  17. Copolymer-1 Promotes Neurogenesis and Improves Functional Recovery after Acute Ischemic Stroke in Rats

    PubMed Central

    Cruz, Yolanda; Lorea, Jonathan; Mestre, Humberto; Kim-Lee, Jennifer Hyuna; Herrera, Judith; Mellado, Raúl; Gálvez, Vanesa; Cuellar, Leopoldo; Musri, Carolina; Ibarra, Antonio

    2015-01-01

    Stroke triggers a systemic inflammatory response that exacerbates the initial injury. Immunizing with peptides derived from CNS proteins can stimulate protective autoimmunity (PA). The most renowned of these peptides is copolymer-1 (Cop-1) also known as glatiramer acetate. This peptide has been approved for use in the treatment of multiple sclerosis. Cop-1-specific T cells cross the blood-brain barrier and secrete neurotrophins and anti-inflammatory cytokines that could stimulate proliferation of neural precursor cells and recruit them to the injury site; making it an ideal therapy for acute ischemic stroke. The aim of this work was to evaluate the effect of Cop-1 on neurogenesis and neurological recovery during the acute phase (7 days) and the chronic phase of stroke (60 days) in a rat model of transient middle cerebral artery occlusion (tMCAo). BDNF and NT-3 were quantified and infarct volumes were measured. We demonstrated that Cop-1 improves neurological deficit, enhances neurogenesis (at 7 and 60 days) in the SVZ, SGZ, and cerebral cortex through an increase in NT-3 production. It also decreased infarct volume even at the chronic phase of tMCAo. The present manuscript fortifies the support for the use of Cop-1 in acute ischemic stroke. PMID:25821957

  18. Reorganization of Motor Execution Networks During Sub-Acute Phase After Stroke.

    PubMed

    Cheng, Lin; Wu, Zhiyuan; Sun, Junfeng; Fu, Yi; Wang, Xinning; Yang, Guo-Yuan; Miao, Fei; Tong, Shanbao

    2015-07-01

    Numerous studies focused on brain reorganization after stroke from aspects of task-related brain activity and resting-state brain networks. However, studies focusing on the longitudinal reorganization of task-state brain networks were scarce. In this study, functional magnetic resonance imaging data were collected from twelve stroke patients during blocked finger-tapping task at four post-stroke time points (less than 10 days, around 2 weeks, 1 month and 3 months), respectively. The dynamic changes and prognostic value of the network parameters (i.e., topological parameters, functional connectivity and nodal parameters) in task-state motor execution networks were thoroughly evaluated. We found that the topological configuration (clustering coefficient and characteristic path length) of task-state motor execution networks underwent significant shift during stroke recovery. Especially, we found the topological configuration of task-state motor execution networks at the early recovery stage were capable of predicting the motor function restoration during sub-acute phase. In addition, we found increasing functional connectivity between ipsilesional cerebellum and motor cortices in task-state motor execution networks. In general, this study demonstrated the reorganization and prognostic value of task-state brain network after stroke, which provides new insights into understanding the brain reorganization and rehabilitation after stroke. PMID:26151748

  19. Platelets Proteomic Profiles of Acute Ischemic Stroke Patients

    PubMed Central

    Baykal, Ahmet Tarik; Sener, Azize

    2016-01-01

    Platelets play a crucial role in the pathogenesis of stroke and antiplatelet agents exist for its treatment and prevention. Through the use of LC-MS based protein expression profiling, platelets from stroke patients were analyzed and then correlated with the proteomic analyses results in the context of this disease. This study was based on patients who post ischemic stroke were admitted to hospital and had venous blood drawn within 24 hrs of the incidence. Label-free protein expression analyses of the platelets’ tryptic digest was performed in triplicate on a UPLC-ESI-qTOF-MS/MS system and ProteinLynx Global Server (v2.5, Waters) was used for tandem mass data extraction. The peptide sequences were searched against the reviewed homo sapiens database (www.uniprot.org) and the quantitation of protein variation was achieved through Progenesis LC-MS software (V4.0, Nonlinear Dynamics). These Label-free differential proteomics analysis of platelets ensured that 500 proteins were identified and 83 of these proteins were found to be statistically significant. The differentially expressed proteins are involved in various processes such as inflammatory response, cellular movement, immune cell trafficking, cell-to-cell signaling and interaction, hematological system development and function and nucleic acid metabolism. The expressions of myeloperoxidase, arachidonate 12-Lipoxygenase and histidine-rich glycoprotein are involved in cellular metabolic processes, crk-like protein and ras homolog gene family member A involved in cell signaling with vitronectin, thrombospondin 1, Integrin alpha 2b, and integrin beta 3 involved in cell adhesion. Apolipoprotein H, immunoglobulin heavy constant gamma 1 and immunoglobulin heavy constant gamma 3 are involved in structural, apolipoprotein A-I, and alpha-1-microglobulin/bikunin precursor is involved in transport, complement component 3 and clusterin is involved in immunity proteins as has been discussed. Our data provides an insight

  20. Platelets Proteomic Profiles of Acute Ischemic Stroke Patients.

    PubMed

    Cevik, Ozge; Baykal, Ahmet Tarik; Sener, Azize

    2016-01-01

    Platelets play a crucial role in the pathogenesis of stroke and antiplatelet agents exist for its treatment and prevention. Through the use of LC-MS based protein expression profiling, platelets from stroke patients were analyzed and then correlated with the proteomic analyses results in the context of this disease. This study was based on patients who post ischemic stroke were admitted to hospital and had venous blood drawn within 24 hrs of the incidence. Label-free protein expression analyses of the platelets' tryptic digest was performed in triplicate on a UPLC-ESI-qTOF-MS/MS system and ProteinLynx Global Server (v2.5, Waters) was used for tandem mass data extraction. The peptide sequences were searched against the reviewed homo sapiens database (www.uniprot.org) and the quantitation of protein variation was achieved through Progenesis LC-MS software (V4.0, Nonlinear Dynamics). These Label-free differential proteomics analysis of platelets ensured that 500 proteins were identified and 83 of these proteins were found to be statistically significant. The differentially expressed proteins are involved in various processes such as inflammatory response, cellular movement, immune cell trafficking, cell-to-cell signaling and interaction, hematological system development and function and nucleic acid metabolism. The expressions of myeloperoxidase, arachidonate 12-Lipoxygenase and histidine-rich glycoprotein are involved in cellular metabolic processes, crk-like protein and ras homolog gene family member A involved in cell signaling with vitronectin, thrombospondin 1, Integrin alpha 2b, and integrin beta 3 involved in cell adhesion. Apolipoprotein H, immunoglobulin heavy constant gamma 1 and immunoglobulin heavy constant gamma 3 are involved in structural, apolipoprotein A-I, and alpha-1-microglobulin/bikunin precursor is involved in transport, complement component 3 and clusterin is involved in immunity proteins as has been discussed. Our data provides an insight into

  1. Ischemic penumbra in acute stroke: Demonstration by PET with fluorine-18 fluoromisonidazole

    SciTech Connect

    Yeh, S.H.; Liu, R.S.; Hu, H.H.

    1994-05-01

    Ischemic penumbra (IP) in acute stroke has gained clinical interest since tissue functions may be recovered if perfusion can be reestablished. However, such therapeutic intervention is {open_quotes}blind{close_quotes} since clinical examination can not distinguish IP from developing infarction. In vivo demonstration of IP may have significance for stroke patient management. This study was a preliminary evaluation of detecting IP in vivo by F-18 fluoromisonidazole ([F-18]-FMISO), a hypoxic imaging agent. Static PET imaging was performed after IV injection of 370 MBq of [F-18]-FMISO at 20 and 120 min. Tomograms were reconstructed and evaluated visually in correlation with CT or MR scans. In acute stroke, patients (pts) were called back for the second PET study one month after the initial study. CT was used for confirming infarction. In 6 pts with acute cerebral infarction, three of them had intense [F-18]-FMISO retention in the penumbra surrounding the central, eclipse-like zone of absent radio-activity (infarction) at 2 hr in the acute state, and the penumbra disappeared in association with increased area of infarction on CT in one case in the chronic state. In five pts with chronic infarction, all had no penumbra of [F-18]-FMISO retention. In summary, our preliminary results demonstrate the feasibility of using [F-18]-FMISO PET to detect ischemic penumbra in vivo.

  2. Phase-based metamorphosis of diffusion lesion in relation to perfusion values in acute ischemic stroke.

    PubMed

    Rekik, Islem; Allassonnière, Stéphanie; Luby, Marie; Carpenter, Trevor K; Wardlaw, Joanna M

    2015-01-01

    Examining the dynamics of stroke ischemia is limited by the standard use of 2D-volume or voxel-based analysis techniques. Recently developed spatiotemporal models such as the 4D metamorphosis model showed promise for capturing ischemia dynamics. We used a 4D metamorphosis model to evaluate acute ischemic stroke lesion morphology from the acute diffusion-weighted imaging (DWI) to final T2-weighted imaging (T2-w). In 20 representative patients, we metamorphosed the acute lesion to subacute lesion to final infarct. From the DWI lesion deformation maps we identified dynamic lesion areas and examined their association with perfusion values inside and around the lesion edges, blinded to reperfusion status. We then tested the model in ten independent patients from the STroke Imaging Repository (STIR). Perfusion values varied widely between and within patients, and were similar in contracting and expanding DWI areas in many patients in both datasets. In 25% of patients, the perfusion values were higher in DWI-contracting than DWI-expanding areas. A similar wide range of perfusion values and ongoing expansion and contraction of the DWI lesion were seen subacutely. There was more DWI contraction and less expansion in patients who received thrombolysis, although with widely ranging perfusion values that did not differ. 4D metamorphosis modeling shows promise as a method to improve use of multimodal imaging to understand the evolution of acute ischemic tissue towards its fate. PMID:26288755

  3. Predictors of diagnostic neuroimaging delays among adults presenting with symptoms suggestive of acute stroke in Ontario: a prospective cohort study

    PubMed Central

    Burton, Kirsteen R.; Kapral, Moira K.; Li, Shudong; Fang, Jiming; Moody, Alan R.; Krahn, Murray; Laupacis, Andreas

    2016-01-01

    Background: Many studies have examined the timeliness of thrombolysis for acute ischemic stroke, but less is known about door-to-imaging time. We conducted a prospective cohort study to assess the timing of neuroimaging among patients with suspected acute stroke in the province of Ontario, Canada, and to examine factors associated with delays in neuroimaging. Methods: We included all patients 18 years and older with suspected acute stroke seen at hospitals with neuroimaging capacity within the Ontario Stroke Registry between Apr. 1, 2010, and Mar. 31, 2011. We used a hierarchical, multivariable Cox proportional hazards model to evaluate the association between patient and hospital factors and the likelihood of receiving timely neuroimaging (≤ 25 min) after arrival in the emergency department. Results: A total of 13 250 patients presented to an emergency department with stroke-like symptoms during the study period. Of the 3984 who arrived within 4 hours after symptom onset, 1087 (27.3%) had timely neuroimaging. The factors independently associated with an increased likelihood of timely neuroimaging were less time from symptom onset to presentation, more severe stroke, male sex, no history of stroke or transient ischemic attack, arrival to hospital from a setting other than home and presentation to a designated stroke centre or an urban hospital. Interpretation: A minority of patients with stroke-like symptoms who presented within the 4-hour thrombolytic treatment window received timely neuroimaging. Neuroimaging delays were influenced by various patient and hospital factors, some of which are modifiable. PMID:27398382

  4. Review of technology development and clinical trials of transcranial laser therapy for acute ischemic stroke treatment

    NASA Astrophysics Data System (ADS)

    Catanzaro, Brian E.; Streeter, Jackson; de Taboada, Luis

    2010-02-01

    Stroke is the one of the leading causes of mortality in the United States, claiming 600,000 lives each year. Evidence suggests that near infrared (NIR) illumination has a beneficial effect on a variety of cells when these cells are exposed to adverse conditions. Among these conditions is the hypoxic state produced by acute ischemic stroke (AIS). To demonstrate the impact NIR Transcranial Laser Therapy (TLT) has on AIS in humans, a series of double blind, placebo controlled clinical trials were designed using the NeuroThera(R) System (NTS). The NTS was designed and developed to treat subjects non-invasively using 808 nm NIR illumination. TLT, as it applies to stroke therapy, and the NTS will be described. The results of the two clinical trials: NeuroThera(R) Safety and Efficacy Trial 1 (NEST-1) and NeuroThera(R) Safety and Efficacy Trial 2 (NEST-2) will be reviewed and discussed.

  5. New windows, same old house: an update on acute stroke management.

    PubMed

    Weant, Kyle A; Baker, Stephanie N

    2012-01-01

    Acute stroke is a common presentation to emergency departments and is the third leading cause of death in the United States. Despite the frequency of this event, and its substantial morbidity and mortality, few therapies exist to limit the damage from this devastating diagnosis. One pharmacotherapy for ischemic stroke that has demonstrated efficacy in this setting is tissue plasminogen activator (Activase; tPA; alteplase). Current guidelines for this agent recommend its use within the first 3 hr of the onset of stroke symptoms in patients who meet specified criteria. However, more recent data have lead to recommending the extension of this time frame to 4.5 hr after onset of symptoms in specific patient populations. Although this therapy has demonstrated efficacy in improving outcomes, its use is often complicated by complex inclusion and exclusion criteria, risk of hemorrhage, requirement for intense patient monitoring, substantial cost, and the potential for devastating medication errors. PMID:22561222

  6. [Promising new treatment for acute ischemic stroke--Sonothrombolysis can enhance the effect of intravenous thrombolysis].

    PubMed

    Gu, Thomas; Wester, Per; Johansson, Elias

    2015-01-01

    Intravenous thrombolysis has been a break-through for treatment of acute ischemic stroke. However, total recanalization is only achieved in 18%. Sonothrombolysis aims at enhancing the recanalization effect by adding continuous transcranial ultrasound. Sonothrombolysis may facilitate the recanalization rate without increased risk of intracerebral hemorrhage. This further results in decreased risk of disability compared with only intravenous thrombolysis. Intravenously applied micro-bubbles is an additive treatment to sonothrombolysis which might further increase the recanalization rate but perhaps at the expense of increased risk of intracerebral hemorrhage. In a case-series at Umeå Stroke Center, we report the results of the first 20 ischemic stroke patients treated with sonothrombolysis in Sweden. Our initial results look promising with recanalization rates similar to earlier published data. No intracerebral hemorrhage occurred among our sonothrombolysed patients. PMID:25647105

  7. Availability of Diagnostic and Treatment Services for Acute Stroke in Frontier Counties in Montana and Northern Wyoming

    ERIC Educational Resources Information Center

    Okon, Nicholas J.; Rodriguez, Daniel V.; Dietrich, Dennis W.; Oser, Carrie S.; Blades, Lynda L.; Burnett, Anne M.; Russell, Joseph A.; Allen, Martha J.; Chasson, Linda; Helgerson, Steven D.; Gohdes, Dorothy; Harwell, Todd S.

    2006-01-01

    Context: Rapid diagnosis and treatment of ischemic stroke can lead to improved patient outcomes. Hospitals in rural and frontier counties, however, face unique challenges in providing diagnostic and treatment services for acute stroke. Purpose: The aim of this study was to assess the availability of key diagnostic technology and programs for acute…

  8. Elevated Total Homocysteine Levels in Acute Ischemic Stroke Are Associated With Long-Term Mortality

    PubMed Central

    Shi, Zhihong; Guan, Yalin; Huo, Ya Ruth; Liu, Shuling; Zhang, Meilin; Lu, Hui; Yue, Wei; Wang, Jinhuan

    2015-01-01

    Background and Purpose— Total homocysteine (tHcy) levels are associated with secondary vascular events and mortality after stroke. The aim of this study was to investigate whether tHcy levels in the acute phase of a stroke contribute to the recurrence of cerebro-cardiovascular events and mortality. Methods— A total of 3799 patients were recruited after hospital admission for acute ischemic stroke. Levels of tHcy were measured within 24 hours after primary admission. Patients were followed for a median of 48 months. Results— During the follow-up period, 233 (6.1%) patients died. After adjustment for age, smoking status, diabetes mellitus, and other cardiovascular risk factors, patients in the highest tHcy quartile (>18.6 μmol/L) had a 1.61-fold increased risk of death (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.03–2.53) compared with patients in the lowest quartile (≤10 μmol/L). Further subgroup analysis showed that this correlation was only significant in the large-artery atherosclerosis stroke subtype (adjusted HR, 1.80; 95% CI, 1.05–3.07); this correlation was not significant in the small-vessel occlusion subtype (adjusted HR, 0.80; 95% CI, 0.30–2.12). The risk of stroke-related mortality was 2.27-fold higher for patients in the third tHcy quartile (adjusted HR, 2.27; 95% CI, 1.06–4.86) and 2.15-fold more likely for patients in the fourth quartile (adjusted HR, 2.15; 95% CI, 1.01–4.63) than for patients in the lowest tHcy quartile. The risk of cardiovascular-related mortality and the risk of recurrent ischemic stroke were not associated with tHcy levels. Conclusions— Our findings suggest that elevated tHcy levels in the acute phase of an ischemic stroke can predict mortality, especially in stroke patients with the large-vessel atherosclerosis subtype. PMID:26199315

  9. Glycated Hemoglobin Independently Predicts Stroke Recurrence within One Year after Acute First-Ever Non-Cardioembolic Strokes Onset in A Chinese Cohort Study

    PubMed Central

    Wu, Shuolin; Shi, Yuzhi; Wang, Chunxue; Jia, Qian; Zhang, Ning; Zhao, Xingquan; Liu, Gaifen; Wang, Yilong; Liu, Liping; Wang, Yongjun

    2013-01-01

    Objective Hyperglycemia is related to stroke. Glycated hemoglobin (HbA1c) can reflect pre-stroke glycaemia status. However, the information on the direct association between HbA1c and recurrence after non-cardioembolic acute ischemic strokes is rare and there is no consistent conclusion. Methods The ACROSS-China database comprised of 2186 consecutive first-ever acute ischemic stroke patients with baseline HbA1c values. After excluding patients who died from non-stroke recurrence and patients lost to follow up, 1817 and 1540 were eligible for 3-month and 1-year analyses, respectively. Multivariate Cox regression was performed to evaluate the associations between HbA1c and 3-month and 1-year stroke recurrence. Results The HbA1c values at admission were divided into 4 levels by quartiles: Q1 (<5.5%); Q2 (5.5 to <6.1%); Q3 (6.1% to <7.2%); and Q4 (≥7.2%). The cumulative recurrence rates were 8.3% and 11.0% for 3 months and 1 year, respectively. In multivariate analyses, when compared with Q1, the adjusted hazard ratios (AHRs) were 2.83 (95% confidence interval (CI) 1.28-6.26) in Q3 and 3.71(95% CI 1.68-8.21) in Q4 for 3-month stroke recurrence; 3.30 (95% CI 1.31-8.34) in Q3 and 3.35 (95% CI 1.36-8.21) in Q4 for 1-year stroke recurrence. Adding fasting plasma glucose in the multivariate analyses did not modify the association: AHRs were 2.75 (95% CI 1.24-6.11) in Q3 and 3.67 (95% CI 1.59-8.53) in Q4 for 3-month analysis; AHRs were 3.08 (95% CI 1.10-8.64) in Q3 and 3.31(95% CI 1.35-8.14) in Q4 for 1-year analysis. Conclusions A higher “normal” HbA1c level reflecting pre-stroke glycaemia status independently predicts stroke recurrence within one year after non-cardioembolic acute ischemic stroke onset. HbA1c is recommended as a routine test in acute ischemic stroke patients. PMID:24236195

  10. The Relationship between C-Reactive Protein Level and Discharge Outcome in Patients with Acute Ischemic Stroke

    PubMed Central

    Geng, He-Hong; Wang, Xin-Wang; Fu, Rong-Li; Jing, Meng-Juan; Huang, Ling-Ling; Zhang, Qing; Wang, Xiao-Xiao; Wang, Pei-Xi

    2016-01-01

    Previous studies showed that C-reactive protein (CRP), an inflammatory marker, was associated with stroke severity and long-term outcome. However, the relationship between the acute-phase CRP level and discharge outcome has received little attention. We prospectively studied 301 patients with acute ischemic stroke (over a period of two weeks) from two hospital stroke wards and one rehabilitation department in Henan, China. Patients’ demographic and clinical data were collected and evaluated at admission. Poor discharge outcome was assessed in patients at discharge using the Modified Rankin Scale (MRS > 2). Multivariate logistic regression analysis was performed to determine the risk factors of poor discharge outcome after adjusting for potential confounders. Poor discharge outcome was observed in 78 patients (25.9%). Univariate analyses showed that factors significantly influencing poor discharge outcome were age, residence, recurrent acute ischemic stroke, coronary heart disease, the National Institutes of Health Stroke Scale (NIHSS) score at admission, non-lacunar stroke, time from onset of stroke to admission, CRP, TBIL (total bilirubin), direct bilirubin (DBIL), ALB (albumin), FIB (fibrinogen) and D-dimer (p < 0.05). After adjusting for age, residence, recurrent ischemic stroke, coronary heart disease, NIHSS score at admission, lacunar stroke, time from onset of stroke to admission, CRP, TBIL, DBIL, ALB, FIB and D-dimer, multivariate logistic regression analyses revealed that poor outcome at discharge was associated with recurrent acute ischemic stroke (OR, 2.115; 95% CI, 1.094–4.087), non-lacunar stroke (OR, 2.943; 95% CI, 1.436–6.032), DBIL (OR, 1.795; 95% CI, 1.311–2.458), and CRP (OR, 4.890; 95% CI, 3.063–7.808). In conclusion, the CRP level measured at admission was found to be an independent predictor of poor outcome at discharge. Recurrent acute ischemic stroke, non-lacunar stroke and DBIL were also significantly associated with discharge

  11. A Model for Predicting Persistent Elevation of Factor VIII among Patients with Acute Ischemic Stroke

    PubMed Central

    Samai, Alyana A.; Boehme, Amelia K.; Shaban, Amir; George, Alexander J.; Dowell, Lauren; Monlezun, Dominique J.; Leissinger, Cindy; Schluter, Laurie; El Khoury, Ramy; Martin-Schild, Sheryl

    2016-01-01

    Background and Purpose Elevated levels of coagulation factor VIII (FVIII) may persist independent of the acute-phase response; however, this relationship has not been investigated relative to acute ischemic stroke (AIS). We examined the frequency and predictors of persistently elevated FVIII in AIS patients. Methods AIS patients admitted between July 2008 and May 2014 with elevated baseline FVIII levels and repeat FVIII levels drawn for more than 7 days postdischarge were included. The patients were dichotomized by repeat FVIII level for univariate analysis at 150% and 200% activity thresholds. An adjusted model was developed to predict the likelihood of persistently elevated FVIII levels. Results Among 1616 AIS cases, 98 patients with elevated baseline FVIII had repeat FVIII levels. Persistent FVIII elevation was found in more than 75% of patients. At the 150% threshold, the prediction score ranged from 0 to 7 and included black race, female sex, prior stroke, hyperlipidemia, smoking, baseline FVIII > 200%, and baseline von Willebrand factor (vWF) level greater than 200%. At the 200% threshold, the prediction score ranged from 0–5 and included female sex, prior stroke, diabetes mellitus, baseline FVIII level greater 200%, and baseline vWF level greater than 200%. For each 1-point increase in score, the odds of persistent FVIII at both the 150% threshold (odds ratio [OR] = 10.4, 95% confidence interval [CI] 1.63–66.9, P = .0134) and 200% threshold (OR = 10.2, 95% CI 1.82–57.5, P = .0083) increased 10 times. Conclusion Because an elevated FVIII level confers increased stroke risk, our model for anticipating a persistently elevated FVIII level may identify patients at high risk for recurrent stroke. FVIII may be a target for secondary stroke prevention. PMID:26777556

  12. Administration of Uric Acid in the Emergency Treatment of Acute Ischemic Stroke.

    PubMed

    Llull, Laura; Amaro, Sergio; Chamorro, Ángel

    2016-01-01

    Oxidative stress is one of the main mechanisms implicated in the pathophysiology of inflammatory and neurodegenerative diseases of the central nervous system (CNS). Uric acid (UA) is the end product of purine catabolism in humans, and it is the main endogenous antioxidant in blood. Low circulating UA levels have been associated with an increased prevalence and worse clinical course of several neurodegenerative and inflammatory diseases of the CNS, including Parkinson's disease and multiple sclerosis. Moreover, the exogenous administration of UA exerts robust neuroprotective properties in experimental models of CNS disease, including brain ischemia, spinal cord injury, meningitis, and experimental allergic encephalitis. In experimental brain ischemia, exogenous UA and the thrombolytic agent alteplase exert additive neuroprotective effects when administered in combination. UA is rapidly consumed following acute ischemic stroke, and higher UA levels at stroke admission are associated with a better outcome and reduced infarct growth at follow-up. A recent phase II trial demonstrated that the combined intravenous administration of UA and alteplase is safe and prevents an early decrease of circulating UA levels in acute ischemic stroke patients. Moreover, UA prevents the increase in the circulating levels of the lipid peroxidation marker malondialdehyde and of active matrix metalloproteinase (MMP) 9, a marker of blood-brain barrier disruption. The moderately sized URICOICTUS phase 2b trial showed that the addition of UA to thrombolytic therapy resulted in a 6% absolute increase in the rate of excellent outcome at 90 days compared to placebo. The trial also showed that UA administration resulted in a significant increment of excellent outcome in patients with pretreatment hyperglycemia, in females and in patients with moderate strokes. Overall, the encouraging neuroprotective effects of UA therapy in acute ischemic stroke warrants further investigation in adequately

  13. Endovascular Acute Stroke Treatment Performed by Vascular Interventional Radiologists: Is It Safe and Efficacious?

    SciTech Connect

    Fjetland, Lars Roy, Sumit; Kurz, Kathinka D.; Larsen, Jan Petter; Kurz, Martin W.

    2012-10-15

    Purpose: To evaluate the safety and efficacy of neurointerventional procedures in acute stroke patients performed by a team of vascular interventional radiologists in close cooperation with diagnostic neuroradiologists and stroke neurologists and to compare the results with those of previous reports from centres with specialised interventional neuroradiologists. Material and Methods: A total of 39 patients with acute ischemic stroke due to large-vessel occlusion not responding to or not eligible for intravenous thrombolysis were treated with either intra-arterial thrombolysis or mechanical thrombectomy (Penumbra System or solitaire FR thrombectomy system, respectively) and included in our prospective study. Outcomes were measured using the modified Rankin scale after 90 days, and recanalization was assessed by thrombolysis using the myocardial infarction score. Results: Mean patient age was 68.3 {+-} 14.2 years; the average National Institutes of Health Stroke Scale score at hospital admission was 17.2 (SD = 6.2 [n = 38]). Successful recanalization was achieved in 74.4 % of patients. Median time from clinical onset to recanalization was 5 h 11 min. Procedure-related complications occurred in 5 % of patients, and 7.5 % had a symptomatic intracerebral hemorrhage. Of the patients, 22.5 % died within the first 90 postprocedural days, 5 % of these from cerebral causes. Patients who were successfully recanalized had a clinical better outcome at follow-up than those in whom treatment failed. Of the patients, 35.9 % had an mRS score {<=}2 after 90 days. Conclusion: Our results are in line with those in the published literature and show that a treatment strategy with general interventional radiologists performing neurointerventional procedures in acute stroke patients with large vessel occlusions can be achieved to the benefit of patients.

  14. Diagnosis and acute management of perinatal arterial ischemic stroke

    PubMed Central

    Ferriero, Donna M.

    2014-01-01

    Summary Perinatal arterial ischemic stroke (PAIS) can be an unrecognized cause of short- and long-term neurologic disability. Focal clonic seizure in the newborn period is the most common clinical presentation of PAIS. MRI is optimal in diagnosing PAIS; negative cranial ultrasound or CT does not rule out PAIS. Given the low rate of recurrence in combination with risk factors thought to be isolated to the maternal-fetal unit, anticoagulation or antiplatelet treatment is usually not recommended. The majority of newborns with PAIS do not go on to develop epilepsy, although further research is warranted in this area. Long-term morbidity, including motor, cognitive, and behavioral disabilities, can follow PAIS, necessitating early recognition, diagnosis, and therapy initiation. PMID:25317375

  15. Acute stroke trials: the problems of local investigators?

    PubMed

    Toni, D; Sacchetti, M L; Chamorro, A

    2003-01-01

    During stroke trials local investigators have to face many practical problems and time consuming procedures (filling in huge case report forms, performing repeat blood sample drawings for pharmacokinetic studies etc.) which, however, simply require organizational structures which is understood to be necessary to be able to conduct such kind of studies. Other, and most worrisome problems, are indeed to be solved when a sponsored research may rise potential ethical issues, or when academic research proposals clash with the interest of pharmaceutical companies or find difficulties in being funded by public institutions. It is just a greater involvement of these latter, possibly free from bureaucratic laces, which might help a balance to be struck between academic and industrial aims. PMID:12584421

  16. Design of the Intravenous Magnesium Efficacy in Acute Stroke (IMAGES) trial [ISRCTN19943732

    PubMed Central

    Bradford, Andrew; Lees, Kennedy

    2000-01-01

    The Intravenous Magnesium Efficacy in Acute Stroke (IMAGES) trial is a multicentre,randomised, placebo-controlled trial of magnesium sulphate (MgSO4) funded by the UK Medical Research Council. When complete, it will be the largest single neuroprotective study undertaken to date. Conscious patients presenting within 12 h of acute stroke with limb weakness are eligible. The primary outcome measure is combined death and disability as measured using the Barthel Index at 90-day follow up. By randomizing 2700 patients, the study will have 84% power to detect a 5.5% absolute reduction in the primary end-point. By April 2000, 86 centres were participating, with representation in Canada, USA, Europe, South America, Singapore and Australia. So far, 1206 patients have been randomised, of whom 37% were treated within 6 h. Overall 3-month mortality was 20% and the primary outcome event rate was 43%. The study is ongoing and centres worldwide are encouraged to participate. PMID:11714436

  17. Computed tomography angiography in acute stroke (revisiting the 4Ps of imaging).

    PubMed

    Varadharajan, Shriram; Saini, Jitender; Acharya, Ullas V; Gupta, Arun Kumar

    2016-02-01

    Imaging in acute stroke has traditionally focussed on the 4Ps-parenchyma, pipes, perfusion, and penumbra-and has increasingly relied upon advanced techniques including magnetic resonance imaging to evaluate such patients. However, as per European Magnetic Resonance Forum estimates, the availability of magnetic resonance imaging scanners for the general population in India (0.5 per million inhabitants) is quite low as compared to Europe (11 per million) and United States (35 per million), with most of them only present in urban cities. On the other hand, computed tomography (CT) is more widely available and has reduced scanning duration. Computed tomography angiography of cervical and intracranial vessels is relatively simpler to perform with extended coverage and can provide all pertinent information required in such patients. This imaging review will discuss relevant imaging findings on CT angiography in patients with acute ischemic stroke through illustrated cases. PMID:26614583

  18. Meta-Analysis of Local Endovascular Therapy for Acute Ischemic Stroke.

    PubMed

    Kennedy, Sean A; Baerlocher, Mark O; Baerlocher, Felix; Socko, Daniel; Sacks, David; Nikolic, Boris; Wojak, Joan C; Haskal, Ziv J

    2016-03-01

    A meta-analysis was performed to assess randomized controlled trials comparing local endovascular therapy (with and without intravenous thrombolysis) versus standard care (intravenous thrombolysis alone when appropriate) for acute ischemic stroke. Local endovascular therapy showed a significant improvement in functional independence versus standard care (odds ratio, 1.779; 95% confidence interval, 1.262-2.507; P < .001). This benefit strengthened further on subgroup analyses of trials in which a majority of cases used stent retrievers, trials with intravenous thrombolysis use in both arms when appropriate, and trials that required preprocedural imaging of all patients. There were no significant differences between arms in terms of mortality, hemicraniectomy, intracranial hemorrhage, and cerebral edema rates (P > .05). In conclusion, in the treatment of acute ischemic stroke, local endovascular therapy leads to improved functional independence compared with standard care. PMID:26803573

  19. Successful intravenous thrombolysis in a patient with antiphospholipid syndrome, acute ischemic stroke and severe thrombocytopenia.

    PubMed

    Camara-Lemarroy, Carlos R; Infante-Valenzuela, Adrian; Andrade-Vazquez, Catalina J; Enriquez-Noyola, Raul V; Garcia-Valadez, Erick A; Gongora-Rivera, Fernando

    2016-04-01

    Alteplase is the only approved drug for the treatment of acute ischemic stroke, but it is offered to a minority of patients, not only because of the short therapeutic window but also because of the numerous contraindications associated with thrombolysis, such as thrombocytopenia. There is some controversy on the true risk associated with thrombolysis in patients with thrombocytopenia. Here we report the case of a young patient, who developed an in-hospital acute ischemic stroke involving a large territory of the right middle cerebral artery, who was successfully treated with intravenous alteplase, despite having thrombocytopenia and prolonged prothrombin times due to systemic lupus erythematosus and antiphospholipid syndrome. This case exemplifies the need to reassess contraindications for thrombolysis, many based on expert opinion and not clinical evidence, especially in complex clinical situations. PMID:26575492

  20. Oxidative stress in post-acute ischemic stroke patients after intensive neurorehabilitation.

    PubMed

    Ciancarelli, Irene; De Amicis, Daniela; Di Massimo, Caterina; Carolei, Antonio; Ciancarelli, Maria Giuliana Tozzi

    2012-11-01

    We investigated in post-acute ischemic stroke patients the influence of intensive neurorehabilitation on oxidative stress balance during recovery of neurological deficits. For this purpose, fourteen patients were included in the study within 30 days of stroke onset. Outcome measures were the National Institutes of Health Stroke Scale (NIHSS), the modified Rankin Scale (mRS), the Barthel Index, and the Katz Index. Redox balance was assessed by measuring plasma peroxidative by-products, nitrite/nitrate metabolites (NOx), as an index of nitric oxide (NO), Cu/Zn Superoxide Dismutase (Cu/Zn SOD) activity, serum urate concentration, autoantibodies against ox-LDL (OLAB) serum level and plasma antioxidant capacity. Assessments were made before and after neurorehabilitation. Fifteen apparently healthy controls were investigated to compare redox markers. Intensive neurorehabilitation was associated with an improvement of all the outcome measures (P < 0.05). Decreased values of peroxidative by-products and of NOx (P < 0.05) were observed after neurorehabilitation in stroke patients even though their values were higher than in controls (P < 0.05). Changes observed before and after neurorehabilitation in NIHSS scores (Δ NIHSS scores) and in plasma NOx amount (Δ NOx) correlated positively (r=0.79; P < 0.005). No differences in EC-SOD activity, OLAB and serum urate concentrations were found between stroke patients and controls, before and after neurorehabilitation. Total plasma antioxidant capacity, lower in stroke patients than in controls before neurorehabilitation, was unchanged thereafter. Our data provide evidence of the effectiveness of neurorehabilitation on reducing redox unbalance in stroke patients and hints the role of NO as a messenger involved in post-ischemic neuronal plasticity influencing recovery of neurological deficits. PMID:22873723

  1. Trends in the Incidence of Hospitalized Acute Myocardial Infarction and Stroke in Korea, 2006-2010

    PubMed Central

    Kim, Rock Bum; Kim, Byoung-Gwon; Kim, Yu-Mi; Seo, Jeong Wook; Lim, Young Shil; Kim, Hee Sook; Lee, Hey Jean; Moon, Ji Young; Kim, Keon Yeop; Shin, Ji-Yeon; Park, Hyeung-Keun; Song, Jung-Kook; Park, Ki-Soo; Jeong, Baek Geun; Park, Chan Gyeong; Shin, Hee-Young; Kang, Jong-Won; Oh, Gyung-Jae; Lee, Young-Hoon; Seong, In-Whan; Yoo, Weon-Seob

    2013-01-01

    This study attempted to calculate and investigate the incidence of hospitalized acute myocardial infarction (AMI) and stroke in Korea. Using the National Health Insurance claim data, we investigated patients whose main diagnostic codes included AMI or stroke during 2006 to 2010. As a result, we found out that the number of AMI hospitalized patients had decreased since 2006 and amounted to 15,893 in 2010; and that the number of those with stroke had decreased since 2006 and amounted to 73,501 in 2010. The age-standardized incidence rate of hospitalized AMI, after adjustment for readmission, was 41.6 cases per 100,000-population in 2006, and had decreased to 29.4 cases in 2010 (for trend P < 0.001). In the case of stroke was estimated at 172.8 cases per 100,000-population in 2006, and had decreased to 135.1 cases in 2010 (for trend P < 0.001). In conclusion, the age-standardized incidence rates of both hospitalized AMI and stroke in Korea had decreased continuously during 2006 to 2010. We consider this decreasing trend due to the active use of pharmaceuticals, early vascular intervention, and the national cardio-cerebrovascular disease care project as the primary and secondary prevention efforts. PMID:23341707

  2. Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke.

    PubMed

    Kirkman, Matthew A; Lambden, Simon; Smith, Martin

    2016-07-01

    Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research. PMID:26368664

  3. Neuro-mechanics of muscle coordination during recumbent pedaling in post-acute stroke patients.

    PubMed

    De Marchis, C; Ambrosini, E; Schmid, M; Monticone, M; Pedrocchi, A; Ferrigno, G; D'Alessio, T; Conforto, S; Ferrante, S

    2015-01-01

    Motor impairment after stroke has been hypothesized to be related, among others, to impairments in the modular control of movement. In this study we analyzed muscle coordination and pedal forces during a recumbent pedaling exercise from a sample of post-acute stroke patients (n=5) and a population of age-matched healthy individuals (n=4). Healthy subjects and the less impaired patients showed a shared modular organization of pedaling based on 4 similar muscle synergies. The most impaired patient, characterized by a Motricity Index of 52/100, showed a reduced complexity (only 2 muscle synergies for the affected side). Differences between healthy subjects and post-stroke patients in the execution of the task were identified in terms of unbalance in mechanical work production, which well corresponded to the level of impairment. This pedaling unbalance could be traced back to different activation strategies of the 4 identified modules. Investigation on a more representative sample will provide a full characterization of the neuro-mechanics of pedaling after stroke, helping our understandings of the disruption of motor coordination at central level after stroke and of the most effective solutions for functional recovery. PMID:26736246

  4. Temporal Changes in the Quality of Acute Stroke Care in Five National Audits across Europe

    PubMed Central

    Hillmann, Steffi; Wiedmann, Silke; Fraser, Alec; Baeza, Juan; Rudd, Anthony; Norrving, Bo; Asplund, Kjell; Niewada, Maciej; Dennis, Martin; Hermanek, Peter; Wolfe, Charles D. A.; Heuschmann, Peter U.

    2015-01-01

    Background. Data on potential variations in delivery of appropriate stroke care over time are scarce. We investigated temporal changes in the quality of acute hospital stroke care across five national audits in Europe over a period of six years. Methods. Data were derived from national stroke audits in Germany, Poland, Scotland, Sweden, and England/Wales/Northern Ireland participating within the European Implementation Score (EIS) collaboration. Temporal changes in predefined quality indicators with comparable information between the audits were investigated. Multivariable logistic regression analyses were performed to estimate adherence to quality indicators over time. Results. Between 2004 and 2009, individual data from 542,112 patients treated in 538 centers participating continuously over the study period were included. In most audits, the proportions of patients who were treated on a SU, were screened for dysphagia, and received thrombolytic treatment increased over time and ranged from 2-fold to almost 4-fold increase in patients receiving thrombolytic therapy in 2009 compared to 2004. Conclusions. A general trend towards a better quality of stroke care defined by standardized quality indicators was observed over time. The association between introducing a specific measure and higher adherence over time might indicate that monitoring of stroke care performance contributes to improving quality of care. PMID:26783519

  5. Logistical and financial obstacles for endovascular therapy of acute stroke implementation.

    PubMed

    Schellinger, Peter D; Köhrmann, Martin; Nogueira, Raul G

    2016-07-01

    After publication of the recent positive randomized clinical endovascular trials, several questions and obstacles for wide spread implementation remain. We address specific issues namely efficacy, safety, logistics, timing, sedation, numbers, imaging, manpower, centers, geographics, and economical aspects of endovascular therapy. As we move forward, a high degree of collaboration will be crucial to implement a therapy with established overwhelming treatment efficacy for severe acute stroke patients. PMID:27016510

  6. Effect of IMOD™ on the inflammatory process after acute ischemic stroke: a randomized clinical trial

    PubMed Central

    2013-01-01

    Background and purpose of the study Considering the role of inflammation in acute cerebrovascular accidents, anti-inflammatory treatment has been considered as an option in cerebrovascular diseases. Regarding the properties of Setarud (IMOD™) in immune regulation, the aim of the present study was to evaluate the role of this medication in treating patients with acute ischemic stroke. Methods In this randomized clinical trial, 99 patients with their first ever acute ischemic stroke were divided into two groups of IMOD™ (n = 49) and control (n = 50). The control group underwent routine treatment and the intervention group underwent routine treatment plus daily intermittent infusion of IMOD™ (250mg on the first day and then 375mg into DW5% serum during a 30-minute period for 7 days). The serum levels of inflammatory markers were evaluated on the first day (baseline) and on 4th and 7th days. Data were analyzed and the results were compared. Results and major conclusion 58 males (58.6%) and 41 females (41.4%) with a mean age of 67.00 ± 8.82 years, who had their first ever stroke attack, were enrolled in this trial. Treatment with IMOD™ showed a decreasing trend in IL-6 levels compared to the control group (p = 0.04). In addition, the treatment resulted in the control of increasing serum levels of hsCRP after 7 days compared to the control group (p = 0.02). There was an insignificant decrease in TNF-α and IL-1 levels in the IMOD™ group. Considering the prominent role of inflammation after an ischemic cerebral damage, it appears that treatment with IMOD™ improves the inflammatory profile. Therefore, IMOD™ (Setarud) might be considered as a therapeutic option in the acute ischemic stroke. However, future studies are necessary on its long-term results and clinical efficacy. PMID:23514014

  7. Direct evidence of acute, massive striatal dopamine release in gerbils with unilateral strokes.

    PubMed

    Brannan, T; Weinberger, J; Knott, P; Taff, I; Kaufmann, H; Togasaki, D; Nieves-Rosa, J; Maker, H

    1987-01-01

    Dopamine release into the extracellular space was measured with in vivo electrochemical detection in the ipsilateral and contralateral striata in Mongolian gerbils that suffered a stroke after acute unilateral carotid artery ligations. A sevenfold increase in the dopamine signal occurred within 15 minutes of carotid ligation in the ischemic side, while the unlesioned side had no significant change. Increased extracellular levels of dopamine persisted throughout the 3-hour recording period. Pretreatment with alpha-methyl-p-tyrosine 6 hours prior to recording significantly attenuated the signal increase. This study is the first direct demonstration of the marked, continuous dopamine release that occurs during acute cerebral ischemia. PMID:3810742

  8. Assessment of serum and urine ghrelin levels in patients with acute stroke

    PubMed Central

    Seyhanli, Eyyup Sabri; Lok, Ugur; Gulacti, Umut; Buyukaslan, Hasan; Atescelik, Metin; Yildiz, Mustafa; Onur, Mehmet Ruhi; Goktekin, Mehmet Cagri; Aydın, Suleyman

    2015-01-01

    Introduction: Ghrelin is a novel brain-gut peptide hormone consisted of 28 amino-acid. In the plasma, it exists in two major molecular forms, acylated and des-acyled ghrelin, filtered in glomeruli or secreted by nephrons. Primary biological effects of hormones are regulating appetite, foods intake and energy metabolism. We investigated the changing and relationships between serum and urine ghrelin levels in acute stroke patients to provide more information whether diagnostic parameter. Methods: Thirty acute stroke patients and thirty consecutive volunteers included in study prospectively. To analyze serum and urine ghrelin levels, at the time of diagnose, all of participant blood and fresh urine (1 ml serum, 2 ml urine respectively) samples were obtained. Serum ghrelin levels analyzed ELISA technique, and urine ghrelin levels studied by validation technique. To compare quantitative data student’s t test, and for qualitative data chi-square and Fisher’s Exact Chi-square test was used. P<0.05 was considered statistically significant. Results: Urine acyl ghrelin levels found statistically significant between patient and control groups (P=0.001), but there were no statistically significant differences between both groups (P>0.05) in serum acyl gherelin, des-acyl ghrelin and urine des-acyle ghrelin levels. Conclusions: The results indicate that urine acyl ghrelin levels may be considered as a diagnostic parameter in acute ischemic stroke patients. Further studies delineating the mechanism of these observed results are warranted. PMID:25785049

  9. Acute Phase IL-10 Plasma Concentration Associates with the High Risk Sources of Cardiogenic Stroke

    PubMed Central

    Arponen, Otso; Muuronen, Antti; Taina, Mikko; Sipola, Petri; Hedman, Marja; Jäkälä, Pekka; Vanninen, Ritva; Pulkki, Kari; Mustonen, Pirjo

    2015-01-01

    Background Etiological assessment of stroke is essential for accurate treatment decisions and for secondary prevention of recurrence. There is evidence that interleukin-10 (IL-10) associates with ischemic stroke. The aim of this prospective study was to assess the levels of IL-10 in ischemic stroke with unknown or suspected cardiogenic etiology, and evaluate the correlation between IL-10 plasma concentration and the number of diagnosed high risk sources for cardioembolism. Methods A total of 141 patients (97 males; mean age 61±11 years) with acute ischemic stroke with unknown etiology or suspected cardiogenic etiology other than known atrial fibrillation (AF) underwent imaging investigations to assess high risk sources for cardioembolic stroke established by the European Association of Echocardiography (EAE). IL-10 was measured on admission to the hospital and on a three month follow-up visit. Results Acute phase IL-10 concentration was higher in patients with EAE high risk sources, and correlated with their number (p<0.01). In patients with no risk sources (n = 104), the mean IL-10 concentration was 2.7±3.1 ng/L (range 0.3–16.3 ng/L), with one risk source (n = 26) 3.7±5.5 ng/L (0.3–23.6 ng/L), with two risk sources (n = 10) 7.0±10.0 ng/L (1.29–34.8 ng/L) and with three risk sources (n = 1) 37.2 ng/L. IL-10 level was not significantly associated with cerebral infarct volume, presence of previous or recent myocardial infarction, carotid/vertebral artery atherosclerosis, paroxysmal AF registered on 24-hour ECG Holter monitoring or given intravenous thrombolytic treatment. Conclusion IL-10 plasma concentration correlates independently with the number of EAE cardioembolic risk sources in patients with acute stroke. IL-10 may have potential to improve differential diagnostics of stroke with unknown etiology. PMID:25923658

  10. Risk-prediction model for ischemic stroke in patients hospitalized with an acute coronary syndrome (from the global registry of acute coronary events [GRACE]).

    PubMed

    Park, Kay Lee; Budaj, Andrzej; Goldberg, Robert J; Anderson, Frederick A; Agnelli, Giancarlo; Kennelly, Brian M; Gurfinkel, Enrique P; Fitzgerald, Gordon; Gore, Joel M

    2012-09-01

    The risk of stroke in patients hospitalized with an acute coronary syndrome (ACS) ranges from <1% to ≥ 2.5%. The aim of this study was to develop a simple predictive tool for bedside risk estimation of in-hospital ischemic stroke in patients with ACS to help guide clinicians in the acute management of these high-risk patients. Data were obtained from 63,118 patients enrolled from April 1999 to December 2007 in the Global Registry of Acute Coronary Events (GRACE), a multinational registry involving 126 hospitals in 14 countries. A regression model was developed to predict the occurrence of in-hospital ischemic stroke in patients hospitalized with an ACS. The main study outcome was the development of ischemic stroke during the index hospitalization for an ACS. Eight risk factors for stroke were identified: older age, atrial fibrillation on index electrocardiogram, positive initial cardiac biomarkers, presenting systolic blood pressure ≥ 160 mm Hg, ST-segment change on index electrocardiogram, no history of smoking, higher Killip class, and lower body weight (c-statistic 0.7). The addition of coronary artery bypass graft surgery and percutaneous coronary intervention into the model increased the prediction of stroke risk. In conclusion, the GRACE stroke risk score is a simple tool for predicting in-hospital ischemic stroke risk in patients admitted for the entire spectrum of ACS, which is widely applicable to patients in various hospital settings and will assist in the management of high-risk patients with ACS. PMID:22608950

  11. Variability in Motor and Language Recovery during the Acute Stroke Period

    PubMed Central

    Dunn, Lauren E.; Schweber, Adam B.; Manson, Daniel K.; Lendaris, Andrea; Herber, Charlotte; Marshall, Randolph S.; Lazar, Ronald M.

    2016-01-01

    Background Most stroke recovery occurs by 90 days after onset, with proportional recovery models showing an achievement of about 70% of the maximal remaining recovery. Little is known about recovery during the acute stroke period. Moreover, data are described for groups, not for individuals. In this observational cohort study, we describe for the first time the daily changes of acute stroke patients with motor and/or language deficits over the first week after stroke onset. Methods Patients were enrolled within 24-72 h after stroke onset with upper extremity hemiparesis, aphasia, or both, and were tested daily until day 7 or discharge with the upper-extremity Fugl-Meyer Assessment of Motor Recovery after Stroke, the Boston Naming Test, and the comprehension domain from the Western Aphasia Battery. Discharge scores, and absolute and proportional changes were examined using t-tests for pairwise comparisons and linear regression to determine relative contributions of initial impairment, lesion volume, and age to recovery over this period. Results Thirty-four patients were enrolled: 19 had motor deficits alone, 8 had aphasia alone, and 7 had motor and language deficits. In a group analysis, statistically significant changes in absolute scores were found in the motor (p < 0.001) and comprehension (p < 0.001) domains but not in naming. Day-by-day recovery curves for individual patients displayed wide variation with comparable initial impairment. Proportional recovery calculations revealed that, on average, patients achieved less than 1/3 of their potential recovery by the time of discharge. Multivariate regression showed that the amount of variance accounted for by initial severity, age, and lesion volume in this early time period was not significant for motor or language domains. Conclusions Over the first week after stroke onset, recovery of upper extremity hemiparesis and aphasia were not predictable on the basis of initial impairment, lesion volume, or age. In

  12. Motor recovery after acute ischaemic stroke: a metabolic study.

    PubMed Central

    Di Piero, V; Chollet, F M; MacCarthy, P; Lenzi, G L; Frackowiak, R S

    1992-01-01

    The metabolic changes occurring after ischaemic stroke were measured to investigate the functional anatomy of clinical motor recovery. Positron emission tomography (PET) and the steady-state 15O technique was used to compare resting relative metabolic distributions at the onset of functional deficit with those following recovery. Ten patients were studied with repeat scans. Motor recovery was associated in some patients with an increase of relative oxygen metabolism in anatomical structures normally involved in motor function in the affected hemisphere, particularly in the cortical motor areas. In those patients without such metabolic changes in the cortex of the diseased hemisphere, relative increases in cortical metabolism in the contralateral hemisphere were associated with better motor recovery than in patients with no relative cortical metabolic increase in either hemisphere. There was no correlation between the degree of improvement in motor function and the severity of motor deficit at onset, the size and site of the lesion and the metabolic changes in the infarcted zone. No particular pattern of global metabolic changes was observed after recovery. Thus different relative patterns of metabolic recovery were seen in patients with different lesions and evidence was found for the participation of contralateral structures in the recovery process in some patients. Images PMID:1469418

  13. Characterization of patients treated by rehabilitation service after establishing of an acute stroke unit in a Brazilian hospital

    PubMed Central

    Luvizutto, Gustavo José; Gameiro, Mônica de Oliveira Orsi; Schelp, Arthur Oscar; Braga, Gabriel Pereira; Ribeiro, Priscila Watson; Bazan, Rodrigo

    2015-01-01

    [Purpose] The study aimed to characterize patients treated by rehabilitation section after establishment of an acute stroke unit. [Subjects and Methods] Medical consultation records of individuals with ischemic stroke were studied retrospectively, excluding individuals with hemorrhagic stroke, thrombolysis, previous Modified Rankin Scale ≥ 1, prior stroke, structural bone deformities, associated neurological disease, and prior cognitive deficit. The data evaluated were age, gender, etiology, localization, treatment received, ictus onset, hospitalization time, discharge date, and date of first evaluation at the rehabilitation center. The Modified Rankin Scale in 90 days after ictus was utilized to measure functional incapacity with the individuals divided into two groups, before and after acute stroke unit implementation (2010). Functional incapacity was compared between before and after acute stroke unit implementation by the Mann-Whitney test, χ2 test and Fisher’s exact test. [Results] The medical records of 170 patients were evaluated. In the group evaluated after 2010, the patients were significantly older and presented a shorter time between hospitalization and discharge, shorter time until the first evaluation in rehabilitation, and increased percentage of mild incapacity (Modified Rankin Scale = 0 to 2). [Conclusion] After acute stroke unit implementation, the patients treated in the rehabilitation section presented a shorter hospitalization time and rehabilitation delay and less functional incapacity. PMID:26355915

  14. Cerebrolysin effects on neurological outcomes and cerebral blood flow in acute ischemic stroke

    PubMed Central

    Amiri-Nikpour, Mohammad Reza; Nazarbaghi, Surena; Ahmadi-Salmasi, Babak; Mokari, Tayebeh; Tahamtan, Urya; Rezaei, Yousef

    2014-01-01

    Background Cerebrolysin, a brain-derived neuropeptide, has been shown to improve the neurological outcomes of stroke, but no study has demonstrated its effect on cerebral blood flow. This study aimed to determine the cerebrolysin impact on the neurological outcomes and cerebral blood flow. Methods In a randomized, double-blinded, placebo-controlled trial, 46 patients who had acute focal ischemic stroke were randomly assigned into two groups to receive intravenously either 30 mL of cerebrolysin diluted in normal saline daily for 10 days (n=23) or normal saline alone (n=23) adjunct to 100 mg of aspirin daily. All patients were examined using the National Institutes of Health Stroke Scale and transcranial Doppler to measure the mean flow velocity and pulsatility index (PI) of their cerebral arteries at baseline as well as on days 30, 60, and 90. Results The patients’ mean age was 60±9.7 years, and 51.2% of patients were male. The National Institutes of Health Stroke Scale was significantly lower in the cerebrolysin group compared with the placebo group on day 60 (median 10, interquartile range 9–11, P=0.008) and day 90 (median 11, interquartile range 10–13.5, P=0.001). The median of PI in the right middle cerebral artery was significantly lower in the cerebrolysin group compared with the placebo group on days 30, 60, and 90 (P<0.05). One patient in the cerebrolysin group and two patients in the placebo group died before day 30 (4.3% versus 8.7%). Conclusion Cerebrolysin can be useful to improve the neurological outcomes and the PI of middle cerebral artery in patients with acute focal ischemic stroke. PMID:25516711

  15. Severity of Spatial Neglect During Acute Inpatient Rehabilitation Predicts Community Mobility After Stroke

    PubMed Central

    Oh-Park, Mooyeon; Hung, Cynthia; Chen, Peii; Barrett, A.M.

    2014-01-01

    Objective To examine whether stroke survivors with more severe spatial neglect during their acute inpatient rehabilitation had poorer mobility after returning to their communities. Design A prospective observational study. Setting Acute inpatient rehabilitation and follow-up in the community. Participants Thirty-one consecutive stroke survivors with right-brain damage (women, n = 15 [48.4%]), with the mean (standard deviation) age of 60 ± 11.5 years, were included in the study if they demonstrated spatial neglect within 2 months after stroke. Methods Spatial neglect was assessed with the Behavioral Inattention Test (BIT) (range, 0-146 [a lower score indicates more severity]) and the Catherine Bergego Scale (range, 0-30 [a higher score indicates more severity]). A score of the Behavioral Inattention Test <129 or of the Catherine Bergego Scale >0 defined the presence of spatial neglect. Main Outcome Measurements The outcome measure is community mobility, defined by the extent and frequency of traveling within the home and in the community, and is assessed with the University of Alabama at Birmingham Study of Aging Life-Space Assessment (range, 0-120 [a lower score indicates less mobile]). This measure was assessed after participants returned home ≥6 months after stroke. The covariates were age, gender, functional independence at baseline; follow-up interval; and depressed mood, which may affect the relationship between spatial neglect and community mobility. Results A lower Behavioral Inattention Test score was a significant predictor of a lower Life-Space Assessment score after controlling for all the covariates (β = 0.009 [95% confidence interval, 0.008-0.017]); P = .020). The proportion of participants unable to travel independently beyond their homes was 0%, 27.3%, and 72.7% for those with mild, moderate, and severe acute neglect, respectively (Catherine Bergego Scale range, 1-10, 11-20, and 21-30, respectively). Conclusions Our result indicates that acute

  16. Early and intermediate prognosis of intravenous thrombolytic therapy in acute ischemic stroke subtypes according to the causative classification of stroke system

    PubMed Central

    Pashapour, Ali; Atalu, Abolfazl; Farhoudi, Mehdi; Taheraghdam, Ali-Akbar; Sadeghi Hokmabadi, Elyar; Sharifipour, Ehsan; NajafiNeshli, Mehdi

    2013-01-01

    Objectives: Intravenous thrombolytic therapy has established acceptable results in treating ischemic stroke. However, there is little information on treatment outcome especially in different subtypes. The aim of current study was to evaluate early and intermediate prognosis in intravenous thrombolytic therapy for acute ischemic stroke subtypes. Methodology: Forty eligible patients (57.5% male with mean age of 63.18±13.49 years) with definite ischemic stroke who were admitted to emergency department of Imam Reza University Hospital, in the first 180 minutes after occurrence received recombinant tissue plasminogen activator. All investigation findings were recorded and stroke subtypes were determined according to the Causative Classification of Stroke System. Stroke severity forms including modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores were recorded for all patients in first, seven and 90 days after stroke and disease outcome was evaluated. Results: The etiology of stroke was large artery atherosclerosis in 20%, cardio-aortic embolism in 45%, small artery occlusion in 17.5% and undetermined causes in 17.5%. NIHSS and mRS scores were significantly improved during time (P < 0.001 in both cases). Three months mortality rate was 25%. Among the etiologies, patients with small artery occlusion and then cardio-aortic embolism had lower NIHSS score at arrival (P = 0.04). Caplan-meier analysis showed that age, sex and symptom to needle time could predict disease outcome. Conclusion: Intravenous thrombolytic therapy is accompanied by good early and intermediate outcome in most patients with ischemic stroke. Small artery occlusion subtype had less disease severity and higher improvement. PMID:24353536

  17. Treatment of patients with mild acute ischemic stroke and associated large vessel occlusion.

    PubMed

    Cerejo, Russell; Cheng-Ching, Esteban; Hui, Ferdinand; Hussain, M Shazam; Uchino, Ken; Bullen, Jennifer; Toth, Gabor

    2016-08-01

    Several recent studies have shown that patients presenting with mild acute ischemic stroke (mAIS) symptoms may have an unfavorable natural history. The presence of associated large vessel occlusion (LVO) may lead to even worse outcomes, but most mAIS patients are still excluded from acute stroke treatment (AST). A retrospective review of patients with acute ischemic stroke presenting to our institution between 2010 and 2014 was carried out. Inclusion criteria were mAIS (initial National Institutes of Health Stroke Scale [NIHSS] ⩽7) due to LVO, presenting within 6hours from onset. Demographics, treatments and short-term outcomes were analyzed. Favorable 30day outcome was defined as modified Rankin Scale (mRS) ⩽2. Out of 2636 patients, 62 patients (median age 63years, 33 (53.2%) males) met inclusion criteria. The anterior circulation was involved in 74.1%. Median admission NIHSS and pre-admission mRS were 4 and 0, respectively. Twenty-three patients (71.8%) received AST (intravenous tissue plasminogen activator: 14, intra-arterial therapy: 4, both: 5). Favorable outcomes were 4.5 times higher in treated (78.3%) versus untreated (53.8%) patients (odds ratio 4.5, 95% confidence interval 1.26-19.2; p=0.028). None of the treated patients had symptomatic intracranial hemorrhage. We demonstrate that a significant proportion of untreated mAIS patients with LVO have an unfavorable natural history. Our results suggest better outcomes in patients who receive early therapy rather than conservative management. The detection of LVO, even with mild clinical symptoms, may prompt rapid treatment considerations. PMID:27050916

  18. ASTRAL-R score predicts non-recanalisation after intravenous thrombolysis in acute ischaemic stroke.

    PubMed

    Vanacker, Peter; Heldner, Mirjam R; Seiffge, David; Mueller, Hubertus; Eskandari, Ashraf; Traenka, Christopher; Ntaios, George; Mosimann, Pascal J; Sztajzel, Roman; Mendes Pereira, Vitor; Cras, Patrick; Engelter, Stefan; Lyrer, Philippe; Fischer, Urs; Lambrou, Dimitris; Arnold, Marcel; Michel, Patrik

    2015-05-01

    Intravenous thrombolysis (IVT) as treatment in acute ischaemic strokes may be insufficient to achieve recanalisation in certain patients. Predicting probability of non-recanalisation after IVT may have the potential to influence patient selection to more aggressive management strategies. We aimed at deriving and internally validating a predictive score for post-thrombolytic non-recanalisation, using clinical and radiological variables. In thrombolysis registries from four Swiss academic stroke centres (Lausanne, Bern, Basel and Geneva), patients were selected with large arterial occlusion on acute imaging and with repeated arterial assessment at 24 hours. Based on a logistic regression analysis, an integer-based score for each covariate of the fitted multivariate model was generated. Performance of integer-based predictive model was assessed by bootstrapping available data and cross validation (delete-d method). In 599 thrombolysed strokes, five variables were identified as independent predictors of absence of recanalisation: Acute glucose > 7 mmol/l (A), significant extracranial vessel STenosis (ST), decreased Range of visual fields (R), large Arterial occlusion (A) and decreased Level of consciousness (L). All variables were weighted 1, except for (L) which obtained 2 points based on β-coefficients on the logistic scale. ASTRAL-R scores 0, 3 and 6 corresponded to non-recanalisation probabilities of 18, 44 and 74 % respectively. Predictive ability showed AUC of 0.66 (95 %CI, 0.61-0.70) when using bootstrap and 0.66 (0.63-0.68) when using delete-d cross validation. In conclusion, the 5-item ASTRAL-R score moderately predicts non-recanalisation at 24 hours in thrombolysed ischaemic strokes. If its performance can be confirmed by external validation and its clinical usefulness can be proven, the score may influence patient selection for more aggressive revascularisation strategies in routine clinical practice. PMID:25589216

  19. Cost-Effectiveness of Thrombolysis within 4.5 Hours of Acute Ischemic Stroke in China

    PubMed Central

    Zhao, Xingquan; Liao, Xiaoling; Wang, Chunjuan; Du, Wanliang; Liu, Gaifen; Liu, Liping; Wang, Chunxue; Wang, Yilong; Wang, Yongjun

    2014-01-01

    Background Previous economic studies conducted in developed countries showed intravenous tissue-type plasminogen activator (tPA) is cost-effective for acute ischemic stroke. The present study aimed to determine the cost-effectiveness of tPA treatment in China, the largest developing country. Methods A combination of decision tree and Markov model was developed to determine the cost-effectiveness of tPA treatment versus non-tPA treatment within 4.5 hours after stroke onset. Outcomes and costs data were derived from the database of Thrombolysis Implementation and Monitor of acute ischemic Stroke in China (TIMS-China) study. Efficacy data were derived from a pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Costs and quality-adjusted life-years (QALYs) were compared in both short term (2 years) and long term (30 years). One-way and probabilistic sensitivity analyses were performed to test the robustness of the results. Results Comparing to non-tPA treatment, tPA treatment within 4.5 hours led to a short-term gain of 0.101 QALYs at an additional cost of CNY 9,520 (US$ 1,460), yielding an incremental cost-effectiveness ratio (ICER) of CNY 94,300 (US$ 14,500) per QALY gained in 2 years; and to a long-term gain of 0.422 QALYs at an additional cost of CNY 6,530 (US$ 1,000), yielding an ICER of CNY 15,500 (US$ 2,380) per QALY gained in 30 years. Probabilistic sensitivity analysis showed that tPA treatment is cost-effective in 98.7% of the simulations at a willingness-to-pay threshold of CNY 105,000 (US$ 16,200) per QALY. Conclusions Intravenous tPA treatment within 4.5 hours is highly cost-effective for acute ischemic strokes in China. PMID:25329637

  20. Safety and feasibility of intravenous thrombolytic therapy in Iranian patients with acute ischemic stroke

    PubMed Central

    Aghaei, Mahboubeh; Motamed, Mohammad Reza

    2013-01-01

    Background Thrombolytic therapy is the only approved treatment for acute cerebral ischemia. The hemorrhagictransformation is the greatest complication of this treatment, which may occur after recanalization of occludedartery. The aim of this study was to determine factors associated with clinical improvement and worseningin patients with acute ischemic stroke treated with intravenous thrombolysis. Methods Thirty seven patients who were treated with intravenous thrombolysis between August 2010 andAugust 2012 who had the inclusion criteria were studied. In this prospective study, all of the admitted patients instroke unit, monitored for at least 48 hours. We registered all patients’ information in a stroke data registry andfollowed them for at least 6 months. Results Thirty seven patients with acute ischemic stroke who treated with recombinant tissue plasminogenactivator (r-TPA) were studied. There were hemorrhagic transformations in 9 (24%) patients. Seven of them(18%) revealed intracerebral hemorrhages (ICH) within the control brain CT after 24 hours without any deteriorationof neurologic symptoms (asymptomatic ICH). Although outcomes of patients with symptomatic post r-TPA hemorrhages were worse than non-hemorrhagic post r-TPA patients, there were no significant differencesbetween asymptomatic post r-TPA hemorrhages and non-hemorrhagic post r-TPA patients, according to theNational Institutes of Health Stroke Scale (NIHSS) at admission (p = 0.2), after 24 hours (p= 0.07) and after 7days (p= 0.06) post treatment. Conclusion If the r-TPA protocol is followed carefully, the risk of symptomatic hemorrhage is low (about7%). Taking r-TPA was feasible and safe in our study population; thus, it can be applied for other Iranian patients. PMID:24791120

  1. Paradoxical Association of Smoking With In‐Hospital Mortality Among Patients Admitted With Acute Ischemic Stroke

    PubMed Central

    Ali, Syed F.; Smith, Eric E.; Bhatt, Deepak L.; Fonarow, Gregg C.; Schwamm, Lee H.

    2013-01-01

    Background Compared to those who never smoked, a paradoxical effect of smoking on reducing mortality in patients admitted with myocardial ischemia has been reported. We sought to determine if this effect was present in patients hospitalized with ischemic stroke. Methods and Results Using the local Get with the Guidelines‐Stroke registry, we analyzed 4305 consecutively admitted ischemic stroke patients (March 2002–December 2011). The sample was divided into smokers versus nonsmokers. The main outcome of interest was the overall inpatient mortality. Compared to nonsmokers, tobacco smokers were younger, more frequently male and presented with fewer stroke risk factors such as hypertension, hyperlipidemia, diabetes, coronary artery disease, and atrial fibrillation. Smokers also had a lower average NIH Stroke Scale (NIHSS) and fewer received tissue plasminogen activator (tPA). Patients in both groups had similar adherence to early antithrombotics, dysphagia screening prior to oral intake, and deep vein thrombosis (DVT) prophylaxis. Smoking was associated with lower all‐cause in‐hospital mortality (6.6% versus 12.4%; unadjusted OR 0.46; CI [0.34 to 0.63]; P<0.001). In multivariable analysis, adjusted for age, gender, ethnicity, hypertension, diabetes mellitus, hyperlipidemia, CAD, atrial fibrillation, NIHSS, and tPA, smoking remained independently associated with lower mortality (adjusted OR 0.64; CI [0.42 to 0.96]; P=0.03). Conclusions Similar to myocardial ischemia, smoking was independently associated with lower inpatient mortality in acute ischemic stroke. This effect may be due to tobacco‐induced changes in cerebrovascular vasoreactivity, or may be due in part to residual confounding. Larger, multicenter studies are needed to confirm the finding and the effect on 30‐day and 1‐year mortality. PMID:23782919

  2. Changes of deceleration and acceleration capacity of heart rate in patients with acute hemispheric ischemic stroke

    PubMed Central

    Xu, Yan-Hong; Wang, Xing-De; Yang, Jia-Jun; Zhou, Li; Pan, Yong-Chao

    2016-01-01

    Background and purpose Autonomic dysfunction is common after stroke, which is correlated with unfavorable outcome. Phase-rectified signal averaging is a newly developed technique for assessing cardiac autonomic function, by detecting sympathetic and vagal nerve activity separately through calculating acceleration capacity (AC) and deceleration capacity (DC) of heart rate. In this study, we used this technique for the first time to investigate the cardiac autonomic function of patients with acute hemispheric ischemic stroke. Methods A 24-hour Holter monitoring was performed in 63 patients with first-ever acute ischemic stroke in hemisphere and sinus rhythm, as well as in 50 controls with high risk of stroke. DC, AC, heart rate variability parameters, standard deviation of all normal-to-normal intervals (SDNN), and square root of the mean of the sum of the squares of differences between adjacent normal-to-normal intervals (RMSSD) were calculated. The National Institutes of Health Stroke Scale (NIHSS) was used to assess the severity of stroke. We analyzed the changes of DC, AC, SDNN, and RMSSD and also studied the correlations between these parameters and NIHSS scores. Results The R–R (R wave to R wave on electrocardiogram) intervals, DC, AC, and SDNN in the cerebral infarction group were lower than those in controls (P=0.003, P=0.002, P=0.006, and P=0.043), but the difference of RMSSD and the D-value and ratio between absolute value of AC (|AC|) and DC were not statistically significant compared with those in controls. The DC of the infarction group was significantly correlated with |AC|, SDNN, and RMSSD (r=0.857, r=0.619, and r=0.358; P=0.000, P=0.000, and P=0.004). Correlation analysis also showed that DC, |AC|, and SDNN were negatively correlated with NIHSS scores (r=−0.279, r=−0.266, and r=−0.319; P=0.027, P=0.035, and P=0.011). Conclusion Both DC and AC of heart rate decreased in patients with hemispheric infarction, reflecting a decrease in both vagal

  3. Advances in interventional neuroradiology: novel use of mechanical thrombectomy in acute ischemic stroke.

    PubMed

    Nayak, Sanjeev; Fitzpatrick, Sean

    2015-05-01

    Dr Sanjeev Nayak speaks to Sean Fitzpatrick, Commissioning Editor: Dr Sanjeev Nayak is a Consultant Neuroradiologist with special interest in Interventional Neuroradiology at the University Hospital of North Midlands, Stoke on Trent. He was responsible for the development of Interventional Stroke Service which he did immediately following his appointment in 2009 and was the lead neuroradiologist from 2010 to 2013. Dr Nayak and his team have pioneered in the field of mechanical thrombectomy and stenting in acute ischemic stroke and treated the largest number of such cases in the UK. His team has produced one of the best clinical outcomes for such patients with the lowest mortality rates in the UK. This work has been nominated for numerous national awards in various categories of BMJ, Patient Safety and Care integration awards. Dr Nayak was the finalist at the HSJ awards under the category of 'Clinical Leader of the Year 2012' and NHS Leadership awards 'NHS Inspirational Leader of the Year 2013. Dr Nayak is also involved in patents and designs involving new stroke interventional devices and is actively involved in stroke research which has led to numerous publications in peer reviewed journals. Dr Nayak has organized national conferences and lectured at various national and international conferences in his field of interest. PMID:26021630

  4. Antiplatelet Usage Impacts Clot Density in Acute Anterior Circulation Ischemic Stroke.

    PubMed

    Pikija, Slaven; Magdic, Jozef; Lukic, Anita; Schreiber, Catharina; Mutzenbach, Johannes Sebastian; McCoy, Mark R; Sellner, Johann

    2016-01-01

    We explored whether clot density in middle cerebral artery (MCA) occlusion is related to clinical variables, stroke etiology, blood constituents, and prestroke medication. We performed a retrospective chart review of patients with acute ischemic stroke of the anterior circulation admitted to two Central European stroke centers. The acquisition of non-contrast enhanced CT (NECT) and CT angiography (CTA) within 4.5 h of symptom onset was obligatory. We assessed the site of MCA occlusion as well as density, area, and length of the clot in 150 patients. The Hounsfield unit values for the clot were divided with contralateral MCA segment to yield relative Hounsfield Unit ratio (rHU). The site of the vessel occlusion (M1 vs. M2) and antiplatelet usage, but not stroke etiology, significantly influenced rHU. We found an inverse correlation of rHU with erythrocyte count (p < 0.001). The multivariate analysis revealed that a higher rHU (i.e., clot being more hyperdense) was more likely with the use of antiplatelets (OR 4.24, CI 1.10-16.31, p = 0.036). Erythrocyte (OR 0.18, CI 0.05-0.55, p = 0.003), and thrombocyte counts (OR 0.99, CI 0.98-0.99, p = 0.029) were associated with odds for more hypodense clots (lower rHU). Our study disclosed that antiplatelet therapy impacts the composition of intracranial clots of the anterior circulation. PMID:27563874

  5. Immunohistochemical Analysis of Cerebral Thrombi Retrieved by Mechanical Thrombectomy from Patients with Acute Ischemic Stroke

    PubMed Central

    Schuhmann, Michael K.; Gunreben, Ignaz; Kleinschnitz, Christoph; Kraft, Peter

    2016-01-01

    Mechanical thrombectomy is a novel treatment option for patients with acute ischemic stroke (AIS). Only a few studies have previously suggested strategies to categorize retrieved clots according to their histologic composition. However, these reports did not analyze potential biomarkers that are of importance in stroke-related inflammation. We therefore histopathologically investigated 37 intracerebral thrombi mechanically retrieved from patients with AIS, and focused on the composition of immune cells and platelets. We also conducted correlation analyses of distinctive morphologic patterns (erythrocytic, serpentine, layered, red, white, mixed appearance) with clinical parameters. Most T cells and monocytes were detected in erythrocytic and red clots, in which the distribution of these cells was random. In contrast, von Willebrand factor (vWF)-positive areas co-localized with regions of fibrin and collagen. While clots with huge amounts of vWF seem to be associated with a high National Institute of Health Stroke Scale score at admission, histologic findings could not predict the clinical outcome at discharge. In summary, we provide the first histologic description of mechanically retrieved intracerebral thrombi regarding biomarkers relevant for inflammation in ischemic stroke. PMID:26927082

  6. Diffusion weighted magnetic resonance imaging for acute stroke: practical and popular

    PubMed Central

    Tan, P L; King, D; Durkin, C J; Meagher, T M; Briley, D

    2006-01-01

    Aim To evaluate the feasibility and impact of diffusion weighted magnetic resonance imaging (DW MRI) as the first line neuroimaging of stroke at a district general hospital. Methods Prospective audit of all in‐patients admitted with clinically suspected acute stroke and referred for imaging over a consecutive 17 week period. The data collected included scan type, time from cerebral event to imaging request, and time from formal radiological request to neuroimaging. Clinicians' (general physicians, neurologists, and radiologists) perceptions were assessed by a questionnaire. Results 148 patients had neuroimaging for clinically suspected stroke during this period. Eighty one per cent of patients (120 of 148) had DW MRI as first line. Ninety two per cent of these patients had DW MRI within 24 hours of the formal radiological request. Twenty eight patients did not undergo DW MRI because lack of MRI safety, clinical state, unavailability because of maintenance service or lack of trained staff. Clinicians found the introduction of the DW MRI based service a significant improvement on computed tomography, especially for equivocal cases. Conclusion DW based MRI service is both feasible and sustainable in the setting of a district general hospital and most clinicians feel that this is a significant improvement to stroke services. PMID:16597819

  7. Immunohistochemical Analysis of Cerebral Thrombi Retrieved by Mechanical Thrombectomy from Patients with Acute Ischemic Stroke.

    PubMed

    Schuhmann, Michael K; Gunreben, Ignaz; Kleinschnitz, Christoph; Kraft, Peter

    2016-01-01

    Mechanical thrombectomy is a novel treatment option for patients with acute ischemic stroke (AIS). Only a few studies have previously suggested strategies to categorize retrieved clots according to their histologic composition. However, these reports did not analyze potential biomarkers that are of importance in stroke-related inflammation. We therefore histopathologically investigated 37 intracerebral thrombi mechanically retrieved from patients with AIS, and focused on the composition of immune cells and platelets. We also conducted correlation analyses of distinctive morphologic patterns (erythrocytic, serpentine, layered, red, white, mixed appearance) with clinical parameters. Most T cells and monocytes were detected in erythrocytic and red clots, in which the distribution of these cells was random. In contrast, von Willebrand factor (vWF)-positive areas co-localized with regions of fibrin and collagen. While clots with huge amounts of vWF seem to be associated with a high National Institute of Health Stroke Scale score at admission, histologic findings could not predict the clinical outcome at discharge. In summary, we provide the first histologic description of mechanically retrieved intracerebral thrombi regarding biomarkers relevant for inflammation in ischemic stroke. PMID:26927082

  8. Simple In-Hospital Interventions to Reduce Door-to-CT Time in Acute Stroke

    PubMed Central

    Taheraghdam, Aliakbar; Rikhtegar, Reza; Mehrvar, Kaveh; Mehrara, Mehrdad; Hassasi, Rogayyeh; Aliyar, Hannane; Farzi, Mohammadamin; Hasaneh Tamar, Somayyeh

    2016-01-01

    Background. Intravenous tissue plasminogen activator, a time dependent therapy, can reduce the morbidity and mortality of acute ischemic stroke. This study was designed to assess the effect of simple in-hospital interventions on reducing door-to-CT (DTC) time and reaching door-to-needle (DTN) time of less than 60 minutes. Methods. Before any intervention, DTC time was recorded for 213 patients over a one-year period at our center. Five simple quality-improvement interventions were implemented, namely, call notification, prioritizing patients for CT scan, prioritizing patients for lab analysis, specifying a bed for acute stroke patients, and staff education. After intervention, over a course of 44 months, DTC time was recorded for 276 patients with the stroke code. Furthermore DTN time was recorded for 106 patients who were treated with IV thrombolytic therapy. Results. The median DTC time significantly decreased in the postintervention period comparing to the preintervention period [median (IQR); 20 (12–30) versus 75 (52.5–105), P < 0.001]. At the postintervention period, the median (IQR) DTN time was 55 (40–73) minutes and proportion of patients with DTN time less than 60 minutes was 62.4% (P < 0.001). Conclusion. Our interventions significantly reduced DTC time and resulted in an acceptable DTN time. These interventions are feasible in most hospitals and should be considered. PMID:27478641

  9. The Potential Roles of 18F-FDG-PET in Management of Acute Stroke Patients

    PubMed Central

    Bunevicius, Adomas; Yuan, Hong

    2013-01-01

    Extensive efforts have recently been devoted to developing noninvasive imaging tools capable of delineating brain tissue viability (penumbra) during acute ischemic stroke. These efforts could have profound clinical implications for identifying patients who may benefit from tPA beyond the currently approved therapeutic time window and/or patients undergoing neuroendovascular treatments. To date, the DWI/PWI MRI and perfusion CT have received the most attention for identifying ischemic penumbra. However, their routine use in clinical settings remains limited. Preclinical and clinical PET studies with [18F]-fluoro-2-deoxy-D-glucose (18F-FDG) have consistently revealed a decreased 18F-FDG uptake in regions of presumed ischemic core. More importantly, an elevated 18F-FDG uptake in the peri-ischemic regions has been reported, potentially reflecting viable tissues. To this end, this paper provides a comprehensive review of the literature on the utilization of 14C-2-DG and 18F-FDG-PET in experimental as well as human stroke studies. Possible cellular mechanisms and physiological underpinnings attributed to the reported temporal and spatial uptake patterns of 18F-FDG are addressed. Given the wide availability of 18F-FDG in routine clinical settings, 18F-FDG PET may serve as an alternative, non-invasive tool to MRI and CT for the management of acute stroke patients. PMID:23762852

  10. Lower Serum Caveolin-1 Is Associated with Cerebral Microbleeds in Patients with Acute Ischemic Stroke

    PubMed Central

    Zhang, Jun; Zhu, Wusheng; Xiao, Lulu; Cao, Qinqin; Zhang, Hao; Wang, Huaiming; Ye, Zusen; Hao, Yonggang; Dai, Qiliang; Sun, Wen; Liu, Xinfeng; Ye, Ruidong

    2016-01-01

    Caveolin-1 (Cav-1) plays pivotal roles in the endothelial damage following stroke. The present study aimed to investigate whether serum Cav-1 level is associated with the presence of cerebral small vessel disease (cSVD) in patients with acute ischemic stroke. To this end, 156 patients were consecutively enrolled. Cranial magnetic resonance imaging was analyzed to determine the surrogates of cSVD, including cerebral microbleeds (CMBs), silent lacunar infarcts (SLIs), and white matter hyperintensities (WMHs). After adjusting for potential confounders, patients with low Cav-1 level had a higher risk of CMBs than patients with high Cav-1 level (OR: 4.05, 95% CI: 1.77–9.30). However, there was no relationship between Cav-1 and the presence of SLIs or WMHs. When CMBs were stratified by location and number, a similar association was found in patients with deep or infratentorial CMBs (OR: 4.04, 95% CI: 1.59–10.25) and with multiple CMBs (OR: 3.18, 95% CI: 1.16–8.72). These results suggest lower serum Cav-1 levels may be associated with CMBs, especially those that are multiple and located in deep brain or infratentorial structures, in patients with acute ischemic stroke. Cav-1 may be involved in the pathophysiology of CMBs, and may act as a potential target for treating cSVD. PMID:27119011

  11. Neuroprotective effect of osthole against acute ischemic stroke on middle cerebral ischemia occlusion in rats.

    PubMed

    Chao, Xiaodong; Zhou, Jun; Chen, Tao; Liu, Wenbo; Dong, Wenpeng; Qu, Yan; Jiang, Xiaofan; Ji, Xituan; Zhen, Haining; Fei, Zhou

    2010-12-01

    Osthole, a natural coumarin derivative, has taken considerable attention because of its diverse pharmacological functions. It has been reported to be useful in the treatment of chronic cerebral hypoperfusion and neuronal damage. In the present study, we examined the neuroprotective effect of osthole and its potential mechanisms against acute ischemic stroke induced by middle cerebral artery occlusion (MCAO) in rats. The rats were pretreated with osthole 10, 20 and 40 mg/kg 30 min before MCAO. The neuroprotective effect of osthole against acute ischemic stroke was evaluated by neurological deficit score (NDS), dry-wet weight and 2,3,5-triphenyltetrazolium chloride (TTC) staining. The contents of malondialdehyde (MDA) and glutathione (GSH), activity of myeloperoxidase (MPO) and the level of interleukin (IL)-1β and IL-8 after 2h of MCAO in rats were detected to investigate its anti-oxidative action and anti-inflammatory property. Pretreatment with osthole significantly increased in GSH, and decreased the volume of infarction, NDS, edema, MDA, MPO, IL-1β and IL-8 compared with rats in the MCAO group at 24h after MCAO. The study suggests the neuroprotective effect of osthole in the MCAO model of rats. The anti-oxidative action and anti-inflammatory property of osthole may contribute to a beneficial effect against stroke. PMID:20869955

  12. Thrombolysis for acute ischemic stroke by tenecteplase in the emergency department of a Moroccan hospital

    PubMed Central

    Belkouch, Ahmed; Jidane, Said; Chouaib, Naoufal; Elbouti, Anass; Nebhani, Tahir; Sirbou, Rachid; Bakkali, Hicham; Belyamani, Lahcen

    2015-01-01

    Introduction Thrombolysis has radically changed the prognosis of acute ischemic stroke. Tenecteplase is a modified form of rt-PA with greater specificity for fibrin and a longer half-life. We report the experience of a Moroccan tertiary hospital in thrombolysis using Tenecteplase. Methods We conducted an open prospective study of all patients who were treated with Tenecteplase for an acute ischemic stroke admitted to our emergency department. Tenecteplase was administered intravenously at a dose of 0.4 mg/kg single bolus. The primary outcome measure was the proportion of patients achieving significant early neurological recovery defined as an improvement of 4 or more points on the NIHSS score at 24h. Results 13 patients had been treated by intravenous thrombolysis. 31% were women. Mean age was 63 years old. The mean NIHSS score at admission was 14.3 and 24h after was at 9.1. The right middle cerebral artery was involved in 69% of cases. The carotid atherosclerosis was predominant 63.3% and the cardio embolic etiology 27%. The mean time to the first medical contact after the onset of symptoms was 3h 30 min. One patient presented a capsulo-lenticular hematoma of 5 mm3 in the same side of the ischemic stroke. Conclusion Tenecteplase is a more interesting thrombolytic than alteplase, it seems to be more suitable for thrombolysis in our center. PMID:26405473

  13. Role of imaging in current acute ischemic stroke workflow for endovascular therapy.

    PubMed

    Menon, Bijoy K; Campbell, Bruce C V; Levi, Christopher; Goyal, Mayank

    2015-06-01

    Ischemic stroke is caused by a thrombus that blocks an intracranial artery. Brain tissue beyond the blocked artery survives for a variable period of time because of blood and nutrients received through tiny vessels called collaterals. Imaging the brain and the vasculature that supplies it is therefore a vital first step in treating patients with acute ischemic stroke. In this review, we focus on current evidence for imaging selection of patients for endovascular therapy in the context of the recently positive clinical trials, such as Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing Computed Tomography to Recanalization Times (ESCAPE), Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME), and Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA). We discuss evidence for and use of the various imaging paradigms available. We discuss how to set up quick and efficient imaging protocols for patient selection and address common concerns about the use of imaging, including time spent, contrast, radiation, and other advantages and disadvantages. Finally, we briefly comment on how imaging can integrate itself within various health systems of care in the future, thereby potentially improving patient outcomes further. PMID:25944319

  14. Acute Neuronal Injury and Blood Genomic Profiles in a Nonhuman Primate Model for Ischemic Stroke

    PubMed Central

    Rodriguez-Mercado, Rafael; Ford, Gregory D; Xu, Zhenfeng; Kraiselburd, Edmundo N; Martinez, Melween I; Eterović, Vesna A; Colon, Edgar; Rodriguez, Idia V; Portilla, Peter; Ferchmin, Pedro A; Gierbolini, Lynette; Rodriguez-Carrasquillo, Maria; Powell, Michael D; Pulliam, John VK; McCraw, Casey O; Gates, Alicia; Ford, Byron D

    2012-01-01

    The goal of this study was to characterize acute neuronal injury in a novel nonhuman primate (NHP) ischemic stroke model by using multiple outcome measures. Silk sutures were inserted into the M1 segment of the middle cerebral artery of rhesus macaques to achieve permanent occlusion of the vessel. The sutures were introduced via the femoral artery by using endovascular microcatheterization techniques. Within hours after middle cerebral artery occlusion (MCAO), infarction was detectable by using diffusion-weighted MRI imaging. The infarcts expanded by 24 h after MCAO and then were detectable on T2-weighted images. The infarcts seen by MRI were consistent with neuronal injury demonstrated histologically. Neurobehavioral function after MCAO was determined by using 2 neurologic testing scales. Neurologic assessments indicated that impairment after ischemia was limited to motor function in the contralateral arm; other neurologic and behavioral parameters were largely unaffected. We also used microarrays to examine gene expression profiles in peripheral blood mononuclear cells after MCAO-induced ischemia. Several genes were altered in a time-dependent manner after MCAO, suggesting that this ischemia model may be suitable for identifying blood biomarkers associated with the presence and severity of ischemia. This NHP stroke model likely will facilitate the elucidation of mechanisms associated with acute neuronal injury after ischemia. In addition, the ability to identify candidate blood biomarkers in NHP after ischemia may prompt the development of new strategies for the diagnosis and treatment of ischemic stroke in humans. PMID:23114047

  15. Carotid Atherosclerosis Does Not Predict Coronary, Vertebral, or Aortic Atherosclerosis in Patients with Acute Stroke Symptoms

    PubMed Central

    2010-01-01

    PURPOSE The purpose of this study was to determine whether significant atherosclerotic disease in the carotid arteries predicts significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. METHODS Atherosclerotic disease was imaged using computed tomography angiography (CTA) in a prospective study of 120 consecutive patients undergoing emergent CT evaluation for symptoms of stroke. Using a comprehensive CTA protocol that captured the carotid arteries, coronary arteries, vertebral arteries, and aorta, we evaluated these arteries for the presence and severity of atherosclerotic disease. Significant atherosclerotic disease was defined as > 50% stenosis in the carotid, coronary, and vertebral arteries, or ≥ 4mm thickness and encroaching in the aorta. Presence of any and significant atherosclerotic disease were compared in the different types of arteries assessed. RESULTS Of these 120 patients, 79 had CTA exams of adequate image quality and were evaluated in this study. Of these 79 patients, 33 had significant atherosclerotic disease. In 26 of these 33 patients (79%), significant disease was isolated to one type of artery, most often to the coronary arteries (N = 14; 54%). Non-significant atherosclerotic disease was more systemic and involved multiple arteries. CONCLUSIONS Significant atherosclerotic disease in the carotid arteries does not predict significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. Significant atherosclerotic disease is most often isolated to one type of artery in these patients, while non-significant atherosclerotic disease tends to be more systemic. PMID:20595672

  16. Long-Term Survival in Older Critically Ill Patients with Acute Ischemic Stroke

    PubMed Central

    Liou, Jinn-Ing; Smith, Maureen A.

    2009-01-01

    Objective To compare survival in older patients with acute ischemic stroke admitted to intensive care units (ICU) with those not requiring ICU care and to assess the impact of mechanical ventilation (MV) and percutaneous gastrostomy tubes (PEG) on long-term mortality. Design Multi-center retrospective cohort study. Setting Administrative data from the Centers for Medicare and Medicaid Services covering 93 metropolitan counties primarily in the Eastern half of the United States. Patients 31,301 patients discharged with acute ischemic stroke in 2000. Interventions None Measurements Mortality from the time of index hospitalization up to the end of the follow-up period of 12 months. Information was also gathered on use of mechanical ventilation, percutaneous gastrostomy, sociodemographic variables and a host of comorbid conditions. Main Results 26% of all patients with acute ischemic stroke required ICU admission. The crude death rate for ICU stroke patients was 21% at 30 days and 40% at 1-year follow-up. At 30 days, after adjustment of sociodemographic variables and comorbidities, ICU patients had a 29% higher mortality hazard compared to non-ICU patients. Mechanical ventilation was associated with a five-fold higher mortality hazard (hazard ratio 5.59, confidence interval 4.93–6.34). The use of PEG was not associated with mortality at 30 days. By contrast, at 1-year follow up in 30-day survivors, ICU admission was not associated with mortality hazard (hazard ratio 1.01; 95% confidence interval 0.93–1.09). Mechanical ventilation still had a higher risk of death (hazard ratio 1.88, 95% confidence interval 1.57–2.25), and PEG patients had a 2.59 fold greater mortality hazard (95% confidence interval 2.38–2.82). Conclusions Both short-term and long-term mortality in older patients with acute ischemic stroke admitted to ICUs is lower than previously reported. The need for MV and PEG are markers for poor long-term outcome. Future research should focus on the

  17. Quality of acute stroke care improvement framework for the Paul Coverdell National Acute Stroke Registry: facilitating policy and system change at the hospital level.

    PubMed

    LaBresh, Kenneth A

    2006-12-01

    The Paul Coverdell National Acute Stroke Registry prototypes baseline data collection demonstrated a significant gap in the use of evidenced-based interventions. Barriers to the use of these interventions can be characterized as relating to lack of knowledge, attitudes, and ineffective behaviors and systems. Quality improvement programs can address these issues by providing didactic presentations to disseminate the science and peer interactions to address the lack of belief in the evidence, guidelines, and likelihood of improved patient outcomes. Even with knowledge and intention to provide evidenced-based care, the absence of effective systems is a significant behavioral barrier. A program for quality improvement that includes multidisciplinary teams of clinical and quality improvement professionals has been successfully used to carry out redesign of stroke care delivery systems. Teams are given a methodology to set goals, test ideas for system redesign, and implement those changes that can be successfully adapted to the hospital's environment. Bringing teams from several hospitals together substantially accelerates the process by sharing examples of successful change and by providing strategies to support the behavior change necessary for the adoption of new systems. The participation of many hospitals also creates momentum for the adoption of change by demonstrating observable and successful improvement. Data collection and feedback are useful to demonstrate the need for change and evaluate the impact of system change, but improvement occurs very slowly without a quality improvement program. This quality improvement framework provides hospitals with the capacity and support to redesign systems, and has been shown to improve stroke care considerably, when coupled with an Internet-based decision support registry, and at a much more rapid pace than when hospitals use only the support registry. PMID:17178313

  18. Tailor-made rehabilitation approach using multiple types of hybrid assistive limb robots for acute stroke patients: A pilot study.

    PubMed

    Fukuda, Hiroyuki; Morishita, Takashi; Ogata, Toshiyasu; Saita, Kazuya; Hyakutake, Koichi; Watanabe, Junko; Shiota, Etsuji; Inoue, Tooru

    2016-01-01

    This article investigated the feasibility of a tailor-made neurorehabilitation approach using multiple types of hybrid assistive limb (HAL) robots for acute stroke patients. We investigated the clinical outcomes of patients who underwent rehabilitation using the HAL robots. The Brunnstrom stage, Barthel index (BI), and functional independence measure (FIM) were evaluated at baseline and when patients were transferred to a rehabilitation facility. Scores were compared between the multiple-robot rehabilitation and single-robot rehabilitation groups. Nine hemiplegic acute stroke patients (five men and four women; mean age 59.4 ± 12.5 years; four hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using multiple types of HAL robots for 19.4 ± 12.5 days, and 14 patients (six men and eight women; mean age 63.2 ± 13.9 years; nine hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using a single type of HAL robot for 14.9 ± 8.9 days. The multiple-robot rehabilitation group showed significantly better outcomes in the Brunnstrom stage of the upper extremity, BI, and FIM scores. To the best of the authors' knowledge, this is the first pilot study demonstrating the feasibility of rehabilitation using multiple exoskeleton robots. The tailor-made rehabilitation approach may be useful for the treatment of acute stroke. PMID:26478988

  19. Fire-Heat and Qi Deficiency Syndromes as Predictors of Short-term Prognosis of Acute Ischemic Stroke

    PubMed Central

    Cheng, Shu-Chen; Lin, Chien-Hsiung; Chang, Yeu-Jhy; Lee, Tsong-Hai; Ryu, Shan-Jin; Chen, Chun-Hsien; Chang, Her-Kun; Chang, Chee-Jen

    2013-01-01

    Abstract Objectives To explore the relationships between traditional Chinese medicine (TCM) syndromes and disease severity and prognoses after ischemic stroke, such as neurologic deficits and decline in activities of daily living (ADLs). Methods The study included 211 patients who met the inclusion criteria of acute ischemic stroke based on clinical manifestations, computed tomography or magnetic resonance imaging findings, and onset of ischemic stroke within 72 hours with clear consciousness. To assess neurologic function and ADLs in patients with different TCM syndromes, the TCM Syndrome Differentiation Diagnostic Criteria for Apoplexy scale (containing assessments of wind, phlegm, blood stasis, fire-heat, qi deficiency, and yin deficiency with yang hyperactivity syndromes) was used within 72 hours of stroke onset, and Western medicine–based National Institutes of Health Stroke Scale (NIHSS) and Barthel Index (BI) assessments were performed at both admission and discharge. Results The most frequent TCM syndromes associated with acute ischemic stroke were wind syndrome, phlegm syndrome, and blood stasis syndrome. Improvement according to the BI at discharge and days of admission were significantly different between patients with and those without fire-heat syndrome. Patients with qi deficiency syndrome had longer hospital stays and worse NIHSS and BI assessments at discharge than patients without qi deficiency syndrome. All the reported differences reached statistical significance. Conclusions These results provide evidence that fire-heat syndrome and qi deficiency syndrome are essential elements that can predict short-term prognosis of acute ischemic stroke. PMID:23600945

  20. The Effect of Out of Hours Presentation with Acute Stroke on Processes of Care and Outcomes: Analysis of Data from the Stroke Improvement National Audit Programme (SINAP)

    PubMed Central

    Campbell, James T. P.; Bray, Benjamin D.; Hoffman, Alex M.; Kavanagh, Sara J.; Rudd, Anthony G.; Tyrrell, Pippa J.

    2014-01-01

    Background There is inconsistent evidence that patients with stroke admitted to hospital out of regular working hours (such as weekends) experience worse outcomes. We aimed to identify if inequalities in the quality of care and mortality exist in contemporary stroke care in England. Methods SINAP is a prospective database of acute stroke patients, documenting details of processes of care over the first 72 hours. We compared quality of care indicators and mortality at 72 hours, 7 days and 30 days, for patients who arrived within normal hours (Monday–Friday 8am to 6pm) and for those who arrived out of hours, using multivariable logistic and Cox proportional hazard models. Quality of care was defined according to time from arrival at hospital to interventions (e.g., brain scan), and whether the patient received therapeutic interventions (such as thrombolysis). Results 45,726 stroke patients were admitted to 130 hospitals in England between 1 April 2010 and 31 January 2012. Patients admitted out of hours (n = 23779) had more features indicative of worse prognosis (haemorrhagic stroke, reduced consciousness, pre stroke dependency). Out of hours admission was significantly associated with longer delays in receiving a CT scan or being admitted to a stroke unit, and reduced odds of receiving thrombolysis. After adjusting for casemix, there was no consistent evidence of higher mortality for patients admitted out of hours, but patients admitted at the weekends had a higher risk of 30 day mortality (OR 1.14, 95% CI 1.06–1.21) Conclusion Inequalities in the provision of stroke care for people admitted out of regular hours persist in contemporary stroke in England. The association with mortality is small and largely attributable to higher illness severity in patients admitted out of hours. PMID:24533063

  1. Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population

    PubMed Central

    Slocum, Chloe; Gerrard, Paul; Black-Schaffer, Randie; Goldstein, Richard; Singhal, Aneesh; DiVita, Margaret A.; Ryan, Colleen M.; Mix, Jacqueline; Purohit, Maulik; Niewczyk, Paulette; Kazis, Lewis; Zafonte, Ross; Schneider, Jeffrey C.

    2015-01-01

    Objective Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissions in the inpatient rehabilitation stroke population compared with medical comorbidities using a large, administrative data set. Methods A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed examining stroke patients admitted to inpatient rehabilitation facilities. A Basic Model for predicting acute care readmission risk based on age and functional status was compared with models incorporating functional status and medical comorbidities (Basic-Plus) or models including age and medical comorbidities alone (Age-Comorbidity). C-statistics were compared to evaluate model performance. Findings There were a total of 803,124 patients: 88,187 (11%) patients were transferred back to an acute hospital: 22,247 (2.8%) within 3 days, 43,481 (5.4%) within 7 days, and 85,431 (10.6%) within 30 days. The C-statistics for the Basic Model were 0.701, 0.672, and 0.682 at days 3, 7, and 30 respectively. As compared to the Basic Model, the best-performing Basic-Plus model was the Basic+Elixhauser model with C-statistics differences of +0.011, +0.011, and + 0.012, and the best-performing Age-Comorbidity model was the Age+Elixhauser model with C-statistic differences of -0.124, -0.098, and -0.098 at days 3, 7, and 30 respectively. Conclusions Readmission models for the inpatient rehabilitation stroke population based on functional status and age showed better predictive ability than models based on medical comorbidities. PMID

  2. Imaging, Intervention, and Workflow in Acute Ischemic Stroke: The Calgary Approach.

    PubMed

    Zerna, C; Assis, Z; d'Esterre, C D; Menon, B K; Goyal, M

    2016-06-01

    Five recently published clinical trials showed dramatically higher rates of favorable functional outcome and a satisfying safety profile of endovascular treatment compared with the previous standard of care in acute ischemic stroke with proximal anterior circulation artery occlusion. Eligibility criteria within these trials varied by age, stroke severity, imaging, treatment-time window, and endovascular treatment devices. This focused review provides an overview of the trial results and explores the heterogeneity in imaging techniques, workflow, and endovascular techniques used in these trials and the consequent impact on practice. Using evidence from these trials and following a case from start to finish, this review recommends strategies that will help the appropriate patient undergo a fast, focused clinical evaluation, imaging, and intervention. PMID:26659339

  3. [Intervention effect of Tibetan patent medicine Ruyi Zhenbao pills in acute ischemic stroke in rats].

    PubMed

    Liu, Rui-ying; Wu, Wei-jie; Tan, Rui; Xie, Bin; Zhong, Zhen-dong; He, Jing-ping; Chen, Yao; Kang, Xin-li

    2015-02-01

    Ischemic stroke is a primary cause of death and long-term disability all over the world. This disease is resulted from ischemia and hypoxia in brain tissues because of insufficient blood supply and causes a series of physiochemical metabolism disorders and physiological dysfunction. Its high disability ratio has bright huge burdens to society, governments and families. However, there is not efficacious medicine to treat it. In this study, a right middle cerebral artery occlusion was established in rats to observe the multi-path and multi-aspect intervention effects of Tibetan patent medicine Ruyi Zhenbao pills in reducing injuries to Nissl bodies, cerebral edema and inflammatory reactions and preventing cellular apoptosis, in order to lay a foundation for defining its therapeutic mechanism in acute ischemic stroke. PMID:26084187

  4. Modular Ankle Robotics Training in Early Sub-Acute Stroke: A Randomized Controlled Pilot Study

    PubMed Central

    Forrester, Larry W.; Roy, Anindo; Krywonis, Amanda; Kehs, Glenn; Krebs, Hermano Igo; Macko, Richard F.

    2014-01-01

    Background Modular lower extremity (LE) robotics may offer a valuable avenue for restoring neuromotor control after hemiparetic stroke. Prior studies show that visually-guided and visually-evoked practice with an ankle robot (anklebot) improves paretic ankle motor control that translates into improved overground walking. Objective Assess the feasibility and efficacy of daily anklebot training during early sub-acute hospitalization post-stroke. Methods Thirty-four inpatients from a stroke unit were randomly assigned to anklebot (N=18) or passive manual stretching (N=16) treatments. All suffered a first stroke with residual hemiparesis (ankle manual muscle test grade 1/5 to 4/5), and at least trace muscle activation in plantar- or dorsiflexion. Anklebot training employed an “assist-as-needed” approach during > 200 volitional targeted paretic ankle movements, with difficulty adjusted to active range of motion and success rate. Stretching included >200 daily mobilizations in these same ranges. All sessions lasted 1 hour and assessments were not blinded. Results Both groups walked faster at discharge, however the robot group improved more in percent change of temporal symmetry (p=0.032) and also of step length symmetry (p=0.038), with longer nonparetic step lengths in the robot (133%) vs. stretching (31%) groups. Paretic ankle control improved in the robot group, with increased peak (p≤ 0.001) and mean (p≤ 0.01) angular speeds, and increased movement smoothness (p≤ 0.01). There were no adverse events. Conclusion Though limited by small sample size and restricted entry criteria, our findings suggest that modular lower extremity robotics during early sub-acute hospitalization is well tolerated and improves ankle motor control and gait patterning. PMID:24515923

  5. Albumin Administration in Acute Ischemic Stroke: Safety Analysis of the ALIAS Part 2 Multicenter Trial

    PubMed Central

    Hill, Michael D.; Martin, Renee H.; Palesch, Yuko Y.; Moy, Claudia S.; Tamariz, Diego; Ryckborst, Karla J.; Jones, Elizabeth B.; Weisman, David; Pettigrew, Creed; Ginsberg, Myron D.

    2015-01-01

    Background Albumin treatment of ischemic stroke was associated with cardiopulmonary adverse events in previous studies and a low incidence of intracranial hemorrhage. We sought to describe the neurological and cardiopulmonary adverse events in the ALIAS Part 2 Multicenter Trial. Methods Ischemic stroke patients, aged 18–83 and a baseline NIHSS ≥ 6, were randomized to treatment with ALB or saline control within 5 hours of stroke onset. Neurological adverse events included symptomatic intracranial hemorrhage, hemicraniectomy, neurological deterioration and neurological death. Cardiopulmonary adverse events included pulmonary edema/congestive heart failure, acute coronary syndromes, atrial fibrillation, pneumonia and pulmonary thromboembolism. Results Among 830 patients, neurological and cardiopulmonary adverse events were not differentially associated with poor outcome between ALB and saline control subjects. The rate of symptomatic intracranial hemorrhage in the first 24h was low overall (2.9%, 24/830) but more common in the ALB treated subjects (RR = 2.4, CI95 1.01–5.8). The rate of pulmonary edema/CHF in the first 48h was 7.9% (59/830) and was more common among ALB treated subjects (RR = 10.7, CI95 4.3–26.6); this complication was expected and was satisfactorily managed with mandated diuretic administration and intravenous fluid guidelines. Troponin elevations in the first 48h were common, occurring without ECG change or cardiac symptoms in 52 subjects (12.5%). Conclusions ALB therapy was associated with an increase in symptomatic ICH and pulmonary edema/congestive heart failure but this did not affect final outcomes. Troponin elevation occurs routinely in the first 48 hours after acute ischemic stroke. Trial Registration ClincalTrials.gov NCT00235495 PMID:26325387

  6. Dynamic Cerebral Autoregulation Is Heterogeneous in Different Subtypes of Acute Ischemic Stroke

    PubMed Central

    Xing, Yingqi; Yan, Shuo; Lv, Cunling; Jin, Hang; Yang, Yi

    2014-01-01

    Background and Purpose Stroke of large-artery atherosclerosis and small-artery occlusion are two main subtypes of stroke according to TOAST classification. The underlying mechanisms of how these two subtypes affect dynamic cerebral autoregulation (dCA) might be heterogeneous, resulting in varied clinical conditions and outcomes. We therefore studied the pattern of dCA in these two subtypes. Methods Forty-one patients with acute unilateral middle cerebral artery (MCA) territory stroke (15 with ipsilateral large-artery atherosclerosis and 26 with small-artery occlusion) and 20 healthy volunteers were enrolled. Non-invasive continuous cerebral blood flow velocity and arterial blood pressure were recorded simultaneously from each subject in supine position using transcranial Doppler on MCA bilaterally and servo-controlled plethysmograph on the middle finger, respectively. Transfer function analysis was applied to derive autoregulatory parameters, gain, phase difference (PD), and slope of step response. Results In the large-artery atherosclerosis group, PD in affected hemisphere was 42.9±18.5 degree, which is significantly lower than the unaffected hemisphere (72.4±29.9 degree, P<0.01), and the healthy group (P<0.01). However, PD is similar in the unaffected hemisphere and healthy group (P>0.1). In the small-artery occlusion group, PD in the affected hemisphere was similar to that in the contralateral hemisphere (33.8±17.9 vs. 32.6±21.1 degree, P>0.1), both sides were significantly lower than the healthy group (all P<0.001).The results of the slope of step response agree with the findings in PD. Conclusions DCA in different subtypes of acute ischemic stroke is heterogeneous, which might be attributed to the varied pathologic changes of cerebral blood vessels. PMID:24671155

  7. Graduated compression stockings to prevent venous thromboembolism in hospital: evidence from patients with acute stroke.

    PubMed

    Kearon, Clive; O'Donnell, Martin

    2011-01-01

    Pulmonary embolism is the most common preventable cause of death in hospital patients and prevention of venous thromboembolism (VTE) is cost-saving in high-risk patients. Low-dose anticoagulation is very effective at preventing VTE but increases bleeding. Graduated compression stockings and intermittent pneumatic compression devices are also used to prevent VTE and do not increase bleeding, which makes their use appealing in patients who cannot tolerate bleeding, such as patients with acute stroke. Studies that evaluated mechanical methods of preventing VTE were small and mainly used asymptomatic deep vein thrombosis (DVT), detected using screening tests, as the study outcome. The recently published CLOTS Trial 1 (Clots in Legs Or sTockings after Stroke) compared thigh-level compression stockings with no stockings in about 2500 patients with stroke and immobility, and found that thigh-level stockings were not effective. Indirectly, the findings of this study question the ability of stockings to prevent VTE in other patient groups, including those after surgery. CLOTS 1 compared thigh-level and below-knee stockings in about 3000 patients with acute stroke. Given that thigh-level stockings were ineffective in CLOTS 1, it is surprising that they were more effective than below-knee stockings in CLOTS Trial 2. A possible explanation is that below-knee stockings increase DVT, although this seems unlikely. CLOTS 1 and CLOTS 2 question whether graduated compression stockings prevent VTE and suggest the need for further trials evaluating their efficacy in medical and surgical patients. PMID:21346697

  8. Targeting aspirin in acute disabling ischemic stroke: an individual patient data meta‐analysis of three large randomized trials

    PubMed Central

    Murray, Gordon D.; Candelise, Livia; Chen, Zhengming; Sandercock, Peter A. G.; Whiteley, William N.

    2015-01-01

    Background Aspirin is of moderate overall benefit for patients with acute disabling ischemic stroke. It is unclear whether functional outcome could be improved after stroke by targeting aspirin to patients with a high risk of recurrent thrombosis or a low risk of haemorrhage. Aims We aimed to determine whether patients at higher risk of thrombotic events or poor functional outcome, or lower risk of major haemorrhage had a greater absolute risk reduction of poor functional outcome with aspirin than the average patient. Methods We used data on individual ischemic stroke patients from three large trials of aspirin vs. placebo in acute ischemic stroke: the first International Stroke Trial (n = 18 372), the Chinese Acute Stroke Trial (n = 20 172) and the Multicentre Acute Stroke Trial (n = 622). We developed and evaluated clinical prediction models for the following: early thrombotic events (myocardial infarction, ischemic stroke, deep vein thrombosis and pulmonary embolism); early haemorrhagic events (significant intracranial haemorrhage, major extracranial haemorrhage, or haemorrhagic transformation of an infarct); and late poor functional outcome. We calculated the absolute risk reduction of poor functional outcome (death or dependence) at final follow‐up in: quartiles of early thrombotic risk; quartiles of early haemorrhagic risk; and deciles of poor functional outcome risk. Results Ischemic stroke patients who were older, had lower blood pressure, computerized tomography evidence of infarct or more severe deficits due to stroke had increased risk of thrombotic and haemorrhagic events and poor functional outcome. Prediction models built with all baseline variables (including onset to treatment time) discriminated weakly between patients with and without recurrent thrombotic events (area under the receiver operating characteristic curve 0·56, 95% CI:0·53–0·59) and haemorrhagic events (0·57, 0·52–0·64), though well between patients with and

  9. A Comprehensive Review of Prehospital and In-hospital Delay Times in Acute Stroke Care

    PubMed Central

    Evenson, Kelly R.; Foraker, Randi; Morris, Dexter L.; Rosamond, Wayne D.

    2010-01-01

    The purpose of this study was to systematically review and summarize prehospital and in-hospital stroke evaluation and treatment delay times. We identified 123 unique peer-reviewed studies published from 1981 to 2007 of prehospital and in-hospital delay time for evaluation and treatment of patients with stroke, transient ischemic attack, or stroke-like symptoms. Based on studies of 65 different population groups, the weighted Poisson regression indicated a 6.0% annual decline (p<0.001) in hours/year for prehospital delay, defined from symptom onset to emergency department (ED) arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from ED arrival to ED evaluation (3.1%, p=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from ED arrival to neurology evaluation or notification (p=0.23 based on 16 population groups) and a 10.7% annual decline in hours/year for delay time from ED arrival to initiation of computed tomography (p=0.11 based on 23 population groups). Only one study reported on times from arrival to computed tomography scan interpretation, two studies on arrival to drug administration, and no studies on arrival to transfer to an in-patient setting, precluding generalizations. Prehospital delay continues to contribute the largest proportion of delay time. The next decade provides opportunities to establish more effective community based interventions worldwide. It will be crucial to have effective stroke surveillance systems in place to better understand and improve both prehospital and in-hospital delays for acute stroke care. PMID:19659821

  10. The cost-effectiveness of telestroke in the treatment of acute ischemic stroke

    PubMed Central

    Nelson, R.E.; Saltzman, G.M.; Skalabrin, E.J.; Demaerschalk, B.M.

    2011-01-01

    Objective: To conduct a cost-effectiveness analysis of telestroke—a 2-way, audiovisual technology that links stroke specialists to remote emergency department physicians and their stroke patients—compared to usual care (i.e., remote emergency departments without telestroke consultation or stroke experts). Methods: A decision-analytic model was developed for both 90-day and lifetime horizons. Model inputs were taken from published literature where available and supplemented with western states' telestroke experiences. Costs were gathered using a societal perspective and converted to 2008 US dollars. Quality-adjusted life-years (QALYs) gained were combined with costs to generate incremental cost-effectiveness ratios (ICERs). In the lifetime horizon model, both costs and QALYs were discounted at 3% annually. Both one-way sensitivity analyses and Monte Carlo simulations were performed. Results: In the base case analysis, compared to usual care, telestroke results in an ICER of $108,363/QALY in the 90-day horizon and $2,449/QALY in the lifetime horizon. For the 90-day and lifetime horizons, 37.5% and 99.7% of 10,000 Monte Carlo simulations yielded ICERs <$50,000/QALY, a ratio commonly considered acceptable in the United States. Conclusion: When a lifetime perspective is taken, telestroke appears cost-effective compared to usual care, since telestroke costs are upfront but benefits of improved stroke care are lifelong. If barriers to use such as low reimbursement rates and high equipment costs are reduced, telestroke has the potential to diminish the striking geographic disparities of acute stroke care in the United States. PMID:21917781

  11. Humor, laughter, and the cerebellum: insights from patients with acute cerebellar stroke.

    PubMed

    Frank, B; Andrzejewski, K; Göricke, S; Wondzinski, E; Siebler, M; Wild, B; Timmann, D

    2013-12-01

    Extent of cerebellar involvement in cognition and emotion is still a topic of ongoing research. In particular, the cerebellar role in humor processing and control of laughter is not well known. A hypermetric dysregulation of affective behavior has been assumed in cerebellar damage. Thus, we aimed at investigating humor comprehension and appreciation as well as the expression of laughter in 21 patients in the acute or subacute state after stroke restricted to the cerebellum, and in the same number of matched healthy control subjects. Patients with acute and subacute cerebellar damage showed preserved comprehension and appreciation of humor using a validated humor test evaluating comprehension, funniness and aversiveness of cartoons ("3WD Humor Test"). Additionally, there was no difference when compared to healthy controls in the number and intensity of facial reactions and laughter while observing jokes, humorous cartoons, or video sketches measured by the Facial Action Coding System. However, as depression scores were significantly increased in patients with cerebellar stroke, a concealing effect of accompanying depression cannot be excluded. Current findings add to descriptions in the literature that cognitive or affective disorders in patients with lesions restricted to the cerebellum, even in the acute state after damage, are frequently mild and might only be present in more sensitive or specific tests. PMID:23661243

  12. Therapeutic hypothermia for acute ischemic stroke: ready to start large randomized trials?

    PubMed Central

    van der Worp, H Bart; Macleod, Malcolm R; Kollmar, Rainer

    2010-01-01

    Therapeutic hypothermia is a means of neuroprotection well established in the management of acute ischemic brain injuries such as anoxic encephalopathy after cardiac arrest and perinatal asphyxia. As such, it is the only neuroprotective strategy for which there is robust evidence for efficacy. Although there is overwhelming evidence from animal studies that cooling also improves outcome after focal cerebral ischemia, this has not been adequately tested in patients with acute ischemic stroke. There are still some uncertainties about crucial factors relating to the delivery of hypothermia, and the resolution of these would allow improvements in the design of phase III studies in these patients and improvements in the prospects for successful translation. In this study, we discuss critical issues relating first to the targets for therapy including the optimal depth and duration of cooling, second to practical issues including the methods of cooling and the management of shivering, and finally, of factors relating to the design of clinical trials. Consideration of these factors should inform the development of strategies to establish beyond doubt the place of hypothermia in the management of acute ischemic stroke. PMID:20354545

  13. Effectiveness of CT Computed Tomography Perfusion in Diagnostics of Acute Ischemic Stroke

    PubMed Central

    Menzilcioglu, Mehmet Sait; Mete, Ahmet; Ünverdi, Zeyni

    2015-01-01

    Summary Background Stroke is the third most common death reason after the cardiovascular disorders and cancer. Cerebral ischemia is a pathology that stems from a decrease in cerebral perfusion. Computed Tomography Perfusion (CTP) is an additional method to the conventional Computed Tomography (CT) that could be performed by using developed softwares, in a short period of time and with a low risk of complications. CTP not only allows early detection of cerebral ischemia but also gives valuable information on the ischemic penumbra which are very important in early diagnosis and treatment. Acute Ischemic Stroke (AIS) can be cured by trombolytic treapy within 3–6 hours after symptom onset. Since rapid screening and accurate diagnosis increase the success of the treatment, the role of neuroradiology in acute ischemia diagnostics and treatment has become more important. Our aim was to define CT skills in early diagnosis of AIS, to define its contribution to patient’s diagnosis and treatment and to define its importance regarding patient’s prognosis. Material/Methods We included 42 patients that presented to the emergency service and neurology outpatient clinic with the symptoms of acute cerebral incidence. Results In our study, we found that Cerebral Blood Flow (CBF) is 90.91% sensitive and 100% specific in examining ischemia. Conclusions Tissue hemodynamic data, especially sensitivity and specificity rates, which cannot be acquired by conventional CT and MRI methods, can be acquired by the CTP method. PMID:26740827

  14. Acute development of collateral circulation and therapeutic prospects in ischemic stroke

    PubMed Central

    Iwasawa, Eri; Ichijo, Masahiko; Ishibashi, Satoru; Yokota, Takanori

    2016-01-01

    In acute ischemic stroke, collateral circulation plays an important role in maintaining blood flow to the tissue that is at risk of progressing into ischemia, and in increasing the successful recanalization rate without hemorrhagic transformation. We have reported that well-developed collateral circulation is associated with smaller infarct volume and better long-term neurological outcome, and it disappears promptly once the effective recanalization is achieved. Contrary to the belief that collateral vessels develop over time in chronic stenotic condition, there exists a phenomenon that collateral circulation develops immediately in acute stenosis or occlusion of the arteries and it seems to be triggered by fluid shear stress, which occurs between the territories of stenotic/occluded arteries and those fed by surrounding intact arteries. We believe that this acute development of collateral circulation is a target of novel therapeutics in ischemic stroke and refer our recent attempt in enhancing collateral circulation by modulating sphingosine-1-phosphate receptor 1, which is a known shear-stress mechanosensing protein. PMID:27127459

  15. Influence of the application of inelastic taping on shoulder subluxation and pain changes in acute stroke patients

    PubMed Central

    Heo,, Min-Yeong; Kim,, Cheol-Yong; Nam, Chan-Woo

    2015-01-01

    [Purpose] The purpose of this study was to investigate the impact on the shoulder joints of performing inelastic taping and bed physical therapy for acute stroke. [Subjects and Methods] The intervention was conducted for eight weeks with an experimental group of 18 stroke patients who received bed physical therapy and inelastic taping and a control group of 18 stroke patients who received only bed physical therapy. [Results] After the intervention, the subluxation degree of the experimental group, which received bed physical therapy and inelastic taping, was found to be significantly different from that of the control group, which received only bed physical therapy. [Conclusion] In conclusion, the application of inelastic taping for acute stroke patients was confirmed to be effective at reducing shoulder subluxation and pain, and was confirmed to be a good physical therapy intervention, based on its efficacy. PMID:26696705

  16. Effectiveness of Acute Phase Hybrid Assistive Limb Rehabilitation in Stroke Patients Classified by Paralysis Severity

    PubMed Central

    FUKUDA, Hiroyuki; SAMURA, Kazuhiro; HAMADA, Omi; SAITA, Kazuya; OGATA, Toshiyasu; SHIOTA, Etsuji; SANKAI, Yoshiyuki; INOUE, Tooru

    The purpose of the present study was to investigate the effectiveness of acute phase hybrid assistive limb (HAL) rehabilitation training for patients after stroke by measuring the difference in the severity of paralysis. Fifty-three acute stroke patients were enrolled in this prospective cohort study. HAL training was administered about twice per week, and the mean number of sessions was 3.9 ± 2.7. The walking training was performed on a treadmill with individually adjustable body weight support and speed and there was a 10-m walk test (10MWT) before and after each session. Assessment at baseline and at endpoint consisted of the Glasgow Coma Scale (GCS), Revised Hasegawa’s Dementia Scale (HDS-R), Brunnstrom stage (Brs), Functional Independence Measure (FIM), Barthel index (BI), and 10MWT. We measured these assessments at the first walking training session and at the end of the final training session without the HAL. To evaluate the feasibility of training with the HAL, the outcome measures of BI, FIM, and speed and number of steps of 10MWT were compared before and after training using a paired Wilcoxon’s signed-rank test in different Brs. Except for Brs IV, the Brs III or higher subgroups displayed significant amelioration in BI, and the Brs III subgroup displayed significant amelioration in FIM. The Brs V and VI subgroups displayed significant amelioration in 10-m walking speed and steps. In acute phase rehabilitation after stroke, it is thought that the HAL is more effective for patients with less lower-limb paralysis, such as Brs III or higher. PMID:26041627

  17. Iterative Reconstruction Improves Both Objective and Subjective Image Quality in Acute Stroke CTP

    PubMed Central

    Flottmann, Fabian; Kabath, Jan; Illies, Till; Schneider, Tanja; Buhk, Jan-Hendrik; Fiehler, Jens; Kemmling, André

    2016-01-01

    Purpose Computed tomography perfusion (CTP) imaging in acute ischemic stroke (AIS) suffers from measurement errors due to image noise. The purpose of this study was to investigate if iterative reconstruction (IR) algorithms can be used to improve the diagnostic value of standard-dose CTP in AIS. Methods Twenty-three patients with AIS underwent CTP with standardized protocol and dose. Raw data were reconstructed with filtered back projection (FBP) and IR with intensity levels 3, 4, 5. Image quality was objectively (quantitative perfusion values, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR)) and subjectively (overall image quality) assessed. Ischemic core and perfusion mismatch were visually rated. Discriminative power for tissue outcome prediction was determined by the area under the receiver operating characteristic curve (AUC) resulting from the overlap between follow-up infarct lesions and stepwise thresholded CTP maps. Results With increasing levels of IR, objective image quality (SNR and CNR in white matter and gray matter, elimination of error voxels) and subjective image quality improved. Using IR, mean transit time (MTT) was higher in ischemic lesions, while there was no significant change of cerebral blood volume (CBV) and cerebral blood flow (CBF). Visual assessments of perfusion mismatch changed in 4 patients, while the ischemic core remained constant in all cases. Discriminative power for infarct prediction as represented by AUC was not significantly changed in CBV, but increased in CBF and MTT (mean (95% CI)): 0.72 (0.67–0.76) vs. 0.74 (0.70–0.78) and 0.65 (0.62–0.67) vs 0.67 (0.64–0.70). Conclusion In acute stroke patients, IR improves objective and subjective image quality when applied to standard-dose CTP. This adds to the overall confidence of CTP in acute stroke triage. PMID:26930290

  18. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke.

    PubMed Central

    Norton, B.; Homer-Ward, M.; Donnelly, M. T.; Long, R. G.; Holmes, G. K.

    1996-01-01

    OBJECTIVE--To compare percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. DESIGN--Randomised prospective study of inpatients with acute stroke requiring enteral nutrition. SETTING--One university hospital (Nottingham) and one district general hospital (Derby). SUBJECTS--30 patients with persisting dysphagia at 14 days after acute stroke: 16 patients were randomised to gastrostomy tube feeding and 14 to nasogastric tube feeding. MAIN OUTCOME MEASURES--Six week mortality; amount of feed administered; change in nutritional state; treatment failure; and length of hospital stay. RESULTS--Mortality at 6 weeks was significantly lower in the gastrostomy group with two deaths (12%) compared with eight deaths (57%) in the nasogastric group (P < 0.05). All gastrostomy fed patients (16) received the total prescribed feed whereas 10/14 (71%) of nasogastric patients lost at least one day's feed. Nasogastric patients received a significantly (P < 0.001) smaller proportion of their prescribed feed (78%; 95% confidence interval 63% to 94%) compared with the gastrostomy group (100%). Patients fed via a gastrostomy tube showed greater improvement in nutritional state, according to several different criteria at six weeks compared with the nasogastric group. In the gastrostomy group the mean albumin concentration increased from 27.1 g/l (24.5 g/l to 29.7 g/l) to 30.1 g/l (28.3 g/l to 31.9 g/l). In contrast, among the nasogastric group there was a reduction from 31.4 g/l (28.6 g/l to 34.2 g/l) to 22.3 g/l (20.7 g/l to 23.9 g/l) (P < 0.003). In addition, there were fewer treatment failures in the gastrostomy group (0/16 versus 3/14). Six patients from the gastrostomy group were discharged from hospital within six weeks of the procedure compared with none from the nasogastric group (P < 0.05). CONCLUSION--This study indicates that early gastrostomy tube feeding is greatly superior to nasogastric tube feeding and should be the nutritional

  19. Mortality, Recurrence, and Dependency Rates Are Higher after Acute Ischemic Stroke in Elderly Patients with Diabetes Compared to Younger Patients

    PubMed Central

    Long, Xue; Lou, Yongzhong; Gu, Hongfei; Guo, Xiaofei; Wang, Tao; Zhu, Yanxia; Zhao, Wenjuan; Ning, Xianjia; Li, Bin; Wang, Jinghua; An, Zhongping

    2016-01-01

    Stroke has a greater effect on the elderly than on younger patients. However, the long-term outcomes associated with stroke among elderly patients with diabetes are unknown. We aimed to assess the differences in long-term outcomes between young and elderly stroke patients with diabetes. A total of 3,615 acute ischemic stroke patients with diabetes were recruited for this study between 2006 and 2014. Outcomes at 12 and 36 months after stroke (including mortality, recurrence, and dependency) were compared between younger (age <75 years) and elderly (age ≥75 years) patients. The elderly group included 692 patients (19.1%) overall. Elderly patients were more likely than younger patients to have a Trial of Org 10172 in Acute Stroke Treatment classification of stroke due to cardioembolism, moderate and severe stroke, and atrial fibrillation, but less likely to have hypertension and dyslipidemia, current smokers, and alcohol consumers. Mortality, dependency, and recurrence rates at 12 months after stroke were 19.0, 48.5, and 20.9% in the elderly group and 7.4, 30.9, and 15.4% in the younger group, respectively (all P < 0.05). Corresponding rates at 36 months after stroke were 35.4, 78.7, and 53.8% in the elderly group and 13.7, 61.7, and 43.0% in the younger group, respectively (all P < 0.001). The mortality, dependency, and recurrence rates at 12 and 36 months after stroke were significantly higher in the elderly group than in the younger group after adjusting for stroke subtypes, stroke severity, and risk factors. Odds ratios (95% confidence interval) at 12 and 36 months after stroke were 2.18 (1.64–2.89) and 3.10 (2.35–4.08), respectively, for mortality, all P < 0.001; 1.81 (1.49–2.20) and 2.04 (1.57–2.34), respectively, for dependency, all P < 0.001; and 1.37 (1.06–1.76) and 1.40 (1.07–1.85), respectively, for recurrence, P = 0.016. The findings from this study suggest that management and secondary prevention should be emphasized in elderly patients with

  20. Mortality, Recurrence, and Dependency Rates Are Higher after Acute Ischemic Stroke in Elderly Patients with Diabetes Compared to Younger Patients.

    PubMed

    Long, Xue; Lou, Yongzhong; Gu, Hongfei; Guo, Xiaofei; Wang, Tao; Zhu, Yanxia; Zhao, Wenjuan; Ning, Xianjia; Li, Bin; Wang, Jinghua; An, Zhongping

    2016-01-01

    Stroke has a greater effect on the elderly than on younger patients. However, the long-term outcomes associated with stroke among elderly patients with diabetes are unknown. We aimed to assess the differences in long-term outcomes between young and elderly stroke patients with diabetes. A total of 3,615 acute ischemic stroke patients with diabetes were recruited for this study between 2006 and 2014. Outcomes at 12 and 36 months after stroke (including mortality, recurrence, and dependency) were compared between younger (age <75 years) and elderly (age ≥75 years) patients. The elderly group included 692 patients (19.1%) overall. Elderly patients were more likely than younger patients to have a Trial of Org 10172 in Acute Stroke Treatment classification of stroke due to cardioembolism, moderate and severe stroke, and atrial fibrillation, but less likely to have hypertension and dyslipidemia, current smokers, and alcohol consumers. Mortality, dependency, and recurrence rates at 12 months after stroke were 19.0, 48.5, and 20.9% in the elderly group and 7.4, 30.9, and 15.4% in the younger group, respectively (all P < 0.05). Corresponding rates at 36 months after stroke were 35.4, 78.7, and 53.8% in the elderly group and 13.7, 61.7, and 43.0% in the younger group, respectively (all P < 0.001). The mortality, dependency, and recurrence rates at 12 and 36 months after stroke were significantly higher in the elderly group than in the younger group after adjusting for stroke subtypes, stroke severity, and risk factors. Odds ratios (95% confidence interval) at 12 and 36 months after stroke were 2.18 (1.64-2.89) and 3.10 (2.35-4.08), respectively, for mortality, all P < 0.001; 1.81 (1.49-2.20) and 2.04 (1.57-2.34), respectively, for dependency, all P < 0.001; and 1.37 (1.06-1.76) and 1.40 (1.07-1.85), respectively, for recurrence, P = 0.016. The findings from this study suggest that management and secondary prevention should be emphasized in elderly patients with diabetes in

  1. Aspirin Resistance in the Acute Stages of Acute Ischemic Stroke Is Associated with the Development of New Ischemic Lesions

    PubMed Central

    Kim, Joon-Tae; Heo, Suk-Hee; Lee, Ji Sung; Choi, Min-Ji; Choi, Kang-Ho; Nam, Tai-Seung; Lee, Seung-Han; Park, Man-Seok; Kim, Byeong C.; Kim, Myeong-Kyu; Cho, Ki-Hyun

    2015-01-01

    Background Aspirin is a primary antiplatelet agent for the secondary prevention of ischemic stroke. However, if aspirin fails to inhibit platelet function, as is expected in acute ischemic stroke (AIS), it may increase the rate of early clinical events. Therefore, we sought to determine whether aspirin resistance in the acute stage was associated with early radiological events, including new ischemic lesions (NILs). Methods This study was a single-center, prospective, observational study conducted between April 2012 and May 2013. Aspirin 300 mg was initially administered followed by maintenance doses of 100 mg daily. The acute aspirin reaction unit (aARU) was consistently measured after 3 hours of aspirin loading. An aARU value ≥550 IU was defined as biological aspirin resistance (BAR). NILs on follow-up diffusion-weighted imaging (DWI) were defined as lesions separate from index lesions, which were not detected on the initial DWI. Results A total of 367 patients were analyzed in this study. BAR in aARU was detected in 60 patients (16.3%). On follow-up DWI, 81 patients (22.1%) had NILs, which were frequently in the same territory as the index lesions (79%), pial infarcts (61.7%), and located within the cortex (59.3%). BAR was independently associated with NILs on follow-up DWI (adjusted OR 2.00, 95% CIs 1.01–3.96; p = 0.047). Conclusion In conclusion, BAR in aARU could be associated with NILs on follow-up DWI in AIS. Therefore, a further prospective study with a longer follow-up period is necessary to evaluate the clinical implications of aARU in AIS. PMID:25849632

  2. SOD1 overexpression prevents acute hyperglycemia-induced cerebral myogenic dysfunction: relevance to contralateral hemisphere and stroke outcomes

    PubMed Central

    Coucha, Maha; Li, Weiguo; Hafez, Sherif; Abdelsaid, Mohammed; Johnson, Maribeth H.; Fagan, Susan C.

    2014-01-01

    Admission hyperglycemia (HG) amplifies vascular injury and neurological deficits in acute ischemic stroke, but the mechanisms remain controversial. We recently reported that ischemia-reperfusion (I/R) injury impairs the myogenic response in both hemispheres via increased nitration. However, whether HG amplifies contralateral myogenic dysfunction and whether loss of tone in the contralateral hemisphere contributes to stroke outcomes remain to be determined. Our hypothesis was that contralateral myogenic dysfunction worsens stroke outcomes after acute hyperglycemic stroke in an oxidative stress-dependent manner. Male wild-type or SOD1 transgenic rats were injected with saline or 40% glucose solution 10 min before surgery and then subjected to 30 min of ischemia/45 min or 24 h of reperfusion. In another set of animals (n = 5), SOD1 was overexpressed only in the contralateral hemisphere by stereotaxic adenovirus injection 2–3 wk before I/R. Myogenic tone and neurovascular outcomes were determined. HG exacerbated myogenic dysfunction in contralateral side only, which was associated with infarct size expansion, increased edema, and more pronounced neurological deficit. Global and selective SOD1 overexpression restored myogenic reactivity in ipsilateral and contralateral sides, respectively, and enhanced neurovascular outcomes. In conclusion, our results show that SOD1 overexpression nullified the detrimental effects of HG on myogenic tone and stroke outcomes and that the contralateral hemisphere may be a novel target for the management of acute hyperglycemic stroke. PMID:25552308

  3. The role of the cerebral capillaries in acute ischemic stroke: the extended penumbra model

    PubMed Central

    Østergaard, Leif; Jespersen, Sune Nørhøj; Mouridsen, Kim; Mikkelsen, Irene Klærke; Jonsdottír, Kristjana Ýr; Tietze, Anna; Blicher, Jakob Udby; Aamand, Rasmus; Hjort, Niels; Iversen, Nina Kerting; Cai, Changsi; Hougaard, Kristina Dupont; Simonsen, Claus Z; Von Weitzel-Mudersbach, Paul; Modrau, Boris; Nagenthiraja, Kartheeban; Riisgaard Ribe, Lars; Hansen, Mikkel Bo; Bekke, Susanne Lise; Dahlman, Martin Gervais; Puig, Josep; Pedraza, Salvador; Serena, Joaquín; Cho, Tae-Hee; Siemonsen, Susanne; Thomalla, Götz; Fiehler, Jens; Nighoghossian, Norbert; Andersen, Grethe

    2013-01-01

    The pathophysiology of cerebral ischemia is traditionally understood in relation to reductions in cerebral blood flow (CBF). However, a recent reanalysis of the flow-diffusion equation shows that increased capillary transit time heterogeneity (CTTH) can reduce the oxygen extraction efficacy in brain tissue for a given CBF. Changes in capillary morphology are typical of conditions predisposing to stroke and of experimental ischemia. Changes in capillary flow patterns have been observed by direct microscopy in animal models of ischemia and by indirect methods in humans stroke, but their metabolic significance remain unclear. We modeled the effects of progressive increases in CTTH on the way in which brain tissue can secure sufficient oxygen to meet its metabolic needs. Our analysis predicts that as CTTH increases, CBF responses to functional activation and to vasodilators must be suppressed to maintain sufficient tissue oxygenation. Reductions in CBF, increases in CTTH, and combinations thereof can seemingly trigger a critical lack of oxygen in brain tissue, and the restoration of capillary perfusion patterns therefore appears to be crucial for the restoration of the tissue oxygenation after ischemic episodes. In this review, we discuss the possible implications of these findings for the prevention, diagnosis, and treatment of acute stroke. PMID:23443173

  4. Validation and Recalibration of Two Multivariable Prognostic Models for Survival and Independence in Acute Stroke

    PubMed Central

    Teece, Lucy; Dennis, Martin S.; Roffe, Christine

    2016-01-01

    Introduction Various prognostic models have been developed for acute stroke, including one based on age and five binary variables (‘six simple variables’ model; SSVMod) and one based on age plus scores on the National Institutes of Health Stroke Scale (NIHSSMod). The aims of this study were to externally validate and recalibrate these models, and to compare their predictive ability in relation to both survival and independence. Methods Data from a large clinical trial of oxygen therapy (n = 8003) were used to determine the discrimination and calibration of the models, using C-statistics, calibration plots, and Hosmer-Lemeshow statistics. Methods of recalibration in the large and logistic recalibration were used to update the models. Results For discrimination, both models functioned better for survival (C-statistics between .802 and .837) than for independence (C-statistics between .725 and .735). Both models showed slight shortcomings with regard to calibration, over-predicting survival and under-predicting independence; the NIHSSMod performed slightly better than the SSVMod. For the most part, there were only minor differences between ischaemic and haemorrhagic strokes. Logistic recalibration successfully updated the models for a clinical trial population. Conclusions Both prognostic models performed well overall in a clinical trial population. The choice between them is probably better based on clinical and practical considerations than on statistical considerations. PMID:27227988

  5. [Influence of cortical neurotrophic factors on the neurocytokine production system in acute hemorrhagic stroke].

    PubMed

    Kul'chikov, A E; Kositsyn, N S; Svinov, M M; Vasil'eva, I G; Makarenko, A N

    2009-01-01

    The mechanism of therapeutic action of cortical neurotropic factors (CNTF) was studied in hemorrhagic stroke. In intracerebral hemorrhage, CNTFs were shown to elevate the level of nerve growth factor mRNA and at the same time, produce no effect on its level in intact animals. The neuroactivating action of CNTF in the acute phase of hemorrhagic stroke was achieved by intranasal administration due to the retrograde axon transport of CNTF molecules along the olfactory nerve fibers to the brain, by passing the blood-brain barrier. It was ascertained that the molecules of tritium-labeled CHTF accumulated in the central nervous system following 20 minutes and the level of label accumulation is proportionally increased after 120 minutes. The pattern of accumulation of the intranasally administered label in the olfactory tract and olfactory bulb proves CNTF transportation along these structures of the nervous system. Therefore, when intranasally administered, CNTFs are able to transport to the central nervous system along the olfactory tract and to enhance the expression of nerve growth factor mRNA in hemorrhagic stroke. PMID:19919011

  6. Temporal profile of serum anti-inflammatory and pro-inflammatory interleukins in acute ischemic stroke patients.

    PubMed

    Perini, F; Morra, M; Alecci, M; Galloni, E; Marchi, M; Toso, V

    2001-08-01

    The presence of an inflammatory response in the pathophysiology of acute brain ischemia is relatively well established, but less is known about the anti-inflammatory mechanisms. The aim of the present study was to evaluate part of the immune response in acute stroke patients and to analyze a possible correlation with other hematological parameters, clinical outcome, size of infarct and subtypes of strokes. We prospectively studied 42 stroke patients, without signs of infections or inflammatory diseases, at days 0, 1, 3, 7 and 14, and 39 healthy control subjects. We measured serum levels of the anti-inflammatory cytokine interleukin-10 (IL-10) and the pro-inflammatory cytokine interleukin-6 (IL-6) by ELISA method. We observed a highly inverse correlation between these two molecules in control subjects (r=-0.78, p=0.0000001), and this correlation was lost in stroke patients. Patients had significantly lowered IL-10 serum levels soon after the acute event (p=0.00005), with a slight increase at the seventh day. On the other hand, patients had increased IL-6 serum levels compared with controls after day one until day 14 (p<0.04), with a maximum increase at day 3. Interleukin-6 correlated with clinical outcome whereas interleukin-10 did not. Low levels of interleukin-10 indicate that the antiinflammatory response is down-regulated in acute stroke patients. The pro-inflammatory response begins 24 hours after the onset of acute cerebral ischemia, as indicated by the increased serum levels of interleukin-6. The physiological balance between these two molecules is altered in acute stroke patients. PMID:11808851

  7. Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study

    PubMed Central

    Sheppard, J P; Lindenmeyer, A; Mellor, R M; Greenfield, S; Mant, J; Quinn, T; Rosser, A; Sandler, D; Sims, D; Ward, M; McManus, R J

    2016-01-01

    Background Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a ‘prealert’ message can significantly improve the timeliness of treatment. Objective Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert. Methods Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke. Results Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p<0.001; 3 symptoms, OR 75.84, 95% CI 24.68 to 233.03, p<0.001) and EMS contact within 5 h of symptom onset (OR 2.99, 95% CI 1.37 to 6.50 p=0.006) were key predictors of prealerting but eligibility for prealert as a whole was not (OR 1.92, 95% CI 0.85 to 4.34 p=0.12). In qualitative interviews, EMS staff displayed varying understanding of prealert protocols and described frustration when their interpretation of the prealert criteria was not shared by ED staff. Conclusions Up to half of the patients presenting with suspected stroke in this study were prealerted by EMS staff, regardless of eligibility, resulting in disagreements with ED staff during handover. Aligning the expectations of EMS and ED staff, perhaps through simplified prealert protocols, could be

  8. Dynamic cerebral autoregulation is transiently impaired for one week after large-vessel acute ischemic stroke

    PubMed Central

    Petersen, Nils H.; Ortega-Gutierrez, Santiago; Reccius, Andres; Masurkar, Arjun; Huang, Amy; Marshall, Randolph S

    2016-01-01

    Background Dynamic cerebral autoregulation (DCA) is the continuous counterregulation of cerebral blood flow to fluctuations in blood pressure. DCA can become impaired after acute stroke, but it remains unclear to what extent and over what interval this occurs. Methods We included 28 patients (NIHSS=12±6.5, age=68.4±17.1, 16F) with acute large-vessel ischemic stroke in the middle cerebral artery territory and 29 healthy controls (mean age 54.9±9, 16F). DCA was assessed by simultaneous measurement of blood pressure together with blood flow velocities using finger plethysmography/arterial catheter and transcranial Doppler over three 10-minute recordings on days 0–2, 3–6 and >=7 days after stroke. Transfer function analysis was applied to calculate average phase shift (PS) in the low frequency range (0.06–0.12 Hz). Less PS indicated poorer autoregulation. The affected side was compared with the unaffected side and controls. Univariate comparisons of data were performed using t-tests at single time points, and generalized estimating equations with an exchangeable correlation matrix to examine the change in PS over time. Results At mean 1.3±0.5 days after stroke the average PS in the affected hemisphere was 29.6±10.5 degrees versus 42.5±13 degrees in the unaffected hemisphere (p=0.004). At 4.1±1 days, the PS in affected and unaffected hemisphere was 23.2±19.1 vs. 41.7±18.5 degrees, respectively (p=0.003). At mean 9.75±2.2 days stroke there was no difference between affected and unaffected hemisphere (53.2±28.2 versus 50.7±29.2 degrees, p=0.69). Control subjects had an average PS=47.9±16.8, significantly different from patients’ affected hemisphere at the first two measurements (p=0.001), but not the third (p=0.37). The PS in controls remained unchanged on repeat testing after an average 19.1 days (48.4±17.1, p=0.61). Using the last recording as the reference, the average PS in the affected hemisphere was −23.54 (−44.1, −3) degrees lower on

  9. Current perspectives on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke

    PubMed Central

    Chapman, Sherita N; Mehndiratta, Prachi; Johansen, Michelle C; McMurry, Timothy L; Johnston, Karen C; Southerland, Andrew M

    2014-01-01

    In 1995, the NINDS (National Institute of Neurological Disorders and Stroke) tPA (tissue plasminogen activator) Stroke Study Group published the results of a large multicenter clinical trial demonstrating efficacy of intravenous tPA by revealing a 30% relative risk reduction (absolute risk reduction 11%–15%) compared with placebo at 90 days in the likelihood of having minimal or no disability. Since approval in 1996, tPA remains the only drug treatment for acute ischemic stroke approved by the US Food and Drug Administration. Over the years, an abundance of research and clinical data has supported the safe and efficacious use of intravenous tPA in all eligible patients. Despite such supporting data, it remains substantially underutilized. Challenges to the utilization of tPA include narrow eligibility and treatment windows, risk of symptomatic intracerebral hemorrhage, perceived lack of efficacy in certain high-risk subgroups, and a limited pool of neurological and stroke expertise in the community. With recent US census data suggesting annual stroke incidence will more than double by 2050, better education and consensus among both the medical and lay public are necessary to optimize the use of tPA for all eligible stroke patients. Ongoing and future research should continue to improve upon the efficacy of tPA through more rapid stroke diagnosis and treatment, refinement of advanced neuroimaging and stroke biomarkers, and successful demonstration of alternative means of reperfusion. PMID:24591838

  10. Acute stroke thrombolysis: time to dispense with the clock and move to tissue-based decision making?

    PubMed

    Bivard, Andrew; Spratt, Neil; Levi, Christopher R; Parsons, Mark W

    2011-04-01

    Currently, imaging is predominantly used to exclude patients for thrombolysis, rather than identify patients most likely to benefit. This means that patients are being selected for treatment without reference to tissue pathophysiology. Imaging of specific stroke pathophysiology may be the key to selecting patients most likely to benefit from thrombolysis, and could revolutionize acute stroke assessment and treatment. The technology is available to identify the acute infarct core and possibly the penumbra, via magnetic resonance diffusion-weighted imaging, and both magnetic resonance- and computed tomography-perfusion imaging techniques. However, these modalities require fine tuning before they can be reliably implemented in a routine clinical setting. PMID:21517729

  11. Use of a Nonexercise Estimate for Prestroke Peak Vo2 During the Acute Stroke Hospital Stay

    PubMed Central

    Mattlage, Anna E.; Redlin, Sara A.; Rosterman, Lee R.; Harn, Nick; Sisante, Jason-Flor V.; Abraham, Michael G.; Billinger, Sandra A.

    2016-01-01

    Purpose For individuals with acute stroke, it is difficult to conduct an exercise test to assess peak oxygen consumption (peak Vo2). Therefore, the purpose of this study was to use a clinically feasible tool for assessing prestroke peak Vo2 using a nonexercise estimation equation to test whether estimated prestroke peak Vo2 was related to the functional outcome measures at discharge from the hospital in individuals after an acute stroke. We hypothesized that the estimated prestroke peak Vo2 would be significantly related to discharge Physical Performance Test (PPT), 6-minute walk test (6MWT), and lower extremity Fugl-Meyer (LEFM) assessment. Methods Estimated prestroke peak Vo2 was calculated using a previously validated prediction equation using the following variables: body mass index, age, sex, resting heart rate, and a self-reported measure of physical activity. Outcome measures were assessed 4 days after enrollment or immediately before discharge (whichever occurred first). Results Thirty-four participants (mean age = 56.0, SD = 12.6 years; 20 men) with acute stroke were enrolled within 48 hours of admission. For all individuals, mean estimated prestroke peak Vo2 was 27.3 (SD = 7.4) mL·kg−1·min−1 and had a weak, nonsignificant relationship with the PPT (r = 0.19; P = .28), 6MWT (r = 0.10; P = .56), and LEFM (r = 0.32; P = .06). However, when considering sex, women, but not men, had a significant relationship with LEFM (r = 0.73; P = .005) and moderate but nonsignificant relationship with PPT (r = 0.53; P = .06) and 6MWT (r = 0.47; P = .10). Conclusions Within 48 hours of stroke admission, we were able to administer a nonexercise equation to estimate prestroke peak Vo2. For the entire sample, functional measures conducted at discharge were not related to estimated prestroke peak Vo2. However, when considering sex, the relationship between prestroke Vo2 and the functional measures was strengthened.

  12. FASTER (Face, Arm, Speech, Time, Emergency Response): experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke.

    PubMed

    O'Brien, W; Crimmins, D; Donaldson, W; Risti, R; Clarke, T A; Whyte, S; Sturm, J

    2012-02-01

    Despite benefit in acute ischaemic stroke, less than 3% of patients receive tissue plasminogen activator (tPA) in Australia. The FASTER (Face, Arm, Speech, Time, Emergency Response) protocol was constructed to reduce pre-hospital and Emergency Department (ED) delays and improve access to thrombolysis. This study aimed to determine if introduction of the FASTER protocol increases use of tPA using a prospective pre- and post-intervention cohort design in a metropolitan hospital. A pre-hospital assessment tool was used by ambulance services to screen potential tPA candidates. The acute stroke team was contacted, hospital bypass allowed, triage and CT radiology alerted, and the patient rapidly assessed on arrival to ED. Data were collected prospectively during the first 6 months of the new pathway and compared to a 6-month period 12 months prior to protocol initiation. In the 6 months following protocol introduction, 115 patients presented within 24 hours of onset of an ischaemic stroke: 22 (19%) received thrombolysis, significantly greater than five (7%) of 67 patients over the control period, p=0.03. Overall, 42 patients were referred via the FASTER pathway, with 21 of these receiving tPA (50%). One inpatient stroke was also treated. Only two referrals (<5%) were stroke mimics. Introduction of the FASTER pathway also significantly reduced time to thrombolysis and time to admission to the stroke unit. Therefore, fast-track referral of potential tPA patients involving the ambulance services and streamlined hospital assessment is effective and efficient in improving patient access to thrombolysis. PMID:22118794

  13. Partial Aortic Occlusion and Cerebral Venous Steal: Venous Effects of Arterial Manipulation in Acute Stroke

    PubMed Central

    Pranevicius, Osvaldas; Pranevicius, Mindaugas; Liebeskind, David S.

    2011-01-01

    Acute ischemic stroke therapy emphasizes early arterial clot lysis or removal. Partial aortic occlusion has recently emerged as an alternative hemodynamic approach to augment cerebral perfusion in acute ischemic stroke. The exact mechanism of cerebral flow augmentation with partial aortic occlusion remains unclear and may involve more than simple diversion of arterial blood flow from the lower body to cerebral collateral circulation. The cerebral venous steal hypothesis suggests that even a small increase in tissue pressure in the ischemic area will divert blood flow to surrounding regions with lesser tissue pressures. This may cause no-reflow (absence of flow after restoration of arterial patency) in the ischemic core and “luxury perfusion” in the surrounding regions. Such maldistribution may be reversed with increased venous pressure titrated to avoid changes in intracranial pressure. We propose that partial aortic occlusion enhances perfusion in the brain by offsetting cerebral venous steal. Partial aortic occlusion redistributes blood volume into the upper part of the body, manifest by an increase in central venous pressure. Increased venous pressure recruits the collapsed vascular network and, by eliminating cerebral venous steal, corrects perifocal perfusion maldistribution, analogous to positive end expiratory pressure recruitment of collapsed airways to decrease ventilation/perfusion mismatch in the lungs. PMID:21441149

  14. [Asystolias in the acute phase of brain stroke. Report of a case].

    PubMed

    Belvis, R; Marti-Fàbregas, J; Franquet, E; Cocho, D; Valencia, C; Martí-Vilalta, J L

    2003-04-01

    Brain areas involved in heart autonomic control are not well characterized. Insulae have been proposed as control centers. A lesion in these areas may induce a cardiac autonomic dysfunction (arrhythmias, atrioventricular conduction abnormalities). Asystolia has not been previously reported. A 65-year-old man suffered an acute ischemia of the right middle cerebral artery (MCA) territory. NIHSS score was 19 points. Brain CT scan was normal. Transcranial Doppler (TCD) showed occlusion of the right MCA. Fibrinolysis was initiated 135 minutes after stroke onset with TCD monitoring. Twenty minutes later he suffered cardiac arrest with asystolia trace in the ECG monitor. Fibrinolysis was stopped during resuscitation. Four minutes later, he recovered with the same NIHSS score. Aggressive resuscitation maneuvers were not necessary. A repeated brain CT scan showed infarct signs in the whole MCA territory and a new TCD did not show any change. Serial blood analyses including cardiac nzymes were normal. The patient experienced four brief cardiac arrests in the next nine hours, so a temporary cardiac pacemaker was placed for four days. He was treated with aspirin and was discharged 14 days after admission. He has not experienced recurrences during a 6-month follow-up. We could not diagnose the etiology of the cardiac arrests. All the episodes occurred in the acute stroke stage and arrhythmia, atrioventricular block, myocardial ischemia or structural lesions were not found in the cardiac study. We propose that ischemia in the right insula induced sudden and transitory interruptions of the sympathetic cardiac tone. PMID:12677486

  15. Functional cluster analysis of CT perfusion maps: a new tool for diagnosis of acute stroke?

    PubMed

    Baumgartner, Christian; Gautsch, Kurt; Böhm, Christian; Felber, Stephan

    2005-09-01

    CT perfusion imaging constitutes an important contribution to the early diagnosis of acute stroke. Cerebral blood flow (CBF), cerebral blood volume (CBV) and time-to-peak (TTP) maps are used to estimate the severity of cerebral damage after acute ischemia. We introduce functional cluster analysis as a new tool to evaluate CT perfusion in order to identify normal brain, ischemic tissue and large vessels. CBF, CBV and TTP maps represent the basis for cluster analysis applying a partitioning (k-means) and density-based (density-based spatial clustering of applications with noise, DBSCAN) paradigm. In patients with transient ischemic attack and stroke, cluster analysis identified brain areas with distinct hemodynamic properties (gray and white matter) and segmented territorial ischemia. CBF, CBV and TTP values of each detected cluster were displayed. Our preliminary results indicate that functional cluster analysis of CT perfusion maps may become a helpful tool for the interpretation of perfusion maps and provide a rapid means for the segmentation of ischemic tissue. PMID:15827821

  16. Primary Angioplasty Versus Stenting for Endovascular Management of Intracranial Atherosclerotic Disease Following Acute Ischemic Stroke

    PubMed Central

    Villwock, Mark R.; Padalino, David J.; Ramaswamy, Raghu; Deshaies, Eric M.

    2016-01-01

    Background The future of neuroendovascular treatment for intracranial atherosclerotic disease (ICAD) has been debated since the results of SAMMPRIS reflected poor outcomes following endovascular therapy. There is currently a large spectrum of current management strategies. We compared historical outcomes of patients with ICAD and stroke that were treated with angioplasty-alone versus stent placement. Methods We extracted a population from the Nationwide Inpatient Sample (NIS) (2005–2011) and the National Inpatient Sample (NIS) (2012) composed of patients with ICAD and infarction that were admitted nonelectively and received endovascular revascularization. Patients treated with thrombectomy or thrombolysis were excluded. Categorical variables were compared with Chi-squared tests. Binary logistic regression was performed to evaluate mortality while controlling for age, sex, severity, and comorbidities. Results About 2059 admissions met our criteria. A majority were treated via stent placement (71%). Angioplasty-alone had significantly higher mortality (17.6% vs. 8.4%, P<0.001), but no difference in iatrogenic stroke rate (3.4% vs. 3.6%, P=0.826), compared to stent placement. The adjusted odds ratio of mortality for stented patients was 0.536 (95% CI: 0.381–0.753, P<0.001) in comparison to patients treated with angioplasty alone. Conclusions This study found the risk of mortality to be elevated following angioplasty alone in comparison to revascularization with stent placement, without a corresponding significant difference in iatrogenic stroke rate. This may represent selection bias due to patient characteristics not defined in the database, but it also may indicate that patients with ICAD and acute stroke have increased odds of stenosis that is refractory to angioplasty alone and have a high risk of mortality without revascularization. PMID:27403216

  17. Limited Reliability of CT perfusion acute infarct volume measurements compared to DWI in anterior circulation stroke

    PubMed Central

    Schaefer, Pamela W.; Souza, Leticia; Kamalian, Shervin; Hirsch, Joshua A.; Yoo, Albert J.; Kamalian, Shahmir; Gonzalez, R. Gilberto; Lev, Michael H.

    2015-01-01

    Background and Purpose DWI can reliably identify critically ischemic tissue (CIT) shortly after stroke onset. We tested if thresholded CT-CBF and CT-CBV maps are sufficiently accurate to substitute for DWI for estimating CIT volume. Methods Ischemic volumes of 55 patients with acute anterior circulation stroke were assessed on DWI by visual segmentation, and CT-CBF and CT-CBV with segmentation using 15% and 30% thresholds, respectively. The contrast-to-noise ratios (CNR) of ischemic regions on the DWI and CTP images were measured. Correlation and Bland-Altman analyses were used to assess reliability of CTP. Results Mean CNRs for DWI, CT-CBF and CT-CBV were 4.3, 0.9 and 0.4, respectively. CTP and DWI lesion volumes were highly correlated (R2=0.87 for CT-CBF; R2=0.83 for CT-CBV; p<0.001). Bland-Altman analyses revealed little systemic bias (−2.6 ml) but high measurement variability (95% CI ±56.7 ml) between mean CT-CBF and DWI lesion volumes, and systemic bias (−26 ml) and high measurement variability (95% CI ±64.0 ml) between mean CT-CBV and DWI lesion volumes. A simulated treatment study demonstrated that using CTP-CBF instead of DWI for detecting a statistically significant effect would require at least twice as many patients. Conclusions The poor CNRs of CT-CBV and CT-CBF compared to DWI result in large measurement error making it problematic to substitute CTP for DWI in selecting individual acute stroke patients for treatment. CTP could be used for treatment studies of patient groups, but the number of patients needed to identify a significant effect is much higher than if DWI is used. PMID:25550366

  18. Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke

    PubMed Central

    OGATA, Toshiyasu; ABE, Hiroshi; SAMURA, Kazuhiro; HAMADA, Omi; NONAKA, Masani; IWAASA, Mitsutoshi; HIGASHI, Toshio; FUKUDA, Hiroyuki; SHIOTA, Etsuji; TSUBOI, Yoshio; INOUE, Tooru

    2015-01-01

    The efficacy of hybrid assistive limb (HAL) rehabilitation in the acute phase of stroke remains unclear. The purpose of this study was to evaluate the outcomes of patients with acute intracranial hemorrhage (ICH) who were treated with or without HAL rehabilitation. Among 270 patients with acute ICH from 2009 to 2014, 91 patients with supratentorial ICH were included in this retrospective study. Of these, 14 patients (HAL group) received HAL rehabilitation at approximately 1 week after ICH occurrence, while the remaining 77 patients received usual rehabilitation without HAL (N-HAL group). We obtained various patient data from the hospitals where the patients were moved to for further rehabilitation. Statistical comparisons were performed for the characteristics of the ICH patients, and outcomes between the HAL and N-HAL groups. There were no differences in outcomes between the HAL and N-HAL groups. However, patients with right ICH in the HAL group exhibited a significant association with a functional independence measure (FIM) score of ≥ 110 compared with patients in the N-HAL group (HAL group: 81.8%, N-HAL group: 43.9%, P = 0.04). In patients with right ICH, HAL rehabilitation was associated with improved outcomes as evaluated by the FIM score. Thus, HAL rehabilitation may improve outcomes of acute ICH in appropriately selected patients. PMID:26511112

  19. Feasibility of early functional rehabilitation in acute stroke survivors using the Balance-Bed—a technology that emulates microgravity

    PubMed Central

    Oddsson, Lars I. E.; Finkelstein, Marsha J.; Meissner, Sarah

    2015-01-01

    Evidence-based guidelines recommend early functional rehabilitation of stroke patients when risk of patient harm can be managed. Current tools do not allow balance training under load conditions sufficiently low for acute stroke patients. This single-arm pilot study tested feasibility and safety for acute stroke survivors to use “Balance-Bed”, a technology for balance exercises in supine initially developed to emulate microgravity effects on balance. Nine acute stroke patients (50–79 years) participated in 3–10 sessions over 16–46 days as part of their rehabilitation in a hospital inpatient setting. Standard inpatient measures of outcome were monitored where lack of progress from admission to discharge might indicate possible harm. Total FIM scores at admission (median 40, range 22–53) changed to (74, 50–96), Motor FIM scores from (23, 13–32) to (50, 32–68) and Berg Balance scores from (3, 0–6) to (19, 7–43) at discharge. Changes reached Minimal Clinical Important Difference for a sufficient proportion (>0.6) of the patients to indicate no harm to the patients. In addition, therapists reported the technology was safe, provided a positive experience for the patient and fit within the rehabilitation program. They reported the device should be easier to set up and exit. We conclude acute stroke patients tolerated Balance-Bed exercises such as standing on one or two legs, squats, stepping in place as well as balance perturbations provided by the therapist. We believe this is the first time it has been demonstrated that acute stroke patients can safely perform whole body balance training including balance perturbations as part of their rehabilitation program. Future studies should include a control group and compare outcomes from best practices to interventions using the Balance-Bed. In addition, the technology is relevant for countermeasure development for spaceflight and as a test-bed of balance function under microgravity-like conditions. PMID

  20. The function of the left anterior temporal pole: evidence from acute stroke and infarct volume

    PubMed Central

    Tsapkini, Kyrana; Frangakis, Constantine E.

    2011-01-01

    The role of the anterior temporal lobes in cognition and language has been much debated in the literature over the last few years. Most prevailing theories argue for an important role of the anterior temporal lobe as a semantic hub or a place for the representation of unique entities such as proper names of peoples and places. Lately, a few studies have investigated the role of the most anterior part of the left anterior temporal lobe, the left temporal pole in particular, and argued that the left anterior temporal pole is the area responsible for mapping meaning on to sound through evidence from tasks such as object naming. However, another recent study indicates that bilateral anterior temporal damage is required to cause a clinically significant semantic impairment. In the present study, we tested these hypotheses by evaluating patients with acute stroke before reorganization of structure–function relationships. We compared a group of 20 patients with acute stroke with anterior temporal pole damage to a group of 28 without anterior temporal pole damage matched for infarct volume. We calculated the average percent error in auditory comprehension and naming tasks as a function of infarct volume using a non-parametric regression method. We found that infarct volume was the only predictive variable in the production of semantic errors in both auditory comprehension and object naming tasks. This finding favours the hypothesis that left unilateral anterior temporal pole lesions, even acutely, are unlikely to cause significant deficits in mapping meaning to sound by themselves, although they contribute to networks underlying both naming and comprehension of objects. Therefore, the anterior temporal lobe may be a semantic hub for object meaning, but its role must be represented bilaterally and perhaps redundantly. PMID:21685458

  1. The effects of very early mirror therapy on functional improvement of the upper extremity in acute stroke patients.

    PubMed

    Yeldan, Ipek; Huseyınsınoglu, Burcu Ersoz; Akıncı, Buket; Tarakcı, Ela; Baybas, Sevim; Ozdıncler, Arzu Razak

    2015-11-01

    [Purpose] The aim of the study was to evaluate the effects of a very early mirror therapy program on functional improvement of the upper extremity in acute stroke patients. [Subjects] Eight stroke patients who were treated in an acute neurology unit were included in the study. [Methods] The patients were assigned alternatively to either the mirror therapy group receiving mirror therapy and neurodevelopmental treatment or the neurodevelopmental treatment only group. The primary outcome measures were the upper extremity motor subscale of the Fugl-Meyer Assessment, Motricity Index upper extremity score, and the Stroke Upper Limb Capacity Scale. Somatosensory assessment with the Ayres Southern California Sensory Integration Test, and the Barthel Index were used as secondary outcome measures. [Results] No statistically significant improvements were found for any measures in either group after the treatment. In terms of minimally clinically important differences, there were improvements in Fugl-Meyer Assessment and Barthel Index in both mirror therapy and neurodevelopmental treatment groups. [Conclusion] The results of this pilot study revealed that very early mirror therapy has no additional effect on functional improvement of upper extremity function in acute stroke patients. Multicenter trials are needed to determine the results of early application of mirror therapy in stroke rehabilitation. PMID:26696729

  2. Acute cerebrovascular incident in a young woman: Venous or arterial stroke? – Comparative analysis based on two case reports

    PubMed Central

    Sleiman, Katarzyna; Zimny, Anna; Kowalczyk, Edyta; Sąsiadek, Marek

    2013-01-01

    Summary Background Cerebrovascular diseases are the most common neurological disorders. Most of them are arterial strokes, mainly ischemic, less often of hemorrhagic origin. Changes in the course of cerebral venous thrombosis are less common causes of acute cerebrovascular events. Clinical and radiological presentation of arterial and venous strokes (especially in emergency head CT) may pose a diagnostic problem because of great resemblance. However, the distinction between arterial and venous stroke is important from a clinical point of view, as it carries implications for the treatment and determinates patient’s prognosis. Case Report In this article, we present cases of two young women (one with an acute venous infarction, the second with an arterial stroke) who presented with similar both clinical and radiological signs of acute vascular incident in the cerebral cortex. We present main similarities and differences between arterial and venous strokes regarding the etiology, clinical symptoms and radiological appearance in various imaging techniques. Conclusions We emphasize that thorough analysis of CT (including cerebral vessels), knowledge of symptoms and additional clinical information (e.g. risk factors) may facilitate correct diagnosis and allow planning further diagnostic imaging studies. We also emphasize the importance of MRI, especially among young people, in the differential diagnosis of venous and arterial infarcts. PMID:24505227

  3. The effects of very early mirror therapy on functional improvement of the upper extremity in acute stroke patients

    PubMed Central

    Yeldan, Ipek; Huseyınsınoglu, Burcu Ersoz; Akıncı, Buket; Tarakcı, Ela; Baybas, Sevim; Ozdıncler, Arzu Razak

    2015-01-01

    [Purpose] The aim of the study was to evaluate the effects of a very early mirror therapy program on functional improvement of the upper extremity in acute stroke patients. [Subjects] Eight stroke patients who were treated in an acute neurology unit were included in the study. [Methods] The patients were assigned alternatively to either the mirror therapy group receiving mirror therapy and neurodevelopmental treatment or the neurodevelopmental treatment only group. The primary outcome measures were the upper extremity motor subscale of the Fugl-Meyer Assessment, Motricity Index upper extremity score, and the Stroke Upper Limb Capacity Scale. Somatosensory assessment with the Ayres Southern California Sensory Integration Test, and the Barthel Index were used as secondary outcome measures. [Results] No statistically significant improvements were found for any measures in either group after the treatment. In terms of minimally clinically important differences, there were improvements in Fugl-Meyer Assessment and Barthel Index in both mirror therapy and neurodevelopmental treatment groups. [Conclusion] The results of this pilot study revealed that very early mirror therapy has no additional effect on functional improvement of upper extremity function in acute stroke patients. Multicenter trials are needed to determine the results of early application of mirror therapy in stroke rehabilitation. PMID:26696729

  4. Mechanical Thrombectomy in Patients With Acute Ischemic Stroke: A Health Technology Assessment

    PubMed Central

    2016-01-01

    Background In Ontario, current treatment for eligible patients who have an acute ischemic stroke is intravenous thrombolysis (IVT). However, there are some limitations and contraindications to IVT, and outcomes may not be favourable for patients with stroke caused by a proximal intracranial occlusion. An alternative is mechanical thrombectomy with newer devices, and a number of recent studies have suggested that this treatment is more effective for improving functional independence and clinical outcomes. The objective of this health technology assessment was to evaluate the clinical effectiveness and cost-effectiveness of new-generation mechanical thrombectomy devices (with or without IVT) compared to IVT alone (if eligible) in patients with acute ischemic stroke. Methods We conducted a systematic review of the literature, limited to randomized controlled trials that examined the effectiveness of mechanical thrombectomy using stent retrievers and thromboaspiration devices for patients with acute ischemic stroke. We assessed the quality of the evidence using the GRADE approach. We developed a Markov decision-analytic model to assess the cost-effectiveness of mechanical thrombectomy (with or without IVT) versus IVT alone (if eligible), calculated incremental cost-effectiveness ratios using a 5-year time horizon, and conducted sensitivity analyses to examine the robustness of the estimates. Results There was a substantial, statistically significant difference in rate of functional independence (GRADE: high quality) between those who received mechanical thrombectomy (with or without IVT) and IVT alone (odds ratio [OR] 2.39, 95% confidence interval [CI] 1.88–3.04). We did not observe a difference in mortality (GRADE: moderate quality) (OR 0.80, 95% CI 0.60–1.07) or symptomatic intracerebral hemorrhage (GRADE: moderate quality) (OR 1.11, 95% CI 0.66–1.87). In the base-case cost-utility analysis, which had a 5 year time horizon, the costs and effectiveness for

  5. Neurointerventional Treatment in Acute Stroke. Whom to Treat? (Endovascular Treatment for Acute Stroke: Utility of THRIVE Score and HIAT Score for Patient Selection)

    SciTech Connect

    Fjetland, Lars Roy, Sumit Kurz, Kathinka D.; Solbakken, Tore; Larsen, Jan Petter Kurz, Martin W.

    2013-10-15

    Purpose: Intra-arterial therapy (IAT) is used increasingly as a treatment option for acute stroke caused by central large vessel occlusions. Despite high rates of recanalization, the clinical outcome is highly variable. The authors evaluated the Houston IAT (HIAT) and the totaled health risks in vascular events (THRIVE) score, two predicting scores designed to identify patients likely to benefit from IAT. Methods: Fifty-two patients treated at the Stavanger University Hospital with IAT from May 2009 to June 2012 were included in this study. We combined the scores in an additional analysis. We also performed an additional analysis according to high age and evaluated the scores in respect of technical efficacy. Results: Fifty-two patients were evaluated by the THRIVE score and 51 by the HIAT score. We found a strong correlation between the level of predicted risk and the actual clinical outcome (THRIVE p = 0.002, HIAT p = 0.003). The correlations were limited to patients successfully recanalized and to patients <80 years. By combining the scores additional 14.3 % of the patients could be identified as poor candidates for IAT. Both scores were insufficient to identify patients with a good clinical outcome. Conclusions: Both scores showed a strong correlation to poor clinical outcome in patients <80 years. The specificity of the scores could be enhanced by combining them. Both scores were insufficient to identify patients with a good clinical outcome and showed no association to clinical outcome in patients aged {>=}80 years.

  6. Perceived value of stroke outcome measures across the post-acute care continuum: a qualitative case study.

    PubMed

    Danzl, Megan M; Hunter, Elizabeth G

    2013-04-01

    Connecting the continuum of post-acute care stroke services may be important for easing patients' transition between settings and facilitating recovery and community reintegration. The use of outcome measures is suggested as one means of connecting the continuum. The purpose of this qualitative case study is to describe administrators' and physiotherapists' perceived value of an outcomes program across the post-acute care stroke continuum at a rehabilitation hospital. Data were collected through individual interviews and focus groups with 18 participants. Three themes emerged on the value of the outcomes program: 1) enhanced communication; 2) supports clinical decision-making; and 3) value of objective data. These findings lend support for the use of standardized outcome measures by physiotherapists in stroke rehabilitation. Findings from this study may be useful for organizations and physiotherapists who wish to integrate outcome measures into practice. PMID:23039017

  7. Endovascular Mechanical Thrombectomy of an Occluded Superior Division Branch of the Left MCA for Acute Cardioembolic Stroke

    SciTech Connect

    Schumacher, H. C. Meyers, P. M.; Yavagal, D. R.; Harel, N. Y.; Elkind, M. S. V.; Mohr, J. P.; Pile-Spellman, J.

    2003-06-15

    Cardiac embolism accounts for a large proportion of ischemic stroke. Revascularization using systemic or intra-arterial thrombolysis is associated with increasing risks of cerebral hemorrhageas time passes from stroke onset. We report successful mechanicalthrombectomy from a distal branch of the middle cerebral artery (MCA)using a novel technique. A 72-year old man suffered an acute ischemic stroke from an echocardiographically proven ventricular thrombus due toa recent myocardial infarction. Intra-arterial administration of 4 mgrt-PA initiated at 5.7 hours post-ictus failed to recanalize an occluded superior division branch of the left MCA. At 6 hours,symptomatic embolic occlusion persisted. Mechanical extraction of the clot using an Attracter-18 device (Target Therapeutics, Freemont, CA) resulted in immediate recanalization of the MCA branch. Attracter-18 for acute occlusion of MCA branches may be considered in selected patients who fail conventional thrombolysis or are nearing closure of the therapeutic window for use of thrombolytic agents.

  8. Analysis of the Modified Rankin Scale in Randomised Controlled Trials of Acute Ischaemic Stroke: A Systematic Review

    PubMed Central

    Nunn, Aimie; Bath, Philip M.; Gray, Laura J.

    2016-01-01

    Background. Historically, most acute stroke clinical trials were neutral statistically, with trials typically dichotomising ordinal scales, such as the modified Rankin Scale. Studies published before 2007 have shown that preserving the ordinal nature of these scales increased statistical power. A systematic review of trials published since 2007 was conducted to reevaluate statistical methods used and to assess whether practice has changed. Methods. A search of electronic databases identified RCTs published between January 2007 and July 2014 in acute ischaemic stroke using an ordinal dependency scale as the primary outcome. Findings. Forty-two RCTs were identified. The majority used a dichotomous analysis (25, 59.5%), eight (21.4%) retained the ordinal scale, and nine (19.0%) used another type of analysis. Conclusions. Trials published since 2007 still favoured dichotomous analyses over ordinal. Stroke trials, where appropriate, should consider retaining the ordinal nature of dependency scales. PMID:27088036

  9. Accelerated recovery from acute brain injuries: clinical efficacy of neurotrophic treatment in stroke and traumatic brain injuries.

    PubMed

    Bornstein, N; Poon, W S

    2012-04-01

    Stroke is one of the most devastating vascular diseases in the world as it is responsible for almost five million deaths per year. Almost 90% of all strokes are ischemic and mainly due to atherosclerosis, cardiac embolism and small-vessel disease. Intracerebral or subarachnoid hemorrhage can lead to hemorrhagic stroke, which usually has the poorest prognosis. Cerebrolysin is a peptide preparation which mimics the action of a neurotrophic factor, protecting stroke-injured neurons and promoting neuroplasticity and neurogenesis. Cerebrolysin has been widely studied as a therapeutic tool for both ischemic and hemorrhagic stroke, as well as traumatic brain injury. In ischemic stroke, Cerebrolysin given as an adjuvant therapy to antiplatelet and rheologically active medication resulted in accelerated improvement in global, neurological and motor functions, cognitive performance and activities of daily living. Cerebrolysin was also safe and well tolerated when administered in patients suffering from hemorrhagic stroke. Traumatic brain injury leads to transient or chronic impairments in physical, cognitive, emotional and behavioral functions. This is associated with deficits in the recognition of basic emotions, the capacity to interpret the mental states of others, and executive functioning. Pilot clinical studies with adjuvant Cerebrolysin in the acute and postacute phases of the injury have shown faster recovery, which translates into an earlier onset of rehabilitation and shortened hospitalization time. PMID:22514794

  10. Asymmetry of Deep Medullary Veins on Susceptibility Weighted MRI in Patients with Acute MCA Stroke Is Associated with Poor Outcome

    PubMed Central

    Mucke, Johanna; Möhlenbruch, Markus; Kickingereder, Philipp; Kieslich, Pascal J.; Bäumer, Philipp; Gumbinger, Christoph; Purrucker, Jan; Mundiyanapurath, Sibu; Schlemmer, Heinz-Peter; Bendszus, Martin; Radbruch, Alexander

    2015-01-01

    Background and Purpose Due to its sensitivity to deoxyhemoglobin, susceptibility weighted imaging (SWI) enables the visualization of deep medullary veins (DMV) in patients with acute stroke, which are difficult to depict under physiological circumstances. This study assesses the asymmetric appearance of prominent DMV as an independent predictor for stroke severity and outcome. Materials and Methods SWI of 86 patients with acute middle cerebral artery (MCA) stroke were included. A scoring system from 0 (no visible DMV) to 3 (very prominent DMV) was applied for both hemispheres separately. A difference of scores between ipsi- and contralateral side was defined as asymmetric (AMV+). Occurrence of AMV+ was correlated with the National Institute of Health Stroke Scale (NIHSS) Score on admission and discharge, as well as the modified Rankin Scale (mRS) at discharge. Ordinal regression analysis was used to evaluate NIHSS and mRS as predictors of stroke severity, clinical course of disease and outcome. Results 55 patients displayed AMV+ while 31 did not show an asymmetry (AMV–). Median NIHSS on admission was 17 (11–21) in the AMV+ group and 9 (5–15) in the AMV– group (p = 0.001). On discharge median NIHSS was 11 (5–20) for AMV+ and 5 (2–14) for AMV– (p = 0.005). The median mRS at discharge was 4 (3–5) in the AMV+ group and 3 (1–4) in AMV– (p = 0.001). Odds ratio was 3.19 (95% CI: 1.24–8.21) for AMV+ to achieve a higher mRS than AMV– (p = 0.016). Conclusion The asymmetric appearance of DMV on SWI is a fast and easily evaluable parameter for the prediction of stroke severity and can be used as an additional imaging parameter in patients with acute MCA stroke. PMID:25849958

  11. Evaluation of a German version of the Rivermead Mobility Index (RMI) in acute and chronic stroke patients.

    PubMed

    Schindl, M R; Forstner, C; Kern, H; Zipko, H T; Rupp, M; Zifko, U A

    2000-09-01

    The English Rivermead Mobility Index (RMI) has been proposed as a simple, valid and reliable measure in stroke rehabilitation. A German version was established and validated in two centres. In centre A 46 acute (median: 3.0 days after onset) and in centre B 151 chronic (median: 88.0 days after onset) stroke patients participated. Interrater reliability of the German RMI was tested in 12 subjects in the acute stage of stroke and was found to be statistically significant (r = 0.98, P < 0.0001). In centre A, a statistically significant correlation was found between the German RMI and the 10-m walk time at baseline (r = 0.73, P < 0.0001) and after three weeks (r = 0.92, P < 0.0001). In centre B, the German RMI correlated significantly with the motor part of the Functional Independence Measure (motor-FIM) on admission (r = 0.78, P < 0.0001) and after three weeks (r = 0.79, P < 0.0001), respectively. The change of the RMI correlated significantly with the change in 10-m walk time in acute patients (r = 0.87, P < 0.0001) and with the change in motor-FIM in chronic patients (r = 0.54, P < 0.0001). A moderate ceiling-effect was detected in the chronic study population. The German RMI appears to be a reliable, valid and responsive measure for mobility disability in acute and chronic stroke patients. PMID:11054137

  12. Do Motor Imagery Performances Depend on the Side of the Lesion at the Acute Stage of Stroke?

    PubMed Central

    Kemlin, Claire; Moulton, Eric; Samson, Yves; Rosso, Charlotte

    2016-01-01

    Motor imagery has been considered a substitute for overt motor execution to study post-stroke motor recovery. However, motor imagery abilities at the acute stage (<3 weeks) are poorly known. The aim of this study was to compare explicit and implicit motor imagery abilities in stroke patients and healthy subjects, correlate them with motor function, and investigate the role of right or left hemisphere lesions on performance. Twenty-four stroke patients at the acute stage and 24 age- and gender-matched healthy volunteers performed implicit (Hand Laterality Judgment Task) and explicit (number of imagined/executed hand movements) motor imagery tasks and a clinical motor assessment. Differences between healthy subjects and patients as well as the impact of lesion side on motor imagery were studied using ANOVA. We analyzed the relationship between motor executed and imagined movements (temporal congruence) using Pearson correlations. Our study shows that for implicit imagery, stroke patients had slower reaction times [RTs, t(46) = 1.7, p = 0.02] and higher error rates for the affected hand [t(46) = 3.7, p < 0.01] yet shared similar characteristics [angle effect: F(1,46) = 30.8, p ≤ 0.0001] with respect to healthy subjects. For the unaffected hand, right-sided stroke patients had a higher error rate and similar RTs whereas left sided stroke had higher RTs but similar error rate than healthy subjects. For explicit imagery, patients exhibited bilateral deficits compared to healthy subjects in the executed and imagined condition (p < 0.0001). Patients and healthy subjects exhibited a temporal congruence between executed and imagined movements (p ≤ 0.04) except for right-sided strokes who had no correlation for both hands. When using motor imagery as a tool for upper limb rehabilitation early after stroke, caution must be taken related to the side of the lesion. PMID:27445761

  13. Outcomes After Acute Ischemic Stroke in the United States: Does Residential ZIP Code Matter?

    PubMed Central

    Agarwal, Shikhar; Menon, Venu; Jaber, Wael A.

    2015-01-01

    Background We sought to analyze the impact of socioeconomic status (SES) on in‐hospital outcomes, cost of hospitalization, and resource use after acute ischemic stroke. Methods and Results We used the 2003–2011 Nationwide Inpatient Sample database for this analysis. All admissions with a principal diagnosis of acute ischemic stroke were identified by using International Classification of Diseases, Ninth Revision codes. SES was assessed by using median household income of the residential ZIP code for each patient. Quartile 1 and quartile 4 reflect the lowest‐income and highest‐income SES quartile, respectively. During a 9‐year period, 775 905 discharges with acute ischemic stroke were analyzed. There was a progressive increase in the incidence of reperfusion on the first admission day across the SES quartiles (P‐trend<0.001). In addition, we observed a significant reduction in discharge to nursing facility, across the SES quartiles (P‐trend<0.001). Although we did not observe a significant difference in in‐hospital mortality across the SES quartiles in the overall cohort (P‐trend=0.22), there was a significant trend toward reduced in‐hospital mortality across the SES quartiles in younger patients (<75 years) (P‐trend<0.001). The mean length of stay in the lowest‐income quartile was 5.75 days, which was significantly higher compared with other SES quartiles. Furthermore, the mean adjusted cost of hospitalization among quartiles 2, 3, and 4, compared with quartile 1, was significantly higher by $621, $1238, and $2577, respectively. Compared with the lowest‐income quartile, there was a significantly higher use of echocardiography, invasive angiography, and operative procedures, including carotid endarterectomy, in the highest‐income quartile. Conclusions Patients from lower‐income quartiles had decreased reperfusion on the first admission day, compared with patients from higher‐income quartiles. The cost of hospitalization of patients

  14. EEG in ischaemic stroke: quantitative EEG can uniquely inform (sub-)acute prognoses and clinical management.

    PubMed

    Finnigan, Simon; van Putten, Michel J A M

    2013-01-01

    Investigations of (sub-)acute ischaemic stroke (IS) employing quantitative electroencephalographic (QEEG) methods, in concert with other assessments, are reviewed. Numerous outcomes from hundreds of patients collectively indicate that (sub-)acute QEEG indices from standard systems can uniquely inform clinical management, particularly prognostication of outcomes from IS. Two classes of QEEG indices have proven particularly informative. The first quantifies the power of abnormal, slow activity relative to that of faster activity and the second, interhemispheric voltage asymmetry (broadband). Both have been identified as statistically significant predictors of outcomes assessed (via routine clinical scales) in the weeks and months following IS. Furthermore both have demonstrated higher predictive value than concomitant neurological assessments and scales, and to improve upon outcome prediction afforded by neuroimaging alone. These indices also may continuously provide unique, real-time insights into the efficacy of thrombolytic therapy, prior to clinical changes. Two key applications of QEEG which should prove valuable for future clinical management of IS are: (1) continuous, acute monitoring to inform about the efficacy of thrombolysis and decisions about potential additional interventions, and; (2) brief, subacute recording to inform outcome prognostication and clinical decisions about, for example, rehabilitation strategies. Ongoing research and technological developments will continue to facilitate clinical translation of QEEG investigations reviewed herein. PMID:22858178

  15. The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke

    PubMed Central

    Pancioli, Arthur M.; Broderick, Joseph; Brott, Thomas; Tomsick, Thomas; Khoury, Jane; Bean, Judy; del Zoppo, Gregory; Kleindorfer, Dawn; Woo, Daniel; Khatri, Pooja; Castaldo, John; Frey, James; Gebel, James; Kasner, Scott; Kidwell, Chelsea; Kwiatkowski, Thomas; Libman, Richard; Mackenzie, Richard; Scott, Phillip; Starkman, Sidney; Thurman, R. Jason

    2008-01-01

    Background and Purpose Multiple approaches are being studied to enhance the rate of thrombolysis for acute ischemic stroke. Treatment of myocardial infarction with a combination of a reduced-dose fibrinolytic agent and a glycoprotein (GP) IIb/IIIa receptor antagonist has been shown to improve the rate of recanalization versus fibrinolysis alone. The combined approach to lysis utilizing eptifibatide and recombinant tissue-type plasminogen activator (rt-PA) (CLEAR) stroke trial assessed the safety of treating acute ischemic stroke patients within 3 hours of symptom onset with this combination. Methods The CLEAR trial was a National Institutes of Health/National Institute of Neurological Disorders and Stroke–funded multicenter, double-blind, randomized, dose-escalation and safety study. Patients were randomized 3:1 to either low-dose rt-PA (tier 1=0.3 mg/kg, tier 2=0.45 mg/kg) plus eptifibatide (75 μg/kg bolus followed by 0.75 μg/kg per min infusion for 2 hours) or standard-dose rt-PA (0.9 mg/kg). The primary safety end point was the incidence of symptomatic intracerebral hemorrhage within 36 hours. Secondary analyses were performed regarding clinical efficacy. Results Ninety-four patients (40 in tier 1 and 54 in tier 2) were enrolled. The combination group of the 2 dose tiers (n=69) had a median age of 71 years and a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 14, and the standard-dose rt-PA group (n=25) had a median age of 61 years and a median baseline NIHSS score of 10 (P=0.01 for NIHSS score). Fifty-two (75%) of the combination treatment group and 24 (96%) of the standard treatment group had a baseline modified Rankin scale score of 0 (P=0.04). There was 1 (1.4%; 95% CI, 0% to 4.3%) symptomatic intracranial hemorrhage in the combination group and 2 (8.0%; 95% CI, 0% to 19.2%) in the rt-PA–only arm (P=0.17). During randomization in tier 2, a review by the independent data safety monitoring board demonstrated that the safety

  16. Diagnosing Stroke in Acute Vertigo: The HINTS Family of Eye Movement Tests and the Future of the "Eye ECG".

    PubMed

    Newman-Toker, David E; Curthoys, Ian S; Halmagyi, G Michael

    2015-10-01

    Patients who present to the emergency department with symptoms of acute vertigo or dizziness are frequently misdiagnosed. Missed opportunities to promptly treat dangerous strokes can result in poor clinical outcomes. Inappropriate testing and incorrect treatments for those with benign peripheral vestibular disorders leads to patient harm and unnecessary costs. Over the past decade, novel bedside approaches to diagnose patients with the acute vestibular syndrome have been developed and refined. A battery of three bedside tests of ocular motor physiology known as "HINTS" (head impulse, nystagmus, test of skew) has been shown to identify acute strokes more accurately than even magnetic resonance imaging with diffusion-weighted imaging (MRI-DWI) when applied in the early acute period by eye-movement specialists. Recent advances in lightweight, high-speed video-oculography (VOG) technology have made possible a future in which HINTS might be applied by nonspecialists in frontline care settings using portable VOG. Use of technology to measure eye movements (VOG-HINTS) to diagnose stroke in the acute vestibular syndrome is analogous to the use of electrocardiography (ECG) to diagnose myocardial infarction in acute chest pain. This "eye ECG" approach could transform care for patients with acute vertigo and dizziness around the world. In the United States alone, successful implementation would likely result in improved quality of emergency care for hundreds of thousands of peripheral vestibular patients and tens of thousands of stroke patients, as well as an estimated national health care savings of roughly $1 billion per year. In this article, the authors review the origins of the HINTS approach, empiric evidence and pathophysiologic principles supporting its use, and possible uses for the eye ECG in teleconsultation, teaching, and triage. PMID:26444396

  17. Outcomes following sonothrombolysis in severe acute ischemic stroke:subgroup analysis of the CLOTBUST trial

    PubMed Central

    Barlinn, Kristian; Tsivgoulis, Georgios; Barreto, Andrew D; Alleman, John; Molina, Carlos A; Mikulik, Robert; Saqqur, Maher; Demchuk, Andrew M; Schellinger, Peter D; Howard, George; Alexandrov, Andrei V.

    2014-01-01

    Background Sonothrombolysis is safe and may increase the likelihood of early recanalization in acute ischemic stroke (AIS) patients Aims In preparation of a phase III clinical trial, we contrast the likelihood of achieving a sustained recanalization and functional independence in a post-hoc subgroup analysis of patients randomized to transcranial Doppler monitoring plus intravenous (IV) tPA (sonothrombolysis) compared to IV tPA alone in the CLOTBUST trial Methods We analyzed the data from all randomized AIS patients with pre-treatment NIHSS scores ≥10 points and proximal intracranial occlusions in the CLOTBUST trial. We compared sustained complete recanalization rate (TIBI flow grades 4-5) and functional independence (modified Rankin Scale [mRS] 0-1) at 90 days. Safety was evaluated by the rate of symptomatic intracranial hemorrhage (ICH) within 72 hours of stroke-onset Results Of 126 patients, a total of 85 AIS patients met our inclusion criteria: mean age 71±11years, 56% men, median NIHSS 17 (interquartile range 14-20). Of these patients, 41 (48%) and 44 (52%) were randomized to IV tPA alone and sonothrombolysis, respectively. More patients achieved sustained complete recanalization in the sonothrombolysis than in the IV tPA alone group (38.6% vs. 17.1%; p=0.032). Functional independence at 90 days was more frequently achieved in the sonothrombolysis than in the IV tPA alone group (37.2% vs. 15.8%; p=0.045). Symptomatic ICH rate was similar in both groups (4.9% vs. 4.6%; p=1.00) Conclusions Our results point to a signal of efficacy and provide information to guide the subsequent phase III randomized trial of sonothrombolysis in patients with severe ischemic strokes PMID:25079049

  18. Mechanical thrombectomy in acute ischaemic stroke: a review of the literature, clinical effectiveness and future use.

    PubMed

    Lally, Frank; Grunwald, Iris Q; Sanyal, Ranjan; Natarajan, Indira; Roffe, Christine

    2013-03-01

    The only effective treatment licensed for acute ischaemic stroke is intravenous thrombolysis within 4.5 hours from stroke onset. An alternative method of restoring blood flow is mechanical thrombectomy (MT). Although this is highly effective at recanalization, it remains unclear whether it is more effective than thrombolysis in improving clinical outcomes. This review examines key clinical outcomes from published studies and reviews ongoing studies to identify devices, patient population, and stated outcomes of MT. We discuss the issues when comparing clinical outcomes from different trials and suggest measures to help standardize reporting. We used routine review methodology to search relevant databases for stroke and MT published between 1999 - 2012 and active trials between August 2011 - May 2012. The studies in this review had an overall patient population of 8354. The most widely used primary outcome (94% of studies) was successful recanalization. The mean mortality across the studies was 17% (range 7 - 44), 64% of studies reported neurological improvement and 97% reported functional outcome with 42% (range 15 - 54)] achieving independence in activities of daily living. Mean symptomatic intracerebral haemorrhage was 11% (range 0 - 45%). There were significant differences in outcome reporting between studies. Evidence from published studies shows a strong relationship between recanalization and good outcomes although non-standardization makes comparisons difficult. There is a trend towards higher recanalization, lower mortality, and better functional outcome in more recent studies. To examine effectiveness of MT vs thrombolysis, randomized controlled trials are needed. Several are currently in progress but it remains to be seen if procedures and outcomes are reported in a standardized manner. PMID:23394538

  19. Leukocytosis in Patients with Neurologic Deterioration after Acute Ischemic Stroke is Associated with Poor Outcomes

    PubMed Central

    Kumar, Andre D.; Boehme, Amelia K.; Siegler, James E.; Gillette, Michael; Albright, Karen C.; Martin-Schild, Sheryl

    2016-01-01

    Background Neurologic deterioration (ND) after acute ischemic stroke (AIS) has been shown to result in poor outcomes. ND is thought to arise from penumbral excitotoxic cell death caused in part by leukocytic infiltration. Elevated admission peripheral leukocyte levels are associated with poor outcomes in stroke patients who suffer ND, but little is known about the dynamic changes that occur in leukocyte counts around the time of ND. We sought to determine if peripheral leukocyte levels in the days surrounding ND are correlated with poor outcomes. Methods Patients with AIS who presented to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review and screened for ND (defined as an increase in National Institutes of Health Stroke Scale score ≥2 within a 24-hour period). Patients were excluded for steroid use during hospitalization or in the month before admission and infection within the 48 hours before or after ND. Demographics, daily leukocyte counts, and poor functional outcome (modified Rankin Scale score 3–6) were investigated. Results Ninety-six of the 292 (33%) patients screened had ND. The mean age was 69.5 years; 62.5% were male and 65.6% were black. Patients with a poor functional outcome had significantly higher leukocyte and neutrophil levels 1 day before ND (P =.048 and P =.026, respectively), and on the day of ND (P =.013 and P =.007, respectively), compared to patients with good functional outcome. Conclusions Leukocytosis at the time of ND correlates with poor functional outcomes and may represent a marker of greater cerebral damage through increased parenchymal inflammation. PMID:23031742

  20. Timing of tissue plasminogen activator for acute ischemic stroke: outcomes-based recommendations for practice.

    PubMed

    Hanselman, Carol J

    2014-12-01

    Acute ischemic stroke (AIS) is a major cause of death and disability in the United States. Tissue plasminogen activator (t-PA) is an intravenously administered therapy that can prevent death and disability for patients presenting within early onset of AIS. There has been a debate around the exact time parameters for administration, because very few patients present to the hospital within the initial 0- to 3-hour window of time. Not all of the current national guidelines for timing of AIS in the United States are in agreement with regards to this issue. To the nurse caring for patients with neurologic illnesses, this topic is of utmost importance. Nurse are not only involved in determining the time of stroke symptom onset, but nurses also hold responsibility for a working knowledge of the latest eligibility and exclusion criteria for t-PA administration. This article examines the central body of research related to the timing of t-PA and makes recommendations for eligible candidates based on this literature. PMID:25365047

  1. Serum Levels of Substance P and Mortality in Patients with a Severe Acute Ischemic Stroke.

    PubMed

    Lorente, Leonardo; Martín, María M; Almeida, Teresa; Pérez-Cejas, Antonia; Ramos, Luis; Argueso, Mónica; Riaño-Ruiz, Marta; Solé-Violán, Jordi; Hernández, Mariano

    2016-01-01

    Substance P (SP), a member of tachykinin family, is involved in the inflammation of the central nervous system and in the appearance of cerebral edema. Higher serum levels of SP have been found in 18 patients with cerebral ischemia compared with healthy controls. The aim of our multi-center study was to analyze the possible association between serum levels of SP and mortality in ischemic stroke patients. We included patients with malignant middle cerebral artery infarction (MMCAI) and a Glasgow Coma Scale (GCS) lower than 9. Non-surviving patients at 30 days (n = 31) had higher serum concentrations of SP levels at diagnosis of severe MMCAI than survivors (n = 30) (p < 0.001). We found in multiple regression an association between serum concentrations of SP higher than 362 pg/mL and mortality at 30 days (Odds Ratio = 5.33; 95% confidence interval = 1.541-18.470; p = 0.008) after controlling for age and GCS. Thus, the major novel finding of our study was the association between serum levels of SP and mortality in patients suffering from severe acute ischemic stroke. PMID:27338372

  2. The Nature of Naming Errors in Primary Progressive Aphasia Versus Acute Post-Stroke Aphasia

    PubMed Central

    Budd, Maggi A.; Kortte, Kathleen; Cloutman, Lauren; Newhart, Melissa; Gottesman, Rebecca F.; Davis, Cameron; Heidler-Gary, Jennifer; Seay, Margaret W.; Hillis, Argye E.

    2011-01-01

    Objective To compare the distribution of error types across subgroups of primary progressive aphasia and poststroke aphasia in different vascular locations. Method We analyzed naming errors in 49 individuals with acute left hemisphere ischemic stroke and 55 individuals with three variants of primary progressive aphasia. Location of atrophy or ischemic stroke was characterized using MRI. Results We found that distribution of error types was very similar across all subgroups, irrespective of the site or etiology of the lesion. The only significant difference across groups was the percentage of circumlocutions (F(7, 96) = 3.02, p = .005). Circumlocution errors were highest among logopenic variant PPA (24%) and semantic variant PPA (24%). Semantic coordinate errors were common in all groups, probably because they can arise from disruption of different cognitive processes underlying naming and, therefore, from different locations of brain damage. Conclusions Semantic errors are common among all types of primary progressive aphasia and poststroke aphasia, and the type of error depends in part on the location of damage. PMID:20804246

  3. Serum Levels of Substance P and Mortality in Patients with a Severe Acute Ischemic Stroke

    PubMed Central

    Lorente, Leonardo; Martín, María M.; Almeida, Teresa; Pérez-Cejas, Antonia; Ramos, Luis; Argueso, Mónica; Riaño-Ruiz, Marta; Solé-Violán, Jordi; Hernández, Mariano

    2016-01-01

    Substance P (SP), a member of tachykinin family, is involved in the inflammation of the central nervous system and in the appearance of cerebral edema. Higher serum levels of SP have been found in 18 patients with cerebral ischemia compared with healthy controls. The aim of our multi-center study was to analyze the possible association between serum levels of SP and mortality in ischemic stroke patients. We included patients with malignant middle cerebral artery infarction (MMCAI) and a Glasgow Coma Scale (GCS) lower than 9. Non-surviving patients at 30 days (n = 31) had higher serum concentrations of SP levels at diagnosis of severe MMCAI than survivors (n = 30) (p < 0.001). We found in multiple regression an association between serum concentrations of SP higher than 362 pg/mL and mortality at 30 days (Odds Ratio = 5.33; 95% confidence interval = 1.541–18.470; p = 0.008) after controlling for age and GCS. Thus, the major novel finding of our study was the association between serum levels of SP and mortality in patients suffering from severe acute ischemic stroke. PMID:27338372

  4. Trends in oral anticoagulant choice for acute stroke patients with nonvalvular atrial fibrillation in Japan: The SAMURAI‐NVAF Study

    PubMed Central

    Arihiro, Shoji; Todo, Kenichi; Yamagami, Hiroshi; Kimura, Kazumi; Furui, Eisuke; Terasaki, Tadashi; Shiokawa, Yoshiaki; Kamiyama, Kenji; Takizawa, Shunya; Okuda, Satoshi; Okada, Yasushi; Kameda, Tomoaki; Nagakane, Yoshinari; Hasegawa, Yasuhiro; Mochizuki, Hiroshi; Ito, Yasuhiro; Nakashima, Takahiro; Takamatsu, Kazuhiro; Nishiyama, Kazutoshi; Kario, Kazuomi; Sato, Shoichiro; Koga, Masatoshi; Nagatsuka, K; Minematsu, K; Nakagawara, J; Akiyama, H; Shibazaki, K; Maeda, K; Shibuya, S; Yoshimura, S; Endo, K; Miyagi, T; Osaki, M; Kobayashi, J; Okata, T; Tanaka, E; Sakamoto, Y; Takizawa, H; Takasugi, J; Tokunaga, K; Homma, K; Kinoshita, N; Matsuki, T; Higashida, K; Shiozawa, M; Kanai, H; Uehara, S

    2015-01-01

    Background Large clinical trials are lack of data on non‐vitamin K antagonist oral anticoagulants for acute stroke patients. Aim To evaluate the choice of oral anticoagulants at acute hospital discharge in stroke patients with nonvalvular atrial fibrillation and clarify the underlying characteristics potentially affecting that choice using the multicenter Stroke Acute Management with Urgent Risk‐factor Assessment and Improvement‐NVAF registry (ClinicalTrials.gov NCT01581502). Method The study included 1192 acute ischemic stroke/transient ischemic attack patients with nonvalvular atrial fibrillation (527 women, 77·7 ± 9·9 years old) between September 2011 and March 2014, during which three nonvitamin K antagonist oral anticoagulant oral anticoagulants were approved for clinical use. Oral anticoagulant choice at hospital discharge (median 23‐day stay) was assessed. Results Warfarin was chosen for 650 patients, dabigatran for 203, rivaroxaban for 238, and apixaban for 25. Over the three 10‐month observation periods, patients taking warfarin gradually decreased to 46·5% and those taking nonvitamin K antagonist oral anticoagulants increased to 48·0%. As compared with warfarin users, patients taking nonvitamin K antagonist oral anticoagulants included more men, were younger, more frequently had small infarcts, and had lower scores for poststroke CHADS 2, CHA 2 DS 2‐VASc, and HAS‐BLED, admission National Institutes of Health stroke scale, and discharge modified Rankin Scale. Nonvitamin K antagonist oral anticoagulants were started at a median of four‐days after stroke onset without early intracranial hemorrhage. Patients starting nonvitamin K antagonist oral anticoagulants earlier had smaller infarcts and lower scores for the admission National Institutes of Health stroke scale and the discharge modified Rankin Scale than those starting later. Choice of nonvitamin K antagonist oral anticoagulants was independently associated with 20‐day or

  5. Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection.

    PubMed

    Lapchak, Paul A

    2015-10-01

    Today, there is an enormous amount of excitement in the field of stroke victim care due to the recent success of MR. CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, and REVASCAT endovascular trials. Successful intravenous (IV) recombinant tissue plasminogen activator (rt-PA) clinical trials [i.e., National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial, Third European Cooperative Acute Stroke Study (ECASSIII), and Third International Stroke study (IST-3)] also need to be emphasized. In the recent endovascular and thrombolytic trials, there is statistically significant improvement using both the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Score (mRS) scale, but neither approach promotes complete recovery in patients enrolled within any particular NIHSS or mRS score tier. Absolute improvement (mRS 0-2 at 90 days) with endovascular therapy is 13.5-31 %, whereas thrombolytics alone also significantly improve patient functional independence, but to a lesser degree (NINDS rt-PA trial 13 %). This article has 3 main goals: (1) first to emphasize the utility and cost-effectiveness of rt-PA to treat stroke; (2) second to review the recent endovascular trials with respect to efficacy, safety, and cost-effectiveness as a stroke treatment; and (3) to further consider and evaluate strategies to develop novel neuroprotective drugs. A thesis will be put forth so that future stroke trials and therapy development can optimally promote recovery so that stroke victims can return to "normal" life. PMID:26314402

  6. Tissue plasminogen activator for acute ischemic stroke: a New York city emergency medicine perspective.

    PubMed

    Chan, Yu-Feng; Kwiatkowski, Thomas G; Rella, Joseph G; Rennie, William P; Kwon, Robert K; Silverman, Robert A

    2005-11-01

    Nationally, only 2-3% of patients with acute ischemic stroke (AIS) currently receive tissue plasminogen activator (TPA). To better understand the reasons, we investigated the practice patterns, level of familiarity and acceptance of TPA for AIS among emergency physicians in New York City (NYC). Fifty-seven 911-receiving hospital emergency department directors were surveyed regarding TPA use. Of those responding, 37% had never used TPA to treat AIS. Lack of neurological support was reported by 33%. Departments with formal protocols were more likely to use TPA for AIS. In conclusion, there is considerable variation in the practice, knowledge, and attitudes regarding the use of TPA for AIS in NYC emergency departments. Improved educational efforts and institutional support may be necessary to ensure the appropriate use of TPA by emergency physicians. PMID:16243196

  7. A comparison of intravenous and subcutaneous hydration in elderly acute stroke patients.

    PubMed Central

    Challiner, Y. C.; Jarrett, D.; Hayward, M. J.; al-Jubouri, M. A.; Julious, S. A.

    1994-01-01

    The aim of this study was to compare the effectiveness of subcutaneous and intravenous fluid therapy in hydrating, elderly acute stroke patients. Thirty-four such patients, needing parenteral fluids because of impaired consciousness or dysphagia, were randomly allocated to receive either subcutaneous or intravenous fluids (2 litres of dextrose-saline/24 hours). Serum osmolality was measured before starting fluid therapy (Day 1) and on Days 2 and 3. An analysis of covariance of the osmolalities showed no statistical difference between the two groups (P = 0.12). The total cost of cannulae used over the 3 days for the subcutaneous route was approximately a third of that for the intravenous route. Complication rates were similar for the two groups. The results suggest that subcutaneous fluid therapy is an effective alternative to the intravenous route. PMID:8183752

  8. Mechanical thrombectomy with ‘ADAPT’ technique by transcervical access in acute ischemic stroke

    PubMed Central

    Remollo, Sebastian; García, Maria Rosa; Hidalgo, Cristina; Hernández-Perez, Maria; Ciorba, Mihaela

    2015-01-01

    Background The mechanical thrombectomy (MT) for endovascular clot retrieval has dramatically improved successful revascularization and clinical outcome in selected acute stroke patients. MT is typically performed via a transfemoral approach, but catheterization of the occluded vessel can be problematic in cases of extensive vessel tortuosity. We describe a case of MT with the ‘ADAPT’ technique by direct carotid access due to an inability to catheterize the ICA by a transfemoral approach for acute cerebral ischemia in the setting of left MCA occlusion. Excellent angiographic and good clinical results were obtained without any complications. Case report An 80-year-old woman was admitted with a stroke by occlusion of the left MCA, with an NIHSS: 11, and an ASPECT: 7 in the CT. Under sedation a transfemoral angiography was performed, but after multiple attempts, it was impossible to make a stable catheterization of the left CCA. A transcervical approach was pursued. With ultrasound guidance the CCA was catheterized. Using the ‘ADAPT’ technique, we performed a successful MT. Post-procedure angiography (at 14 minutes) demonstrated recanalization of the entire left MCA (TICI: 3), without complications. The carotid access point was closed with a percutaneous closure. Control TC at 24 h showed a slight hypodensity in the left lenticular nucleus, and loss of gray-white matter differentiation in the adjacent cortex. Neurologically, the patient presented with progressive improvement. At discharge, she had an NIHSS: 0, mRS: 0 and Barthel: 100. Conclusions MT by direct carotid access is an effective alternative technique in those cases where it is not accessible by a transfemoral approach. PMID:26443297

  9. Mechanical thrombectomy in patients with acute ischemic stroke: a cost-utility analysis

    PubMed Central

    Xie, Xuanqian; Lambrinos, Anna; Chan, Brian; Dhalla, Irfan A.; Krings, Timo; Casaubon, Leanne K.; Lum, Cheemun; Sikich, Nancy; Bharatha, Aditya; Pereira, Vitor Mendes; Stotts, Grant; Saposnik, Gustavo; O'Callaghan, Christina; Kelloway, Linda; Hill, Michael D.

    2016-01-01

    Background: The beneficial effects of endovascular treatment with new-generation mechanical thrombectomy devices compared with intravenous thrombolysis alone to treat acute large-artery ischemic stroke have been shown in randomized controlled trials (RCTs). This study aimed to estimate the cost utility of mechanical thrombectomy compared with the established standard of care. Methods: We developed a Markov decision process analytic model to assess the cost-effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis versus treatment with intravenous thrombolysis alone from the public payer perspective in Canada. We conducted comprehensive literature searches to populate model inputs. We estimated the efficacy of mechanical thrombectomy plus intravenous thrombolysis from a meta-analysis of 5 RCTs, and we used data from the Oxford Vascular Study to model long-term clinical outcomes. We calculated incremental cost-effectiveness ratios (ICER) using a 5-year time horizon. Results: The base case analysis showed the cost and effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis to be $126 939 and 1.484 quality-adjusted life-years (QALYs), respectively, and the cost and effectiveness of treatment with intravenous thrombolysis alone to be $124 419 and 1.273 QALYs, respectively. The mechanical thrombectomy plus intravenous thrombolysis strategy was associated with an ICER of $11 990 per QALY gained. Probabilistic sensitivity analysis showed that the probability of treatment with mechanical thrombectomy plus intravenous thrombolysis being cost-effective was 57.5%, 89.7% and 99.6% at thresholds of $20 000, $50 000 and $100 000 per QALY gained, respectively. The main factors influencing the ICER were time horizon, extra cost of mechanical thrombectomy treatment and age of the patient. Interpretation: Mechanical thrombectomy as an adjunct therapy to intravenous thrombolysis is cost-effective compared with

  10. [Outcomes of carotid endarterectomy performed in acute stage of ischaemic stroke].

    PubMed

    Shatravka, A V; Sokurenko, G Yu; Suvorov, S A; Rizakhanova, M R; Loginov, I A; Alekseeva, N V

    2016-01-01

    Recent years have witnessed several studies concerning optimal terms of performing carotid endarterectomy after endured acute cerebral circulation disorder (ACCD). However up to now there is no common opinion regarding feasibility and safety of performing carotid endarterectomy in the acute period of ischaemic stroke. The 2013 Russian National Guidelines on surgical management of diseases of extracranial arteries point to feasibility of performing carotid endarterectomy at terms within up to 2 weeks after endured ischaemic stroke (level B evidence). At the same time, there is no data concerning possibility of performing this type of operation in patients with neurological deficit scoring 4 points according to the Rankin scale. Analysing the results of 110 carotid endarterectomies performed in patients with haemodynamically meaningful stenosis of carotid arteries at terms varying from 2 to 14 days after the development of ipsilateral ACCD showed safety of the operation (the rate of postoperative cerebral circulation disorders amounted to 0.9% - 1 patient) and its efficacy in prevention of recurrent ischaemic complications, also determining regression of neurological symptomatology in the overwhelming majority - 86 (78%) patients. Despite the absence of recommendations on possibility to perform carotid endarterectomy in patients after endured ACCD with neurological deficiency scoring 4 points according to the modified Rankin scale we proved efficiency and feasibility of performing this type of operation in the cohort of patients concerned. There was not a single case of transformation of the ischaemic focus into haemorrhagic one. One patient developed fatal ACCD. During the follow up period (12 months) regression of neurological symptomatology was observed in 16 (66.7%) patients of 24 operated patients with baseline deficit of stage 4 according to the Rankin scale. PMID:27336345

  11. Automated prediction of tissue outcome after acute ischemic stroke in computed tomography perfusion images

    NASA Astrophysics Data System (ADS)

    Vos, Pieter C.; Bennink, Edwin; de Jong, Hugo; Velthuis, Birgitta K.; Viergever, Max A.; Dankbaar, Jan Willem

    2015-03-01

    Assessment of the extent of cerebral damage on admission in patients with acute ischemic stroke could play an important role in treatment decision making. Computed tomography perfusion (CTP) imaging can be used to determine the extent of damage. However, clinical application is hindered by differences among vendors and used methodology. As a result, threshold based methods and visual assessment of CTP images has not yet shown to be useful in treatment decision making and predicting clinical outcome. Preliminary results in MR studies have shown the benefit of using supervised classifiers for predicting tissue outcome, but this has not been demonstrated for CTP. We present a novel method for the automatic prediction of tissue outcome by combining multi-parametric CTP images into a tissue outcome probability map. A supervised classification scheme was developed to extract absolute and relative perfusion values from processed CTP images that are summarized by a trained classifier into a likelihood of infarction. Training was performed using follow-up CT scans of 20 acute stroke patients with complete recanalization of the vessel that was occluded on admission. Infarcted regions were annotated by expert neuroradiologists. Multiple classifiers were evaluated in a leave-one-patient-out strategy for their discriminating performance using receiver operating characteristic (ROC) statistics. Results showed that a RandomForest classifier performed optimally with an area under the ROC of 0.90 for discriminating infarct tissue. The obtained results are an improvement over existing thresholding methods and are in line with results found in literature where MR perfusion was used.

  12. The velocity of collateral filling predicts recanalization in acute ischemic stroke after intravenous thrombolysis.

    PubMed

    Zhang, Sheng; Zhang, Xiaocheng; Yan, Shenqiang; Lai, Yangxiao; Han, Quan; Sun, Jianzhong; Zhang, Minming; Parsons, Mark W; Wang, Shaoshi; Lou, Min

    2016-01-01

    The aim of this study was to evaluate the impact of pretreatment quality of collaterals, involving velocity and extent of collateral filling, on recanalization after intravenous thrombolysis (IVT). A retrospective analysis was performed of 66 patients with acute middle cerebral artery (MCA) M1 segment occlusion who underwent MR perfusion (MRP) imaging before IVT. The velocity of collateral filling was defined as arrival time delay (ATD) of contrast bolus to Sylvian fissure between the normal and the affected hemisphere. The extent of collateral filling was assessed according to the Alberta Stroke Program Early CT (ASPECT) score on temporally fused maximum intensity projections (tMIP). Arterial occlusive lesion (AOL) score was used to assess the degree of arterial recanalization. ATD (OR = 0.775, 95% CI = 0.626-0.960, p = 0.020), but not tMIP-ASPECT score (OR = 1.073, 95% CI = 0.820-1.405, p = 0.607), was independently associated with recanalization (AOL score of 2 and 3) at 24 hours after IVT. When recanalization was achieved, hemorrhagic transformation (HT) occurred more frequently in patients with slow collaterals (ATD ≥ 2.3 seconds) than those with rapid collaterals (ATD < 2.3 seconds) (88.9% vs 38.1%, p = 0.011). In conclusion, the velocity of collaterals related to recanalization, which may guide the decision-making of revascularization therapy in acute ischemic stroke. PMID:27296511

  13. The velocity of collateral filling predicts recanalization in acute ischemic stroke after intravenous thrombolysis

    PubMed Central

    Zhang, Sheng; Zhang, Xiaocheng; Yan, Shenqiang; Lai, Yangxiao; Han, Quan; Sun, Jianzhong; Zhang, Minming; Parsons, Mark W.; Wang, Shaoshi; Lou, Min

    2016-01-01

    The aim of this study was to evaluate the impact of pretreatment quality of collaterals, involving velocity and extent of collateral filling, on recanalization after intravenous thrombolysis (IVT). A retrospective analysis was performed of 66 patients with acute middle cerebral artery (MCA) M1 segment occlusion who underwent MR perfusion (MRP) imaging before IVT. The velocity of collateral filling was defined as arrival time delay (ATD) of contrast bolus to Sylvian fissure between the normal and the affected hemisphere. The extent of collateral filling was assessed according to the Alberta Stroke Program Early CT (ASPECT) score on temporally fused maximum intensity projections (tMIP). Arterial occlusive lesion (AOL) score was used to assess the degree of arterial recanalization. ATD (OR = 0.775, 95% CI = 0.626–0.960, p = 0.020), but not tMIP-ASPECT score (OR = 1.073, 95% CI = 0.820–1.405, p = 0.607), was independently associated with recanalization (AOL score of 2 and 3) at 24 hours after IVT. When recanalization was achieved, hemorrhagic transformation (HT) occurred more frequently in patients with slow collaterals (ATD ≥ 2.3 seconds) than those with rapid collaterals (ATD < 2.3 seconds) (88.9% vs 38.1%, p = 0.011). In conclusion, the velocity of collaterals related to recanalization, which may guide the decision-making of revascularization therapy in acute ischemic stroke. PMID:27296511

  14. Apolipoprotein E polymorphism and acute ischemic stroke: a diffusion- and perfusion-weighted magnetic resonance imaging study.

    PubMed

    Liu, Yawu; Laakso, Mikko P; Karonen, Jari O; Vanninen, Ritva L; Nuutinen, Juho; Soimakallio, Seppo; Aronen, Hannu J

    2002-11-01

    Diffusion- and perfusion-weighted magnetic resonance imaging (MRI) was used to study the putative effects of apolipoprotein E (ApoE) polymorphism in stroke. Thirty-one patients with acute stroke, comparative for age and gender were scanned, nine of whom were ApoE allele epsilon 4 carriers. Initially, less than 24 hours from the onset of stroke, the epsilon 4 carriers had significantly smaller volumes of hypoperfusion on relative cerebral blood volume map (P = 0.001), and smaller infarct volumes (P = 0.008) compared with the noncarriers. By day 8, this difference in the infarct volumes had disappeared, suggesting relatively enhanced infarct growth. On average, the total infarct volume increased 145% of the initial infarct volume in the epsilon 4 carriers, and 84% in the noncarriers. There were strong correlations between the imaging findings and clinical status initially and with the outcome 3 months after the stroke in the epsilon 4 noncarriers, but, with a single exception at acute phase, a lack thereof in the epsilon 4 carriers. These patterns were virtually similar in a subgroup of patients with middle cerebral artery stroke. These data support the hypothesis of increased general vulnerability of the brain in the epsilon 4 carriers. Thus, the effects of ApoE polymorphism should be accounted for when interpreting diffusion- and perfusion-weighted MRI studies, particularly if predicting lesion growth. PMID:12439291

  15. CT Perfusion ASPECTS in the Evaluation of Acute Ischemic Stroke: Thrombolytic Therapy Perspective

    PubMed Central

    Sillanpaa, Niko; Saarinen, Jukka T.; Rusanen, Harri; Hakomaki, Jari; Lahteela, Arto; Numminen, Heikki; Elovaara, Irina; Dastidar, Prasun; Soimakallio, Seppo

    2011-01-01

    Background and Purpose Advances in the management of acute ischemic stroke and medical imaging are creating pressure to replace the rigid one-third middle cerebral artery (MCA) and non-contrast-enhanced CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS) thresholds used for the selection of patients eligible for intravenous thrombolytic therapy. The identification of potentially salvageable ischemic brain tissue lies at the core of this issue. In this study, the role of CT perfusion ASPECTS in the detection of reversible ischemia was analyzed. Materials and Methods We retrospectively reviewed the clinical and imaging data of 92 consecutive patients who received intravenous thrombolytic therapy for acute (duration <3 h) ischemic stroke. Most of the patients underwent admission multimodal CT, and all patients had follow-up NCCT at 24 h. ASPECTS was assigned to all modalities and correlated with clinical and imaging parameters. Receiver-operating characteristic curve analysis was performed to determine optimal thresholds for different parameters to predict clinical outcome. Results A perfusion defect could be detected in 50% of the patients. ASPECTS correlated inversely with the clinical outcome in the following order: follow-up NCCT > cerebral blood volume (CBV) > mean transit time (MTT) > admission NCCT. The follow-up NCCT and the CBV displayed a statistically significant difference from the admission NCCT, while the MTT did not reach statistical significance. The threshold that best differentiated between good and bad clinical outcome on admission was CBV ASPECTS ≥7. In patients with CT perfusion ASPECTS mismatch, MTT and CBV ASPECTS essentially provided the lower and upper limits for the follow-up NCCT ASPECTS, thus defining the spectrum of possible outcomes. Furthermore, CT perfusion ASPECTS mismatch strongly correlated (r = 0.83) with the mismatch between the tissue at risk and the final infarct, i.e. the amount of salvaged tissue. This finding suggests

  16. Quantifying the risk of heart disease following acute ischaemic stroke: a meta-analysis of over 50 000 participants

    PubMed Central

    Gunnoo, Trishna; Hasan, Nazeeha; Khan, Muhammad Saleem; Slark, Julia; Bentley, Paul; Sharma, Pankaj

    2016-01-01

    Objective Following an acute stroke, there is a high risk of recurrence. However, the leading cause of mortality following a stroke is due to coronary artery disease (CAD) and myocardial infarction (MI) but that risk has not been robustly quantified. We sought to reliably quantify the risk of ischaemic heart disease (IHD) in patients presenting with acute ischaemic stroke (AIS) in the absence of a known cardiac history. Setting A meta-analysis study. PubMed, MEDLINE, EMBASE and Google Scholar were searched for potential studies up to October 2015. Included studies reported an acute cerebral ischaemic event and followed for CAD or MI within 1 year in patients without known IHD. Using arcsine transformed proportions for meta-analysis, studies were combined using a generic inverse variance random-effects model to calculate the pooled standardised mean difference and 95% CIs. These were interpreted as the percentage prevalence of CAD or incidence of MI following AIS. Results 17 studies with 4869 patients with AIS demonstrated a mean average of asymptomatic CAD in 52%. Anatomical methods of CAD detection revealed a prevalence of asymptomatic ≥50% coronary stenosis in 32% (95% CI 19% to 47%; p<0.00001). 8 studies with 47229 patients with ischaemic stroke revealed an overall risk of MI in the year following stroke of 3% (95% CI 1% to 5%; p<0.00001) despite the absence of any cardiac history. Conclusions One-third of patients with ischaemic stroke with no cardiac history have more than 50% coronary stenosis and 3% are at risk of developing MI within a year. Our findings provide a reliable quantitative measure of the risk of IHD following AIS in patients with no cardiac history. PMID:26792217

  17. Impact of transfer status on hospitalization cost and discharge disposition for acute ischemic stroke across the US.

    PubMed

    Sonig, Ashish; Lin, Ning; Krishna, Chandan; Natarajan, Sabareesh K; Mokin, Maxim; Hopkins, L Nelson; Snyder, Kenneth V; Levy, Elad I; Siddiqui, Adnan H

    2016-05-01

    OBJECT In this study, the authors used information provided in the Nationwide Inpatient Sample (NIS) to study the impact of transferring stroke patients from one facility to a center where they received some form of active stroke intervention (intravenous tissue plasminogen activator, thrombectomy, or a combination of both therapies). METHODS Patient demographic characteristics and hospital factors obtained from the 2008-2010 acute stroke NIS data were analyzed. Discharge disposition, hospitalization cost, and mortality were the dependent variables studied. Univariate analysis and multivariate binary logistic regression analysis were performed. Data analysis focused on the cohort of acute stroke patients who received some form of active intervention (55,913 of 1,311,511 patients in the NIS). RESULTS When overall outcome was considered, transferred patients had a significantly higher number of other-than-routine (OTR, i.e., other than discharge to home without home health care) discharge dispositions (p < 0.0001). In multivariate regression analysis including pertinent patient and hospital factors, transfer-in patients had significantly worse OTR discharge disposition (p < 0.0001, odds ratio [OR] 2.575, 95% CI 2.341-2.832). Mean hospitalization cost including an intervention was $70,325.11 for direct admissions and $97,546.92 for transferred patients. Transfer from another facility (p < 0.001, OR 1.677, 95% CI 1.548-1.817) was associated with higher hospitalization cost. CONCLUSIONS The study showed that hospital cost for acute stroke intervention is significantly higher for a transferred patient than for a direct admission. Moreover, the frequency of OTR discharge was significantly higher among transferred patients than direct admissions. Future strategies should focus on ways and means of transporting patients appropriately and directly to stroke centers. PMID:26452123

  18. Prognostic value of trans-thoracic echocardiography in patients with acute stroke and atrial fibrillation: findings from the RAF study.

    PubMed

    Paciaroni, Maurizio; Agnelli, Giancarlo; Falocci, Nicola; Caso, Valeria; Becattini, Cecilia; Marcheselli, Simona; Rueckert, Christina; Pezzini, Alessandro; Poli, Loris; Padovani, Alessandro; Csiba, Laszló; Szabó, Lilla; Sohn, Sung-Il; Tassinari, Tiziana; Abdul-Rahim, Azmil H; Michel, Patrik; Cordier, Maria; Vanacker, Peter; Remillard, Suzette; Alberti, Andrea; Venti, Michele; Acciarresi, Monica; D'Amore, Cataldo; Mosconi, Maria Giulia; Scoditti, Umberto; Denti, Licia; Orlandi, Giovanni; Chiti, Alberto; Gialdini, Gino; Bovi, Paolo; Carletti, Monica; Rigatelli, Alberto; Putaala, Jukka; Tatlisumak, Turgut; Masotti, Luca; Lorenzini, Gianni; Tassi, Rossana; Guideri, Francesca; Martini, Giuseppe; Tsivgoulis, Georgios; Vadikolias, Kostantinos; Liantinioti, Chrissoula; Corea, Francesco; Del Sette, Massimo; Ageno, Walter; De Lodovici, Maria Luisa; Bono, Giorgio; Baldi, Antonio; D'Anna, Sebastiano; Sacco, Simona; Carolei, Antonio; Tiseo, Cindy; Imberti, Davide; Zabzuni, Dorjan; Doronin, Boris; Volodina, Vera; Consoli, Domenico; Galati, Franco; Pieroni, Alessio; Toni, Danilo; Monaco, Serena; Baronello, Mario Maimone; Barlinn, Kristian; Pallesen, Lars-Peder; Kepplinger, Jessica; Bodechtel, Ulf; Gerber, Johannes; Deleu, Dirk; Melikyan, Gayane; Ibrahim, Faisal; Akhtar, Naveed; Lees, Kennedy R

    2016-02-01

    Anticoagulant therapy is recommended for the secondary prevention of stroke in patients with atrial fibrillation (AF). T he identification of patients at high risk for early recurrence, which are potential candidates to prompt anticoagulation, is crucial to justify the risk of bleeding associated with early anticoagulant treatment. The aim of this study was to evaluate in patients with acute ischemic stroke and AF the association between findings at trans-thoracic echocardiography (TTE) and 90 days recurrence. In consecutive patients with acute ischemic stroke and AF, TTE was performed within 7 days from hospital admission. Study outcomes were recurrent ischemic cerebrovascular events (stroke or TIA) and systemic embolism. 854 patients (mean age 76.3 ± 9.5 years) underwent a TTE evaluation; 63 patients (7.4%) had at least a study outcome event. Left atrial thrombosis was present in 11 patients (1.3%) among whom 1 had recurrent ischemic event. Left atrial enlargement was present in 548 patients (64.2%) among whom 51 (9.3%) had recurrent ischemic events. The recurrence rate in the 197 patients with severe left atrial enlargement was 11.7%. On multivariate analysis, the presence of atrial enlargement (OR 2.13; 95% CI 1.06-4.29, p = 0.033) and CHA2DS2-VASc score (OR 1.22; 95% CI 1.04-1.45, p = 0.018, for each point increase) were correlated with ischemic recurrences. In patients with AF-associated acute stroke, left atrial enlargement is an independent marker of recurrent stroke and systemic embolism. The risk of recurrence is accounted for by severe atrial enlargement. TTE-detected left atrial thrombosis is relatively uncommon. PMID:26566907

  19. Enhanced clarity and holism: the outcome of implementing the ICF with an acute stroke multidisciplinary team in England

    PubMed Central

    Harries, Priscilla; Kilbride, Cherry; De Souza, Lorraine

    2013-01-01

    Purpose: Although it is recommended that the ICF (International Classification of Functioning, Disability and Health) should be implemented to aid communication within multidisciplinary stroke services, there is no empirical evidence to demonstrate the outcomes of such implementation. Working with one stroke service, this project aimed to address this gap and sought to evaluate the outcomes of implementing an ICF-based clinical tool into practice. Method: Using an action research framework with mixed methods, data were collected from individual interviews, a focus group, questionnaires, email communications, minutes from relevant meetings and field notes. Thematic analysis was undertaken, using immersion and crystallisation, to define overall themes. Descriptive statistics were used to analyse quantitative data. Data from both sources were combined to create key findings. Results: Three findings were determined from the data analysis. The ICF (1) fosters communication within and beyond the multidisciplinary stroke team; (2) promotes holistic thinking; and (3) helps to clarify team roles. Conclusions: The ICF enhanced clarity of communication and team roles within the acute stroke multidisciplinary team as well as with other clinicians, patients and their relatives. In addition, the ICF challenged stroke clinicians to think holistically, thereby appropriately extending their domain of concern beyond their traditional remit. Implications for Rehabilitation The ICF is a globally accepted framework to describe functioning and is in use in a variety of clinical settings. Yet, the outcomes of using it in clinical practice have yet to be fully explored. This study found that the ICF enhanced clarity of communication and team roles within an acute stroke multidisciplinary team and to others beyond the team, including clinicians, patients and their relatives. Using the ICF also challenged clinicians to think holistically about patient needs following a stroke. PMID:23530624

  20. The Usefulness of the TOAST Classification and Prognostic Significance of Pyramidal Symptoms During the Acute Phase of Cerebellar Ischemic Stroke.

    PubMed

    Dziadkowiak, Edyta; Chojdak-Łukasiewicz, Justyna; Guziński, Maciej; Noga, Leszek; Paradowski, Bogusław

    2016-04-01

    Cerebellar stroke is a rare condition with very nonspecific clinical features. The symptoms in the acute phase could imitate acute peripheral vestibular disorders or a brainstem lesion. The aim of this study was to assess the usefulness of the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification in cerebellar stroke and the impact of clinical features on the prognosis. We retrospectively analyzed 107 patients with diagnosed ischemic cerebellar infarction. We studied the clinical features and compared them based on the location of the ischemic lesion and its distribution in the posterior interior cerebellar artery (PICA), superior cerebellar artery (SCA), and anterior inferior cerebellar artery (AICA) territories. According to the TOAST classification, stroke was more prevalent in atrial fibrillation (26/107) and when the lesion was in the PICA territory (39/107). Pyramidal signs occurred in 29/107 of patients and were more prevalent when the lesion was distributed in more than two vascular regions (p = 0.00640). Mortality was higher among patients with ischemic lesion caused by cardiac sources (p = 0.00094) and with pyramidal signs (p = 0.00640). The TOAST classification is less useful in assessing supratentorial ischemic infarcts. Cardioembolic etiology, location of the ischemic lesion, and pyramidal signs support a negative prognosis. PMID:26041073

  1. Increased Risk of Post-Trauma Stroke after Traumatic Brain Injury-Induced Acute Respiratory Distress Syndrome.

    PubMed

    Chen, Gunng-Shinng; Liao, Kuo-Hsing; Bien, Mauo-Ying; Peng, Giia-Sheun; Wang, Jia-Yi

    2016-07-01

    This study determines whether acute respiratory distress syndrome (ARDS) is an independent risk factor for an increased risk of post-traumatic brain injury (TBI) stroke during 3-month, 1-year, and 5-year follow-ups, respectively, after adjusting for other covariates. Clinical data for the analysis were from the National Health Insurance Database 2000, which covered a total of 2121 TBI patients and 101 patients with a diagnosis of TBI complicated with ARDS (TBI-ARDS) hospitalized between January 1, 2001 and December 31, 2005. Each patient was tracked for 5 years to record stroke occurrences after discharge from the hospital. The prognostic value of TBI-ARDS was evaluated using a multivariate Cox proportional hazard model. The main outcome found that stroke occurred in nearly 40% of patients with TBI-ARDS, and the hazard ratio for post-TBI stroke increased fourfold during the 5-year follow-up period after adjusting for other covariates. The increased risk of hemorrhagic stroke in the ARDS group was considerably higher than in the TBI-only cohort. This is the first study to report that post-traumatic ARDS yielded an approximate fourfold increased risk of stroke in TBI-only patients. We suggest intensive and appropriate medical management and intensive follow-up of TBI-ARDS patients during the beginning of the hospital discharge. PMID:26426583

  2. A practical assessment of magnetic resonance diffusion-perfusion mismatch in acute stroke: observer variation and outcome.

    PubMed

    Kane, I; Hand, P J; Rivers, C; Armitage, P; Bastin, M E; Lindley, R; Dennis, M; Wardlaw, J M

    2009-11-01

    MR diffusion/perfusion mismatch may help identify patients for acute stroke treatment, but mixed results from clinical trials suggest that further evaluation of the mismatch concept is required. To work effectively, mismatch should predict prognosis on arrival at hospital. We assessed mismatch duration and associations with functional outcome in acute stroke. We recruited consecutive patients with acute stroke, recorded baseline clinical variables, performed MR diffusion and perfusion imaging and assessed 3-month functional outcome. We assessed practicalities, agreement between mismatch on mean transit time (MTT) or cerebral blood flow (CBF) maps, visually and with lesion volume, and the relationship of each to functional outcome. Of 82 patients starting imaging, 14 (17%) failed perfusion imaging. Overall, 42% had mismatch (56% at <6 h; 41% at 12-24 h; 23% at 24-48 h). Agreement for mismatch by visual versus volume assessment was fair using MTT (kappa 0.59, 95% CI 0.34-0.84) but poor using CBF (kappa 0.24, 95% CI 0.01-0.48). Mismatch by either definition was not associated with functional outcome, even when the analysis was restricted to just those with mismatch. Visual estimation is a reasonable proxy for mismatch volume on MTT but not CBF. Perfusion is more difficult for acute stroke patients than diffusion imaging. Mismatch is present in many patients beyond 12 h after stroke. Mismatch alone does not distinguish patients with good and poor prognosis; both can do well or poorly. Other factors, e.g. reperfusion, may influence outcome more strongly, even in patients without mismatch. PMID:19536582

  3. Provider perceptions of barriers to the emergency use of tPA for Acute Ischemic Stroke: A qualitative study

    PubMed Central

    2011-01-01

    Background Only 1-3% of ischemic stroke patients receive thrombolytic therapy. Provider barriers to adhering with guidelines recommending tPA delivery in acute stroke are not well known. The main objective of this study was to describe barriers to thrombolytic use in acute stroke care. Methods Twenty-four hospitals were randomly selected and matched into 12 pairs. Barrier assessment occurred at intervention sites only, and utilized focus groups and structured interviews. A pre-specified taxonomy was employed to characterize barriers. Two investigators independently assigned themes to transcribed responses. Seven facilitators (three emergency physicians, two nurses, and two study coordinators) conducted focus groups and interviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators (12), and three others (hospitalists and pharmacist). Results The following themes represented the most important external barriers: environmental and patient factors. Important barriers internal to the clinician included familiarity with and motivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy. The following themes were not substantial barriers: lack of awareness of the existence of acute stroke guidelines, presence of conflicting guidelines, and lack of agreement with the guidelines. Conclusions Healthcare providers perceive environmental and patient-related factors as the primary barriers to adherence with acute stroke treatment guidelines. Interventions focused on increasing physician familiarity with and motivation to follow guidelines may be of highest yield in improving adherence. Improving self-efficacy in performing guideline concordant care may also be useful. Trial Registration ClinicalTrials.gov identifier: NCT00349479 PMID:21548943

  4. Cerebrolysin adjuvant treatment in Broca's aphasics following first acute ischemic stroke of the left middle cerebral artery

    PubMed Central

    Muresanu, DF; Bajenaru, O; Popescu, BO; Deme, SM; Moessler, H; Meinzingen, SZ; Petrica, L; Serpe, M; Ursoniu, S

    2010-01-01

    Background: The aim of our study was to assess the efficacy of Cerebrolysin administration in Broca's aphasics with acute ischemic stroke. Methods: We registered 2,212 consecutive Broca's aphasics following an acute ischemic stroke admitted in four departments of neurology in Romania, between September 2005 and September 2009. Language was evaluated with the Romanian version of the Western Aphasia Battery (WAB). The following inclusion criteria were used for this study: age 20%75 years, admission in the hospital within 12 hours from the onset of the symptoms, diagnosis of first acute left middle cerebral artery (MCA) ischemic stroke, presence of large artery disease (LAD) stroke, a NIHSS score of 5%22 points, and a therapeutic time window within 72 h. Fifty two patients were treated with Cerebrolysin (Cerebrolysin group) as an adjunctive treatment. A placebo group, which received saline infusions (n=104 patients) were matched to the NIHSS and WAB scores, gender and age of the Cerebrolysin group at baseline. We assessed spontaneous speech (SS), comprehension (C), repetition (R), naming (N), and Aphasia Quotient (AQ) scores of the two groups in an open label design, over 90 days, the mRS scores and mortality. Results: The Cerebrolysin and the placebo groups had similar age (66+/%8 versus 65+/%8 years) and sex ratio (14/38 versus 30/74). The mean AQ scores and the mean subscores for 3 subtests of WAB (SS, R, N) were similar at baseline and improved in the Cerebrolysin group significantly (p<0.05) over placebo group at all study time points. The mRS score at 90 days was also lower in the Cerebrolysin group than in the placebo group. Cerebrolysin and placebo were both tolerated and safe, and no difference in the mortality rate was seen (3.8% in each group). Conclusion: Cerebrolysin is effective for the treatment of Broca's aphasics with a first acute ischemic stroke of the left MCA territory. PMID:20945821

  5. Accessing Inpatient Rehabilitation after Acute Severe Stroke: Age, Mobility, Prestroke Function and Hospital Unit Are Associated with Discharge to Inpatient Rehabilitation

    ERIC Educational Resources Information Center

    Hakkennes, Sharon; Hill, Keith D.; Brock, Kim; Bernhardt, Julie; Churilov, Leonid

    2012-01-01

    The objective of this study was to identify the variables associated with discharge to inpatient rehabilitation following acute severe stroke and to determine whether hospital unit contributed to access. Five acute hospitals in Victoria, Australia participated in this study. Patients were eligible for inclusion if they had suffered an acute severe…

  6. Tauroursodeoxycholic acid reduces apoptosis and protects against neurological injury after acute hemorrhagic stroke in rats

    PubMed Central

    Rodrigues, Cecilia M. P.; Solá, Susana; Nan, Zhenhong; Castro, Rui E.; Ribeiro, Paulo S.; Low, Walter C.; Steer, Clifford J.

    2003-01-01

    Tauroursodeoxycholic acid (TUDCA), an endogenous bile acid, modulates cell death by interrupting classic pathways of apoptosis. Intracerebral hemorrhage (ICH) is a devastating acute neurological disorder, without effective treatment, in which a significant loss of neuronal cells is thought to occur by apoptosis. In this study, we evaluated whether TUDCA can reduce brain injury and improve neurological function after ICH in rats. Administration of TUDCA before or up to 6 h after stereotaxic collagenase injection into the striatum reduced lesion volumes at 2 days by as much as 50%. Apoptosis was ≈50% decreased in the area immediately surrounding the hematoma and was associated with a similar inhibition of caspase activity. These changes were also associated with improved neurobehavioral deficits as assessed by rotational asymmetry, limb placement, and stepping ability. Furthermore, TUDCA treatment modulated expression of certain Bcl-2 family members, as well as NF-κB activity. In addition to its protective action at the mitochondrial membrane, TUDCA also activated the Akt-1/protein kinase Bα survival pathway and induced Bad phosphorylation at Ser-136. In conclusion, reduction of brain injury underlies the wide-range neuroprotective effects of TUDCA after ICH. Thus, given its clinical safety, TUDCA may provide a potentially useful treatment in patients with hemorrhagic stroke and perhaps other acute brain injuries associated with cell death by apoptosis. PMID:12721362

  7. Acute exacerbation of COPD: is it the “stroke of the lungs”?

    PubMed Central

    Hillas, Georgios; Perlikos, Fotis; Tzanakis, Nikolaos

    2016-01-01

    Chronic obstructive pulmonary disease (COPD) is one of the top five major causes of morbidity and mortality worldwide. Despite worldwide health care efforts, costs, and medical research, COPD figures demonstrate a continuously increasing tendency in mortality. This is contrary to other top causes of death, such as neoplasm, accidents, and cardiovascular disease. A major factor affecting COPD-related mortality is the acute exacerbation of COPD (AECOPD). Exacerbations and comorbidities contribute to the overall severity in individual patients. Despite the underestimation by the physicians and the patients themselves, AECOPD is a really devastating event during the course of the disease, similar to acute myocardial infarction in patients suffering from coronary heart disease. In this review, we focus on the evidence that supports the claim that AECOPD is the “stroke of the lungs”. AECOPD can be viewed as: a Semicolon or disease’s full-stop period, Triggering a catastrophic cascade, usually a Relapsing and Overwhelming event, acting as a Killer, needing Emergent treatment. PMID:27471380

  8. Role of Diffusion-weighted Imaging in Acute Stroke Management using Low-field Magnetic Resonance Imaging in Resource-limited Settings

    PubMed Central

    Okorie, Chinonye K; Ogbole, Godwin I; Owolabi, Mayowa O; Ogun, Olufunmilola; Adeyinka, Abiodun; Ogunniyi, Adesola

    2015-01-01

    A variety of imaging modalities exist for the diagnosis of stroke. Several studies have been carried out to ascertain their contribution to the management of acute stroke and to compare the benefits and limitations of each modality. Diffusion-weighted imaging (DWI) has been described as the optimal imaging technique for diagnosing acute ischemic stroke, yet limited evidence is available on the value of DWI in the management of ischemic stroke with low-field magnetic resonance (MR) systems. Although high-field MR imaging (MRI) is desirable for DWI, low-field scanners provide an acceptable clinical compromise which is of importance to developing countries posed with the challenge of limited availability of high-field units. The purpose of this paper was to systematically review the literature on the usefulness of DWI in acute stroke management with low-field MRI scanners and present the experience in Nigeria. PMID:26709342

  9. [Efficacy and safety of the combined therapy with citicholine and actovegin in the acute period of ischemic stroke].

    PubMed

    Shamalov, N A; Stakhovskaia, L V; Shetova, I M; Efremova, N M; Anisimov, K V

    2010-01-01

    One hundred and four patients with acute carotid ischemic stroke were included in the study. Patients were divided into 4 groups. Patients of control group (group 1) were treated with equal basic and reperfusional therapy without any cytoprotectors. Patients of the 2nd group received citicholine in dose 1000 mg per day. Patients of the 3rd group were treated with 250 ml actovegin per day. The NIH stroke scale, the modified Rankin scale and the Barthel index were used to assess neurological status dynamics. The significant decrease of neurological deficit and improvement of functional recovery were seen in patients treated both with citicholine and actovegin (p < 0.005) to the 30th day compared to the control group. There was a trend towards the decrease of brain infarction volume within 5 days after stroke in patients of the 4th group. No side-effects of citicholine and actovegin were found. PMID:21462435

  10. Acute ischemic stroke treated with intravenous tissue plasminogen activator in a patient taking dabigatran with radiographic evidence of recanalization.

    PubMed

    Sangha, Navdeep; El Khoury, Ramy; Misra, Vivek; Lopez, George

    2012-11-01

    Dabigatran etexelate is a new oral direct thrombin inhibitor that has been approved by the US Food and Drug Administration to prevent stroke in patients with nonvalvular atrial fibrillation. A 51-year-old man with a history of atrial fibrillation who was taking dabigatran presented with an acute ischemic stroke. The patient had a normal international normalized ratio, activated partial thromboplastin time, and an elevated thrombin time of 26.4 seconds. Recanalization of the middle cerebral artery with intravenous tissue plasminogen activator was apparent on digital subtraction angiography, and there was no evidence of intracerebral hemorrhage on the repeat computed tomographic scan. This is the first report of a patient who was taking dabigatran etexilate and who had an ischemic stroke caused by a middle cerebral artery occlusion, with an elevated thrombin time and radiographic recanalization with intravenous tissue plasminogen activator without evidence of hemorrhagic transformation. PMID:22683118

  11. Combined neurothrombectomy or thrombolysis with adjunctive delivery of 3K3A-activated protein C in acute ischemic stroke

    PubMed Central

    Amar, Arun Paul; Griffin, John H.; Zlokovic, Berislav V.

    2015-01-01

    In the treatment of acute ischemic stroke (AIS), vessel recanalization correlates with improved functional status and reduced mortality. Mechanical neurothrombectomy achieves a higher likelihood of revascularization than intravenous thrombolysis (IVT), but there remains significant discrepancy between rates of recanalization and rates of favorable outcome. The poor neurological recovery among some stroke patients despite successful recanalization confirms the need for adjuvant therapy, such as pharmacological neuroprotection. Prior clinical trials of neuroprotectant drugs failed perhaps due to inability of the agent to reach the ischemic tissue beyond the occluded artery. A protocol that couples mechanical neurothrombectomy with concurrent delivery of a neuroprotectant overcomes this pitfall. Activated protein C (APC) exerts pleiotropic anti-inflammatory, anti-apoptotic, antithrombotic, cytoprotective, and neuroregenerative effects in stroke and appears a compelling candidate for this novel approach. PMID:26388732

  12. Procedural Predictors of Outcome in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

    SciTech Connect

    Rai, Ansaar T. Jhadhav, Yahodeep; Domico, Jennifer; Hobbs, Gerald R.

    2012-12-15

    Purpose: To identify factors impacting outcome in patients undergoing interventions for acute ischemic stroke (AIS). Materials and Methods: This was a retrospective analysis of patients undergoing endovascular therapy for AIS secondary during a 30 month period. Outcome was based on modified Rankin score at 3- to 6-month follow-up. Recanalization was defined as Thrombolysis in myocardial infarction score 2 to 3. Collaterals were graded based on pial circulation from the anterior cerebral artery either from an ipsilateral injection in cases of middle cerebral artery (MCA) occlusion or contralateral injection for internal carotid artery terminus (ICA) occlusion as follows: no collaterals (grade 0), some collaterals with retrograde opacification of the distal MCA territory (grade 1), and good collaterals with filling of the proximal MCA (M2) branches or retrograde opacification up to the occlusion site (grade 2). Occlusion site was divided into group 1 (ICA), group 2 (MCA with or without contiguous M2 involvement), and group 3 (isolated M2 or M3 branch occlusion). Results: A total of 89 patients were studied. Median age and National Institutes of health stroke scale (NIHSS) score was 71 and 15 years, respectively. Favorable outcome was seen in 49.4% of patients and mortality in 25.8% of patients. Younger age (P = 0.006), lower baseline NIHSS score (P = 0.001), successful recanalization (P < 0.0001), collateral support (P = 0.0008), distal occlusion (P = 0.001), and shorter procedure duration (P = 0.01) were associated with a favorable outcome. Factors affecting successful recanalization included younger age (P = 0.01), lower baseline NIHSS score (P = 0.05), collateral support (P = 0.01), and shorter procedure duration (P = 0.03). An ICA terminus occlusion (P < 0.0001), lack of collaterals (P = 0.0003), and unsuccessful recanalization (P = 0.005) were significantly associated with mortality. Conclusion: Angiographic findings and preprocedure variables can help

  13. Homocysteine Level Is Associated with White Matter Hyperintensity Locations in Patients with Acute Ischemic Stroke

    PubMed Central

    Song, Bo; Qin, Jie; Fang, Hui; Ji, Yan; Zhang, Rui; Sun, Shilei; Xu, Yuming

    2015-01-01

    Background and Purpose The relationship between plasma level of total homocysteine (tHcy) and white matter hyperintensities (WMHs), especially in patients with acute ischemic stroke (AIS), is controversial. The present study investigated the association between these two as well as WMH locations in a large cohort of patients with AIS. Methods Consecutive patients were reviewed from a prospective ischemic stroke database. Clinical data, including tHcy level and WMHs, were assessed. WMHs were assessed using the Fazekas scale and Age-Related White Matter Changes (ARWMC) visual grading scale. The association between tHcy and WMH locations was investigated by using multivariate logistic regression analyses. Results A total of 923 out of 1,205 patients were examined. The average age was 58.9 ± 11.9 years; 31.6% were female. Elevated tHcy level was significantly associated with WMHs. For the highest tHcy quartile, the odds ratio (OR) (95% confidence interval; CI) was 1.891 (1.257; 2.843) according to the Fazekas scale and 1.781 (1.185; 2.767) according to the ARWMC scale when compared to the lowest quartile. However, in a subgroup analysis, only WMHs in the periventricular area and left or right frontal areas were found to be independently associated with tHcy level. For the highest tHcy quartile, the OR (95% CI) was 1.761 (1.172; 2.648) for the periventricular WMHs, 1.768 (1.134; 2.756)for the left frontal WMHs, and 1.890 (1.206; 2.960)for the right frontal WMHs. Conclusions In patients with AIS, plasma tHcy level is related to WMHs, especially WMHs distributed within the periventricular and frontal areas. PMID:26641086

  14. A longitudinal study of hand motor recovery after sub-acute stroke: a study combined FMRI with diffusion tensor imaging.

    PubMed

    Wei, Wenjuan; Bai, Lijun; Wang, Jun; Dai, Ruwei; Tong, Raymond Kai-yu; Zhang, Yumei; Song, Zheng; Jiang, Wen; Shi, Chuanying; Li, Mengyuan; Ai, Lin; Tian, Jie

    2013-01-01

    Previous studies have shown that motor recovery of stroke can be assessed by the cortical activity and the structural integrity of the corticospinal tract (CST), but little is known about the relation between the cortical activity and the structural integrity during motor recovery. In the present study, we investigated the changes in brain activities evoked by twenty days' functional electrical stimulation (FES) training in twelve sub-acute stroke patients with unilateral upper-limb disability. We compared cortex activity evoked by wrist movement of eleven stroke patients to that of eleven age-matched healthy subjects to figure out how cortex activity changed after stroke. We also measured the structural integrity represented by the fractional anisotropy (FA) asymmetry of the posterior limb of the internal capsule (PLIC) to find the relationship between the brain activity and the structure integrity. In our study, we found that patients with sub-acute stroke have shown greater activity in the contralesional primary motor cortex (M1) during the affected hand's movement compared with healthy group, while the activity in ipsilesional M1 was decreased after the therapy compared to that before therapy, and the contralesional non-primary motor cortex showed greater activity after therapy. At the baseline we found that the positive correlation between the FA asymmetry of PLIC and the contralesional non-primary motor cortex activity showed that the greater damaged CST, the greater contralesional non-primary motor cortex recruited. While the negative correlation between them after the FES training indicates that after recovery the non-primary motor cortex plays different role in different stroke phases. Our study demonstrates that functional organization of a residual distributed motor system is related to the degree of disruption to the CST, and the non-primary motor areas plays an important role in motor recovery. PMID:23724030

  15. Inflammatory and metabolic markers and short-time outcome in patients with acute ischemic stroke in relation to TOAST subtypes.

    PubMed

    Lehmann, Marcio Francisco; Kallaur, Ana Paula; Oliveira, Sayonara Rangel; Alfieri, Daniela Frizon; Delongui, Franciele; de Sousa Parreira, Johnathan; de Araújo, Maria Caroline Martins; Rossato, Carolina; de Almeida, Jéssica Tavares; Pelegrino, Larissa Moliterno; Bragato, Erick Frank; Lehmann, Ana Lucia Cruz Fürstenberger; Morimoto, Helena Kaminami; Lozovoy, Marcell Alysson Batisti; Simão, Andrea Name Colado; Kaimen-Maciel, Damácio Ramon; Reiche, Edna Maria Vissoci

    2015-12-01

    The aim of this study was to evaluate the association between inflammatory and metabolic markers and short-time outcome with acute ischemic stroke subtypes. A total of 121 patients was classified according to TOAST criteria, such as large artery atherosclerosis (LAAS), lacunar infarct (LAC), cardioembolic infarct (CEI), other determined etiology (ODE), and undetermined etiology (UDE). The functional impairment was evaluated within the first eight hours of stroke and the outcome after three-month follow-up using the modified Rankin Scale. Blood samples were obtained up to 24 h of stroke. Compared with 96 controls, patients with LAAS, CEI, and LAC subtypes showed higher levels of white blood cells, high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6), metalloproteinase 9 (MMP-9), glucose, and iron (p < 0.05); and lower high-density lipoprotein cholesterol (HDL-C) (p < 0.0001); platelets, insulin, insulin resistance, and homocysteine were higher in LAC (p < 0.0001); ferritin was higher in LAAS (p < 0.0001); and total cholesterol (TC) was lower in LAAS and CEI (p < 0.01). When stroke subtypes were compared, insulin was higher in LAAS vs. LAC and in LAC vs. CEI (p < 0.05); and TC was lower in LAAS vs. LAC (p < 0.05). Outcome and rate of mortality after three-month were higher in LAAS vs. LAC (p < 0.001 and p = 0.0391 respectively). The results underscored the important role of the inflammatory response and metabolic changes in the pathogenesis of ischemic stroke subtypes that might be considered on the initial evaluation of stroke patients to identify those that could benefit with individualized therapeutic strategies that taken into account these markers after acute ischemic event. PMID:26359121

  16. Ischemic Stroke.

    PubMed

    Capriotti, Teri; Murphy, Teresa

    2016-05-01

    Each year, more than 795,000 people in the United States suffer a stroke and by 2030, it is estimated that 4% of the U.S. population will have had a stroke. Home healthcare clinicians will be increasingly called upon to assist stroke survivors and their caregivers adjust to disability and assist the survivor during their reintegration into the community. Therapeutic modalities are changing with advanced technology. Great strides are being made in the treatment of acute stroke; particularly endovascular interventions. More patients are surviving the acute stroke event and therefore will need to learn how to live with various degrees of disability. It is important for home healthcare clinicians to understand the process from acute event to medical stabilization, and from rehabilitation to long-term adaptation. PMID:27145407

  17. Study design for the FEASt trial: a randomized controlled intervention for improving dysphagia after acute ischemic stroke

    PubMed Central

    Marchina, Sarah; Schlaug, Gottfried; Kumar, Sandeep

    2014-01-01

    Background Dysphagia is a major stroke complication but lacks effective therapy that can facilitate the course of recovery. Non-invasive brain-stimulation with and without peripheral sensorimotor activities may be an attractive treatment option for swallowing recovery but has not been systematically investigated in the stroke population. Objective To describe the rationale and methodology for the first prospective, single-center, double-blinded trial of anodal versus sham transcranial direct current stimulation (tDCS) used in combination with swallowing exercises in patients with dysphagia from an acute ischemic stroke. The aim of this study is to gather safety data on cumulative sessions of tDCS in acute-subacute phases of stroke, obtain information about effects of this intervention on important physiological and clinically relevant swallowing parameters, and examine possible dose effects. Methods 99 consecutive patients with dysphagia from an acute unilateral hemispheric infarction with a Penetration and Aspiration Scale (PAS) score ≥ 4 and without other confounding reasons for dysphagia will be enrolled at a single tertiary care center. Subjects will be randomized to either a high or low dose tDCS or a sham group and will undergo 10 sessions over 5 consecutive days concomitantly with effortful swallowing maneuvers. The main efficacy measures are a change in the PAS score before and after treatment; the main safety measures are mortality, seizures, neurological, motor and swallowing deterioration. Conclusion The knowledge gained from this study will help plan a larger confirmatory trial for treating stroke related dysphagia and advance our understanding of important covariates influencing swallowing recovery and response to the proposed intervention. PMID:25534369

  18. Generalization of the Right Acute Stroke Prevention Strategies in Reducing in-Hospital Delays

    PubMed Central

    Ji, Xun-ming; Cheng, Wei-yang; Feng, Juan; Wu, Jian; Ma, Qing-feng

    2016-01-01

    The aim of this study was to reduce the door-to-needle (DTN) time of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) through a comprehensive, hospital-based implementation strategy. The intervention involved a systemic literature review, identifying barriers to rapid IVT treatment at our hospital, setting target DTN time intervals, and building an evolving model for IVT candidate selection. The rate of non-in-hospital delay (DTN time ≤ 60 min) was set as the primary endpoint. A total of 348 IVT cases were enrolled in the study (202 and 146 in the pre- and post-intervention group, respectively). The median age was 61 years in both groups; 25.2% and 26.7% of patients in the pre- and post-intervention groups, respectively, were female. The post-intervention group had higher rates of dyslipidemia and minor stroke [defined as National Institutes of Health Stroke Scale (NIHSS) ≤ 3]; less frequent atrial fibrillation; higher numbers of current smokers, heavy drinkers, referrals, and multi-model head imaging cases; and lower NIHSS scores and blood sugar level (all P < 0.05). All parameters including DTN, door-to-examination, door-to-imaging, door-to-laboratory, and final-test-to-needle times were improved post-intervention (all P < 0.05), with net reductions of 63, 2, 4, 28, and 23 min, respectively. The rates of DTN time ≤ 60 min and onset-to-needle time ≤ 180 min were significantly improved by the intervention (pre: 9.9% vs. post: 60.3%; P < 0.001 and pre: 23.3% vs. post: 53.4%; P < 0.001, respectively), which was accompanied by an increase in the rate of neurological improvement (pre: 45.5% vs. post: 59.6%; P = 0.010), while there was no change in incidence of mortality or systemic intracranial hemorrhage at discharge (both P > 0.05). These findings indicate that it is possible to achieve a DTN time ≤ 60 min for up to 60% of hospitals in the current Chinese system, and that this logistical change can yield a notable improvement in the outcome of

  19. Acute stroke treatment in the community: improving our performance and expanding our options.

    PubMed

    Russman, Andrew N; Katzan, Irene L

    2005-12-01

    Three-quarters of all strokes are managed outside of academic medical centers, making optimization of stroke care in the community setting a central part of minimizing the disability from stroke. In addition, the care of stroke patients crosses multiple different components of the health care system and requires a multifaceted and coordinated approach. This article reviews the current status of stroke care across the care continuum and reviews methods found to be effective in educating the public and organizing regional delivery of hyperacute stroke care. Successful community-based stroke care models and current national initiatives in improving hospital management are discussed. Local implementation of these strategies provides an exciting opportunity to improve outcomes after stroke. PMID:16341990

  20. Optical bedside monitoring of cerebral perfusion: technological and methodological advances applied in a study on acute ischemic stroke

    NASA Astrophysics Data System (ADS)

    Steinkellner, Oliver; Gruber, Clemens; Wabnitz, Heidrun; Jelzow, Alexander; Steinbrink, Jens; Fiebach, Jochen B.; MacDonald, Rainer; Obrig, Hellmuth

    2010-11-01

    We present results of a clinical study on bedside perfusion monitoring of the human brain by optical bolus tracking. We measure the kinetics of the contrast agent indocyanine green using time-domain near-IR spectroscopy (tdNIRS) in 10 patients suffering from acute unilateral ischemic stroke. In all patients, a delay of the bolus over the affected when compared to the unaffected hemisphere is found (mean: 1.5 s, range: 0.2 s to 5.2 s). A portable time-domain near-IR reflectometer is optimized and approved for clinical studies. Data analysis based on statistical moments of time-of-flight distributions of diffusely reflected photons enables high sensitivity to intracerebral changes in bolus kinetics. Since the second centralized moment, variance, is preferentially sensitive to deep absorption changes, it provides a suitable representation of the cerebral signals relevant for perfusion monitoring in stroke. We show that variance-based bolus tracking is also less susceptible to motion artifacts, which often occur in severely affected patients. We present data that clearly manifest the applicability of the tdNIRS approach to assess cerebral perfusion in acute stroke patients at the bedside. This may be of high relevance to its introduction as a monitoring tool on stroke units.

  1. Deficit in automatic sound-change detection may underlie some music perception deficits after acute hemispheric stroke.

    PubMed

    Kohlmetz, C; Altenmüller, E; Schuppert, M; Wieringa, B M; Münte, T F

    2001-01-01

    Music perception deficits following acute neurological damage are thought to be rare. By a newly devised test battery of music-perception skills, however, we were able to identify among a group of 12 patients with acute hemispheric stroke six patients with music perception deficits (amusia) while six others had no such deficits. In addition we recorded event-related brain potentials (ERPs) in a passive listening task with frequent standard and infrequent pitch deviants designed to elicit the mismatch negativity (MMN). The MMN in the patients with amusia was grossly reduced, while the non-amusic patients and control subjects had MMNs of equal size. These data show that amusia is quite common in unselected stroke patients. The MMN reduction suggests that amusia is related to unspecific automatic stimulus classification deficits in these patients. PMID:11527548

  2. Effect of forced use of the lower extremity on gait performance and mobility of post-acute stroke patients

    PubMed Central

    Yu, Wen-Hsiu; Liu, Wen-Yu; Wong, Alice May-Kuen; Wang, Tzu-Chi; Li, Yen-Chen; Lien, Hen-Yu

    2015-01-01

    [Purpose] The purpose of this study was to investigate the effects of a forced-use training program on gait, mobility and quality of life of post-acute stroke patients. [Subjects] Twenty-one individuals with unilateral stroke participated in this study. All participants had suffered from first-ever stroke with time since onset of at least 3 months. [Methods] A single-blinded, non-equivalent, pre-post controlled design with 1-month follow-up was adopted. Participants received either a forced-use or a conventional physical therapy program for 2 weeks. The main outcomes assessed were preferred and fastest walking velocities, spatial and temporal symmetry indexes of gait, the timed up and go test, the Rivermead Mobility Index, and the Stroke-Specific Quality of Life Scale (Taiwan version). [Results] Forced-use training induced greater improvements in gait and mobility than conventional physical therapy. In addition, compared to pre-training, patients in the conventional physical therapy group walked faster but more asymmetrically after training. However, neither program effectively improved in-hospital quality of life. [Conclusion] The forced-use approach can be successfully applied to the lower extremities of stroke patients to improve mobility, walking speeds and symmetry of gait. PMID:25729182

  3. Post–Acute Care Data for Predicting Readmission After Ischemic Stroke: A Nationwide Cohort Analysis Using the Minimum Data Set

    PubMed Central

    Fehnel, Corey R; Lee, Yoojin; Wendell, Linda C; Thompson, Bradford B; Potter, N Stevenson; Mor, Vincent

    2015-01-01

    Background Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post–acute care database would improve prediction modeling. Methods and Results Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post–acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92). Conclusions Individual clinical characteristics from the post–acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission. PMID:26396202

  4. Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

    PubMed Central

    Hong, Keun-Sik; Ko, Sang-Bae; Yu, Kyung-Ho; Jung, Cheolkyu; Park, Sukh Que; Kim, Byung Moon; Chang, Chul-Hoon; Bae, Hee-Joon; Heo, Ji Hoe; Oh, Chang Wan; Lee, Byung-Chul; Kim, Bum-Tae; Kim, Bum-soo; Chung, Chin-Sang; Yoon, Byung-Woo; Rha, Joung-Ho

    2016-01-01

    Patients with severe stroke due to acute large cerebral artery occlusion are likely to be severely disabled or dead without timely reperfusion. Previously, intravenous tissue plasminogen activator (IV-TPA) within 4.5 hours after stroke onset was the only proven therapy, but IV-TPA alone does not sufficiently improve the outcome of patients with acute large artery occlusion. With the introduction of the advanced endovascular therapy, which enables more fast and more successful recanalization, recent randomized trials consecutively and consistently demonstrated the benefit of endovascular recanalization therapy (ERT) when added to IV-TPA. Accordingly, to update the recommendations, we assembled members of the writing committee appointed by the Korean Stroke Society, the Korean Society of Interventional Neuroradiology, and the Society of Korean Endovascular Neurosurgeons. Reviewing the evidences that have been accumulated, the writing members revised recommendations, for which formal consensus was achieved by convening a panel composed of 34 experts from the participating academic societies. The current guideline provides the evidence-based recommendations for ERT in patients with acute large cerebral artery occlusion regarding patient selection, treatment modalities, neuroimaging evaluation, and system organization. PMID:26846761

  5. Left ventricular apical thrombus after systemic thrombolysis with recombinant tissue plasminogen activator in a patient with acute ischemic stroke

    PubMed Central

    Doepp, Florian; Sanad, Wasiem; Schreiber, Stephan J; Baumann, Gert; Borges, Adrian C

    2005-01-01

    Background Thrombolysis with recombinant tissue plasminogen activator (rtPA) is an established treatment in acute stroke. To prevent rethrombosis after rtPA therapy, secondary anticoagulation with heparin is commonly performed. However, the recommended time-point and extent of heparin treatment vary and are not well investigated. Case presentation We report a 61-year-old man who developed an acute global aphasia and right-sided hemiparesis. Cranial CT was normal and systemic thrombolytic therapy with tPA was started 120 minutes after symptom onset. Low-dose subcutaneous heparin treatment was initiated 24 hours later. Transthoracic echocardiography (TTE) 12 hours after admission showed slightly reduced left ventricular ejection fraction (LVEF) but was otherwise normal. 48 hours later the patient suddenly deteriorated with clinical signs of dyspnea and tachycardia. TTE revelead a large left ventricular apical thrombus as well as a reduction of LVEF to 20 %. Serial further TTE investigations demonstrated a complete resolution of the thrombus and normalisation of LVEF within two days. Conclusion Our case demonstrates an intracardiac thrombus formation following rtPA treatment of acute stroke, probably caused by secondary hypercoagulability. Rethrombosis or new thrombus formation might be an underestimated complication of rtPA therapy and potentially explain cases of secondary stroke progression. PMID:15918893

  6. Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke.

    PubMed

    Hong, Keun-Sik; Ko, Sang-Bae; Yu, Kyung-Ho; Jung, Cheolkyu; Park, Sukh Que; Kim, Byung Moon; Chang, Chul-Hoon; Bae, Hee-Joon; Heo, Ji Hoe; Oh, Chang Wan; Lee, Byung-Chul; Kim, Bum-Tae; Kim, Bum-Soo; Chung, Chin-Sang; Yoon, Byung-Woo; Rha, Joung-Ho

    2016-01-01

    Patients with severe stroke due to acute large cerebral artery occlusion are likely to be severely disabled or dead without timely reperfusion. Previously, intravenous tissue plasminogen activator (IV-TPA) within 4.5 hours after stroke onset was the only proven therapy, but IV-TPA alone does not sufficiently improve the outcome of patients with acute large artery occlusion. With the introduction of the advanced endovascular therapy, which enables more fast and more successful recanalization, recent randomized trials consecutively and consistently demonstrated the benefit of endovascular recanalization therapy (ERT) when added to IV-TPA. Accordingly, to update the recommendations, we assembled members of the writing committee appointed by the Korean Stroke Society, the Korean Society of Interventional Neuroradiology, and the Society of Korean Endovascular Neurosurgeons. Reviewing the evidences that have been accumulated, the writing members revised recommendations, for which formal consensus was achieved by convening a panel composed of 34 experts from the participating academic societies. The current guideline provides the evidence-based recommendations for ERT in patients with acute large cerebral artery occlusion regarding patient selection, treatment modalities, neuroimaging evaluation, and system organization. PMID:26846761

  7. CD28 superagonist-mediated boost of regulatory T cells increases thrombo-inflammation and ischemic neurodegeneration during the acute phase of experimental stroke.

    PubMed

    Schuhmann, Michael K; Kraft, Peter; Stoll, Guido; Lorenz, Kristina; Meuth, Sven G; Wiendl, Heinz; Nieswandt, Bernhard; Sparwasser, Tim; Beyersdorf, Niklas; Kerkau, Thomas; Kleinschnitz, Christoph

    2015-01-01

    While the detrimental role of non-regulatory T cells in ischemic stroke is meanwhile unequivocally recognized, there are controversies about the properties of regulatory T cells (Treg). The aim of this study was to elucidate the role of Treg by applying superagonistic anti-CD28 antibody expansion of Treg. Stroke outcome, thrombus formation, and brain-infiltrating cells were determined on day 1 after transient middle cerebral artery occlusion. Antibody-mediated expansion of Treg enhanced stroke size and worsened functional outcome. Mechanistically, Treg increased thrombus formation in the cerebral microvasculature. These findings confirm that Treg promote thrombo-inflammatory lesion growth during the acute stage of ischemic stroke. PMID:25315859

  8. Diagnostic value of Hoover sign and motor-evoked potentials in acute somatoform unilateral weakness and sensory impairment mimicking vascular stroke.

    PubMed

    Shahar, Eli; Ravid, Sarit; Hafner, Hava; Chistyakov, Andrei; Shcif, Aharon

    2012-07-01

    Acute unilateral weakness along with sensory impairment is commonly caused by obstruction of major cortical arteries in either adults or children. A somatoform presentation mimicking acute vascular stroke is very rare, especially in the pediatric age group. Here we report three adolescents presenting with acute unilateral weakness and sensory impairment along with diminished tendon reflexes who were suspected to have an acute stroke but who had developed a somatoform psychogenic disorder. Two adolescents had complete hemiplegia and one had weakness of the left leg - two had moved the alleged paralytic limbs during sleep. A normal Hoover sign was suggestive of a somatoform psychogenic etiology rather than true vascular stroke. Cortical and spinal MRI, motor-evoked potentials (MEP) and somatosensory-evoked potentials were normal. All adolescents recovered completely. Therefore, a somatoform conversion reaction should be considered in children presenting with acute unilateral weakness and sensory alterations, which is corroborated by a normal Hoover sign and intact MEP. PMID:22537658

  9. Imaging Evidence for Cerebral Hyperperfusion Syndrome after Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

    PubMed Central

    Zhang, Yi

    2016-01-01

    Background. Cerebral hyperperfusion syndrome (CHS), a rare complication after cerebral revascularization, is a well-described phenomenon after carotid endarterectomy or carotid artery stenting. However, the imaging evidence of CHS after intravenous tissue plasminogen activator (iv tPA) for acute ischemic stroke (AIS) has not been reported. Case Report. Four patients were determined to have manifestations of CHS with clinical deterioration after treatment with iv tPA, including one patient who developed seizure, one patient who had a deviation of the eyes toward lesion with worsened mental status, and two patients who developed worsened hemiparesis. In all four patients, postthrombolysis head CT examinations were negative for hemorrhage; CT angiogram showed patent cervical and intracranial arterial vasculature; CT perfusion imaging revealed hyperperfusion with increased relative cerebral blood flow and relative cerebral blood volume and decreased mean transit time along with decreased time to peak in the clinically related artery territory. Vascular dilation was also noted in three of these four cases. Conclusions. CHS should be considered in patients with clinical deterioration after iv tPA and imaging negative for hemorrhage. Cerebral angiogram and perfusion studies can be useful in diagnosing CHS thereby helping with further management. PMID:27242938

  10. Quantitative permeability magnetic resonance imaging in acute ischemic stroke: how long do we need to scan?

    PubMed

    Vidarsson, Logi; Thornhill, Rebecca E; Liu, Fang; Mikulis, David J; Kassner, Andrea

    2009-11-01

    Blood-brain barrier (BBB) permeability estimation with dynamic contrast-enhanced MRI (DCE-MRI) has shown significant potential for predicting hemorrhagic transformation (HT) in patients presenting with acute ischemic stroke (AIS). In this work, the effects of scan duration on quantitative BBB permeability estimates (KPS) were investigated. Data from eight patients (three with HT) aged 37-93 years old were retrospectively studied by directly calculating the standard deviation of KPS as a function of scan time. The uncertainty in KPS was reduced only slightly for a scan time of 3 min and 30 s (4% reduction in P value from .047 to .045). When more than 3 min and 30 s of data were used, quantitative permeability MRI was able to separate those patients who proceeded to HT from those who did not (P value <.05). Our findings indicate that reducing permeability acquisition times is feasible in keeping with the need to maintain time-efficient MR protocols in the setting of AIS. PMID:19695816

  11. Current concepts on magnetic resonance imaging (MRI) perfusion-diffusion assessment in acute ischaemic stroke: a review & an update for the clinicians.

    PubMed

    Roldan-Valadez, Ernesto; Lopez-Mejia, Mariana

    2014-12-01

    Recently, several medical societies published joint statements about imaging recommendations for acute stroke and transient ischaemic attack patients. In following with these published guidelines, we considered it appropriate to present a brief, practical and updated review of the most relevant concepts on the MRI assessment of acute stroke. Basic principles of the clinical interpretation of diffusion, perfusion, and MRI angiography (as part of a global MRI protocol) are discussed with accompanying images for each sequence. Brief comments on incidence and differential diagnosis are also included, together with limitations of the techniques and levels of evidence. The purpose of this article is to present knowledge that can be applied in day-to-day clinical practice in specialized stroke units or emergency rooms to attend patients with acute ischaemic stroke or transient ischaemic attack according to international standards. PMID:25758570

  12. Validity of Acute Stroke Lesion Volume Estimation by Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomographic Score Depends on Lesion Location in 496 Patients With Middle Cerebral Artery Stroke

    PubMed Central

    Schröder, Julian; Cheng, Bastian; Ebinger, Martin; Köhrmann, Martin; Wu, Ona; Kang, Dong-Wha; Liebeskind, David S.; Tourdias, Thomas; Singer, Oliver C.; Christensen, Soren; Campbell, Bruce; Luby, Marie; Warach, Steven; Fiehler, Jens; Fiebach, Jochen B.; Gerloff, Christian; Thomalla, Götz

    2016-01-01

    Background and Purpose Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) has been used to estimate diffusion-weighted imaging (DWI) lesion volume in acute stroke. We aimed to assess correlations of DWI-ASPECTS with lesion volume in different middle cerebral artery (MCA) subregions and reproduce existing ASPECTS thresholds of a malignant profile defined by lesion volume ≥100 mL. Methods We analyzed data of patients with MCA stroke from a prospective observational study of DWI and fluid-attenuated inversion recovery in acute stroke. DWI-ASPECTS and lesion volume were calculated. The population was divided into subgroups based on lesion localization (superficial MCA territory, deep MCA territory, or both). Correlation of ASPECTS and infarct volume was calculated, and receiver-operating characteristics curve analysis was performed to identify the optimal ASPECTS threshold for ≥100-mL lesion volume. Results A total of 496 patients were included. There was a significant negative correlation between ASPECTS and DWI lesion volume (r=−0.78; P<0.0001). With regards to lesion localization, correlation was weaker in deep MCA region (r=−0.19; P=0.038) when compared with superficial (r=−0.72; P<0.001) or combined superficial and deep MCA lesions (r=−0.72; P<0.001). Receiver-operating characteristics analysis revealed ASPECTS≤6 as best cutoff to identify ≥100-mL DWI lesion volume; however, positive predictive value was low (0.35). Conclusions ASPECTS has limitations when lesion location is not considered. Identification of patients with malignant profile by DWI-ASPECTS may be unreliable. ASPECTS may be a useful tool for the evaluation of noncontrast computed tomography. However, if MRI is used, ASPECTS seems dispensable because lesion volume can easily be quantified on DWI maps. PMID:25316278

  13. A new electromechanical trainer for sensorimotor rehabilitation of paralysed fingers: A case series in chronic and acute stroke patients

    PubMed Central

    Hesse, Stefan; Kuhlmann, H; Wilk, J; Tomelleri, C; Kirker, Stephen GB

    2008-01-01

    Background The functional outcome after stroke is improved by more intensive or sustained therapy. When the affected hand has no functional movement, therapy is mainly passive movements. A novel device for repeating controlled passive movements of paralysed fingers has been developed, which will allow therapists to concentrate on more complicated tasks. A powered cam shaft moves the four fingers in a physiological range of movement. Methods After refining the training protocol in 2 chronic patients, 8 sub-acute stroke patients were randomised to receive additional therapy with the Finger Trainer for 20 min every work day for four weeks, or the same duration of bimanual group therapy, in addition to their usual rehabilitation. Results In the chronic patients, there was a sustained reduction in finger and wrist spasticity, but there was no improvement in active movements. In the subacute patients, mean distal Fugl-Meyer score (0–30) increased in the control group from 1.25 to 2.75 (ns) and 0.75 to 6.75 in the treatment group (p < .05). Median Modified Ashworth score increased 0/5 to 2/5 in the control group, but not in the treatment group, 0 to 0. Only one patient, in the treatment group, regained function of the affected hand. No side effects occurred. Conclusion Treatment with the Finger Trainer was well tolerated in sub-acute & chronic stroke patients, whose abnormal muscle tone improved. In sub-acute stroke patients, the Finger Trainer group showed small improvements in active movement and avoided the increase in tone seen in the control group. This series was too small to demonstrate any effect on functional outcome however. PMID:18771581

  14. Development of clinical practice guidelines for urinary continence care of adult stroke survivors in acute and rehabilitation settings.

    PubMed

    Fisher, Andrea R

    2014-01-01

    This study developed evidence-based clinical practice guidelines for the urinary continence care of adult stroke survivors in acute and rehabilitation settings. The research team conducted a comprehensive review of the literature on urinary continence interventions and outcomes. The team then developed a set of recommendations outlined in the resulting clinical practice guidelines titled Clinical Practice Guidelines (CPGs) for the Urinary Continence Care of Stroke Survivors in Acute and Rehabilitation Settings. The evaluation of the CPGs consisted of a two-part assessment and pilot implementation. An expert panel of 25 local and regional experts in stroke and continence care assessed the proposed CPGs. This assessment consisted of two stages: a) evaluating the guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE) Instrument (http://www. agreetrust.org); and, b) conducting focus groups to identify barriers and facilitators to the implementation of the guidelines using the Ottawa Model of Research Use (OMRU). Results from the expert panel assessments/feedback contributed to the refinement of the CPGs as well as identification and construction of implementation strategies. Two sites conducted a three-month pilot implementation of three recommendations from the CPGs as selected by each site. The two inpatient sites were a rehabilitation setting and a mixed acute and rehabilitation setting. The implementation of the CPGs included the development of learning strategies tailored to the needs of each site and in addition to the creation of an online self-learning portal. This study assessed nurses' knowledge, attitudes, and beliefs regarding urinary continence challenges using a survey before and after the pilot. Chart reviews before and after the pilot implementation audited the nurses' urinary continence practices for patients and uptake of the selected guidelines' recommendations. Study findings suggested the implementation of the CPGs

  15. Vascular Risk Factors and Diseases Modulate Deficits of Reward-Based Reversal Learning in Acute Basal Ganglia Stroke

    PubMed Central

    Wicking, Manon; Bellebaum, Christian; Hermann, Dirk M.

    2016-01-01

    Background Besides motor function, the basal ganglia have been implicated in feedback learning. In patients with chronic basal ganglia infarcts, deficits in reward-based reversal learning have previously been described. Methods We re-examined the acquisition and reversal of stimulus-stimulus-reward associations and acquired equivalence in eleven patients with acute basal ganglia stroke (8 men, 3 women; 57.8±13.3 years), whose performance was compared eleven healthy subjects of comparable age, sex distribution and education, who were recruited outside the hospital. Eleven hospitalized patients with a similar vascular risk profile as the stroke patients but without stroke history served as clinical control group. Results In a neuropsychological assessment 7±3 days post-stroke, verbal and spatial short-term and working memory and inhibition control did not differ between groups. Compared with healthy subjects, control patients with vascular risk factors exhibited significantly reduced performance in the reversal phase (F[2,30] = 3.47; p = 0.044; post-hoc comparison between risk factor controls and healthy controls: p = 0.030), but not the acquisition phase (F[2,30] = 1.01; p = 0.376) and the acquired equivalence (F[2,30] = 1.04; p = 0.367) tasks. In all tasks, the performance of vascular risk factor patients closely resembled that of basal ganglia stroke patients. Correlation studies revealed a significant association of the number of vascular risk factors with reversal learning (r = -0.33, p = 0.012), but not acquisition learning (r = -0.20, p = 0.121) or acquired equivalence (r = -0.22, p = 0.096). Conclusions The previously reported impairment of reward-based learning may be attributed to vascular risk factors and associated diseases, which are enriched in stroke patients. This study emphasizes the necessity of appropriate control subjects in cognition studies. PMID:27163585

  16. Comparison of the new ASCO classification with the TOAST classification in a population with acute ischemic stroke.

    PubMed

    Wolf, M E; Sauer, T; Alonso, A; Hennerici, M G

    2012-07-01

    Precise analysis of stroke subtypes is important for clinical treatment decisions, the prognostic evaluation of patients, as well as defining stroke populations in clinical studies. The TOAST classification is the most widely used and approved form for etiologic subtyping. Increasing knowledge about stroke mechanisms and the introduction of new diagnostic techniques have supported the promotion of the new ASCO phenotypic classification, which aims to characterize patients using different grades of evidence for stroke subtypes. We prospectively assigned 103 consecutive patients from our stroke center for subtype classification using ASCO and TOAST. Clinical features and complementary investigations were recorded according to our standardized acute stroke care protocol. Evidence grade 1 with ASCO was assessed in 12.62% for large artery disease (A), 23.30% small-vessel disease (S), 36.89% cardiac source (C) and 1.94% another cause (O). Evidence grades 1-3 were identified in 60.19% A, 75.73% S, 49.51% C, and 3.88% O. A total of 68.93% of the patients were classified in more than one category, and only 3.88% remained completely undetermined. The κ value for inter-rater agreement was 0.92-1. Using TOAST, the distribution was 9.71% A, 23.30% S, 34.95% C, 1.94% O, and 30.10% undetermined. The ASCO classification showed a good concordance with TOAST. The inter-rater agreement was high. The comprehensive character of ASCO allows the recording of important additional information. This may be helpful for a specific treatment adaptation in each individual patient and creation of different etiological profiles in view of adapted clinical trials. PMID:22146904

  17. Acute Ischemic Stroke Involving Both Anterior and Posterior Circulation Treated by Endovascular Revascularization for Acute Basilar Artery Occlusion via Persistent Primitive Trigeminal Artery

    PubMed Central

    Fujita, Atsushi; Hosoda, Kohkichi; Kohmura, Eiji

    2016-01-01

    We report a case of acute ischemic stroke involving both the anterior and posterior circulation associated with a persistent primitive trigeminal artery (PPTA), treated by endovascular revascularization for acute basilar artery (BA) occlusion via the PPTA. An otherwise healthy 67-year-old man experienced sudden loss of consciousness and quadriplegia. Magnetic resonance imaging showed an extensive acute infarction in the right cerebral hemisphere, and magnetic resonance angiography showed occlusion of the right middle cerebral artery (MCA) and BA. Because the volume of infarction in the territory of the right MCA was extensive, we judged the use of intravenous tissue plasminogen activator to be contraindicated. Cerebral angiography revealed hypoplasia of both vertebral arteries and the presence of a PPTA from the right internal carotid artery. A microcatheter was introduced into the BA via the PPTA and revascularization was successfully performed using a Merci Retriever with adjuvant low-dose intraarterial urokinase. After treatment, his consciousness level and right motor weakness improved. Although persistent carotid-vertebrobasilar anastomoses such as a PPTA are relatively rare vascular anomalies, if the persistent primitive artery is present, it can be an access route for mechanical thrombectomy for acute ischemic stroke. PMID:27446523

  18. Acute Ischemic Stroke Involving Both Anterior and Posterior Circulation Treated by Endovascular Revascularization for Acute Basilar Artery Occlusion via Persistent Primitive Trigeminal Artery.

    PubMed

    Imahori, Taichiro; Fujita, Atsushi; Hosoda, Kohkichi; Kohmura, Eiji

    2016-07-01

    We report a case of acute ischemic stroke involving both the anterior and posterior circulation associated with a persistent primitive trigeminal artery (PPTA), treated by endovascular revascularization for acute basilar artery (BA) occlusion via the PPTA. An otherwise healthy 67-year-old man experienced sudden loss of consciousness and quadriplegia. Magnetic resonance imaging showed an extensive acute infarction in the right cerebral hemisphere, and magnetic resonance angiography showed occlusion of the right middle cerebral artery (MCA) and BA. Because the volume of infarction in the territory of the right MCA was extensive, we judged the use of intravenous tissue plasminogen activator to be contraindicated. Cerebral angiography revealed hypoplasia of both vertebral arteries and the presence of a PPTA from the right internal carotid artery. A microcatheter was introduced into the BA via the PPTA and revascularization was successfully performed using a Merci Retriever with adjuvant low-dose intraarterial urokinase. After treatment, his consciousness level and right motor weakness improved. Although persistent carotid-vertebrobasilar anastomoses such as a PPTA are relatively rare vascular anomalies, if the persistent primitive artery is present, it can be an access route for mechanical thrombectomy for acute ischemic stroke. PMID:27446523

  19. Virtual monochromatic imaging in dual-source and dual-energy CT for visualization of acute ischemic stroke

    NASA Astrophysics Data System (ADS)

    Hara, Hidetake; Muraishi, Hiroshi; Matsuzawa, Hiroki; Inoue, Toshiyuki; Nakajima, Yasuo; Satoh, Hitoshi; Abe, Shinji

    2015-07-01

    We have recently developed a phantom that simulates acute ischemic stroke. We attempted to visualize an acute-stage cerebral infarction by using dual-energy Computed tomography (DECT) to obtain virtual monochromatic images of this phantom. Virtual monochromatic images were created by using DECT voltages from 40 to 100 keV in steps of 10 keV and from 60 to 80 keV in steps of 1 keV, under three conditions of the tube voltage with thin (Sn) filters. Calculation of the CNR values allowed us to evaluate the visualization of acute-stage cerebral infarction. The CNR value of a virtual monochromatic image was the highest at 68 keV under 80 kV / Sn 140 kV, at 72 keV under 100 kV / Sn 140 kV, and at 67 keV under 140 kV / 80 kV. The CNR values of virtual monochromatic images at voltages between 65 and 75 keV were significantly higher than those obtained for all other created images. Therefore, the optimal conditions for visualizing acute ischemic stroke were achievable.

  20. T2* “Susceptibility Vessel Sign” Demonstrates Clot Location and Length in Acute Ischemic Stroke

    PubMed Central

    Naggara, Olivier; Raymond, Jean; Domingo Ayllon, Montserrat; Al-Shareef, Fawaz; Touzé, Emmanuel; Chenoufi, Meriem; Gerber, Sophie; Mellerio, Charles; Zuber, Matthieu; Meder, Jean Francois; Mas, Jean-Louis; Oppenheim, Catherine

    2013-01-01

    Objectives The aim of our study was to evaluate, in acute ischemic stroke patients, the diagnostic accuracy of the MRI susceptibility vessel sign (SVS) against catheter angiography (DSA) for the detection of the clot and its value in predicting clot location and length. Materials and Methods We identified consecutive patients (2006–2012) admitted to our center, where 1.5 T MRI is systematically implemented as first-line diagnostic work-up, with: (1) pre-treatment 6-mm-thick multislice 2D T2* sequence; (2) delay from MRI-to-DSA <3 hrs; (3) no fibrinolysis between MRI and DSA. The location and length of SVS on T2* was independently assessed by three readers, and compared per patient, per artery and per segment, to DSA findings, obtained by two different readers. Clot length measured on T2* and DSA were compared using intra-class correlation coefficient (ICC), Bland & Altman test and Passing & Bablok regression analysis. Results On DSA, a clot was present in 85 patients, in 126 of 1190 (10.6%) arteries and 175 of 1870 (9.4%) segments. Sensitivity of the SVS, as sensed by the used protocol at 1.5 T, was 81.1% (69 of 85 patients) and was higher in anterior (55 of 63, 87.3%), than in posterior circulation stroke (14 of 22, 63.6%, p=0.02). Sensitivity/specificity was 69.8/99.6% (per artery) and 76.6/99.7% (per segment). Positive (PPV) and negative predictive value (NPV) and accuracy were all >94%. Inter- and intra-observer ICC was excellent for clot length as measured on T2* (ĸ ≥0.97) and as measured on DSA (ĸ ≥0.94). Correlation between T2* and DSA for clot length was excellent (ICC: 0.88, 95%CI: 0.81–0.92; Bland & Altman: mean bias of 1.6% [95%CI: -4.7 to 7.8%], Passing & Bablok: 0.91). Conclusions SVS is a specific marker of clot location in the anterior and posterior circulation. Clot length greater than 6 mm can be reliably measured on T2*. PMID:24146915

  1. Neural bases of imitation and pantomime in acute stroke patients: distinct streams for praxis.

    PubMed

    Hoeren, Markus; Kümmerer, Dorothee; Bormann, Tobias; Beume, Lena; Ludwig, Vera M; Vry, Magnus-Sebastian; Mader, Irina; Rijntjes, Michel; Kaller, Christoph P; Weiller, Cornelius

    2014-10-01

    Apraxia is a cognitive disorder of skilled movements that characteristically affects the ability to imitate meaningless gestures, or to pantomime the use of tools. Despite substantial research, the neural underpinnings of imitation and pantomime have remained debated. An influential model states that higher motor functions are supported by different processing streams. A dorso-dorsal stream may mediate movements based on physical object properties, like reaching or grasping, whereas skilled tool use or pantomime rely on action representations stored within a ventro-dorsal stream. However, given variable results of past studies, the role of the two streams for imitation of meaningless gestures has remained uncertain, and the importance of the ventro-dorsal stream for pantomime of tool use has been questioned. To clarify the involvement of ventral and dorsal streams in imitation and pantomime, we performed voxel-based lesion-symptom mapping in a sample of 96 consecutive left-hemisphere stroke patients (mean age ± SD, 63.4 ± 14.8 years, 56 male). Patients were examined in the acute phase after ischaemic stroke (after a mean of 5.3, maximum 10 days) to avoid interference of brain reorganization with a reliable lesion-symptom mapping as best as possible. Patients were asked to imitate 20 meaningless hand and finger postures, and to pantomime the use of 14 common tools depicted as line drawings. Following the distinction between movement engrams and action semantics, pantomime errors were characterized as either movement or content errors, respectively. Whereas movement errors referred to incorrect spatio-temporal features of overall recognizable movements, content errors reflected an inability to associate tools with their prototypical actions. Both imitation and pantomime deficits were associated with lesions within the lateral occipitotemporal cortex, posterior inferior parietal lobule, posterior intraparietal sulcus and superior parietal lobule. However, the areas

  2. Is 6-month GRACE risk score a useful tool to predict stroke after an acute coronary syndrome?

    PubMed Central

    Álvarez-Álvarez, Belén; Raposeiras-Roubín, Sergio; Abu-Assi, Emad; Cambeiro-González, Cristina; Gestal-Romaní, Santiago; López-López, Andrea; Bouzas-Cruz, Noelia; Castiñeira-Busto, María; Saidhodjayeva, Ozoda; Redondo-Diéguez, Alfredo; Pereira López, Eva; García-Acuña, José María; González-Juanatey, José Ramón

    2014-01-01

    Objectives The risk of stroke after an acute coronary syndrome (ACS) has increased. The aim of this study was to do a comparative validation of the 6-month GRACE (Global Registry of Acute Coronary Events) risk score and CH2DS2VASc risk score to predict the risk of post-ACS ischaemic stroke. Methods This was a retrospective study carried out in a single centre with 4229 patients with ACS discharged between 2004 and 2010 (66.9±12.8 years, 27.9% women, 64.2% underwent percutaneous coronary intervention). The primary end point is the occurrence of an ischaemic stroke during follow-up (median 4.6 years, IQR 2.7–7.1 years). Results 184 (4.4%) patients developed an ischaemic stroke; 153 (83.2%) had sinus rhythm and 31 (16.9%) had atrial fibrillation. Patients with stroke were older, with higher rates of hypertension, diabetes, previous stroke and previous coronary artery disease. The HR for CHA2DS2VASc was 1.36 (95% CI, 1.27 to 1.48, p<0.001) and for GRACE, HR was 1.02(95% CI, 1.01 to 1.03, p<0.001). Both risk scores show adequate discriminative ability (c-index 0.63±0.02 and 0.60±0.02 for CHA2DS2VASc and GRACE, respectively). In the reclassification method there was no difference (Net Reclassification Improvement 1.98%, p=0.69). Comparing moderate-risk/high-risk patients with low-risk patients, both risk scores showed very high negative predictive value (98.5% for CHA2DS2VASc, 98.1% for GRACE). The sensitivity of CHA2DS2VASc score was higher than the GRACE risk score (95.1% vs 87.0%), whereas specificity was lower (14.4% vs 30.2%). Conclusions The 6-month GRACE model is a clinical risk score that facilitates the identification of individual patients who are at high risk of ischaemic stroke after ACS discharge. PMID:25544887

  3. A Low Baseline Glomerular Filtration Rate Predicts Poor Clinical Outcome at 3 Months after Acute Ischemic Stroke

    PubMed Central

    Kim, Hyung Jik; Kim, Jwa-Kyung; Oh, Mi Sun; Kim, Sung Gyun; Yu, Kyung-Ho

    2015-01-01

    Background and Purpose Chronic kidney disease (CKD) is an established risk factor for numerous cardiovascular diseases including stroke. The relationship between the baseline estimated glomerular filtration rate (eGFR) and clinical 3-month outcomes in patients with acute ischemic stroke were evaluated in this study. Methods This was a prospective cohort study involving a hospital-based stroke registry; 1373 patients with acute ischemic stroke were enrolled. Patients were divided into the following four groups according their eGFR (calculated using the CKD Epidemiology Collaboration equations): ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. The primary endpoint of poor functional outcome was defined as 3-month death or dependency (modified Rankin Scale score ≥3); secondary endpoints were neurological deterioration (increase in National Institutes of Health Stroke Severity score of ≥4 at discharge compared to baseline) during hospitalization and in-hospital mortality. Results The overall eGFR was 84.5±20.8 mL/min/1.73 m2 (mean±SD). The distribution of baseline renal impairment was as follows: 1,218, 82, 40, and 33 patients had eGFRs of ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2, respectively. At 3 months after the stroke, 476 (34.7%) patients exhibited poor functional outcome. Furthermore, a poor functional outcome occurred more frequently with increasingly advanced stages of CKD (rates of 31.9%, 53.7%, 55.0%, and 63.6% for CKD stages 1/2, 3a, 3b, and 4/5, respectively; p<0.001). Multivariate analysis revealed that a baseline eGFR of <30 mL/min/1.73m2 increased the risk of a poor functional outcome by 2.37-fold (p=0.047). In addition, baseline renal dysfunction was closely associated with neurological deterioration during hospitalization and with in-hospital mortality. Conclusions A low baseline eGFR was strongly predictive of both poor functional outcome at 3 months after ischemic stroke and neurological deterioration/mortality during hospitalization. PMID

  4. Fish Oil Diet Associated with Acute Reperfusion Related Hemorrhage, and with Reduced Stroke-Related Sickness Behaviors and Motor Impairment

    PubMed Central

    Pascoe, Michaela C.; Howells, David W.; Crewther, David P.; Constantinou, Nicki; Carey, Leeanne M.; Rewell, Sarah S.; Turchini, Giovanni M.; Kaur, Gunveen; Crewther, Sheila G.

    2014-01-01

    Ischemic stroke is associated with motor impairment and increased incidence of affective disorders such as anxiety/clinical depression. In non-stroke populations, successful management of such disorders and symptoms has been reported following diet supplementation with long chain omega-3-polyunsaturated-fatty-acids (PUFAs). However, the potential protective effects of PUFA supplementation on affective behaviors after experimentally induced stroke and sham surgery have not been examined previously. This study investigated the behavioral effects of PUFA supplementation over a 6-week period following either middle cerebral artery occlusion or sham surgery in the hooded-Wistar rat. The PUFA diet supplied during the acclimation period prior to surgery was found to be associated with an increased risk of acute hemorrhage following the reperfusion component of the surgery. In surviving animals, PUFA supplementation did not influence infarct size as determined 6 weeks after surgery, but did decrease omega-6-fatty-acid levels, moderate sickness behaviors, acute motor impairment, and longer-term locomotor hyperactivity and depression/anxiety-like behavior. PMID:24567728

  5. Fish oil diet associated with acute reperfusion related hemorrhage, and with reduced stroke-related sickness behaviors and motor impairment.

    PubMed

    Pascoe, Michaela C; Howells, David W; Crewther, David P; Constantinou, Nicki; Carey, Leeanne M; Rewell, Sarah S; Turchini, Giovanni M; Kaur, Gunveen; Crewther, Sheila G

    2014-01-01

    Ischemic stroke is associated with motor impairment and increased incidence of affective disorders such as anxiety/clinical depression. In non-stroke populations, successful management of such disorders and symptoms has been reported following diet supplementation with long chain omega-3-polyunsaturated-fatty-acids (PUFAs). However, the potential protective effects of PUFA supplementation on affective behaviors after experimentally induced stroke and sham surgery have not been examined previously. This study investigated the behavioral effects of PUFA supplementation over a 6-week period following either middle cerebral artery occlusion or sham surgery in the hooded-Wistar rat. The PUFA diet supplied during the acclimation period prior to surgery was found to be associated with an increased risk of acute hemorrhage following the reperfusion component of the surgery. In surviving animals, PUFA supplementation did not influence infarct size as determined 6 weeks after surgery, but did decrease omega-6-fatty-acid levels, moderate sickness behaviors, acute motor impairment, and longer-term locomotor hyperactivity and depression/anxiety-like behavior. PMID:24567728

  6. Effect of space balance 3D training using visual feedback on balance and mobility in acute stroke patients

    PubMed Central

    Ko, YoungJun; Ha, HyunGeun; Bae, Young-Hyeon; Lee, WanHee

    2015-01-01

    [Purpose] The purpose of the study was to determine the effects of balance training with Space Balance 3D, which is a computerized measurement and visual feedback balance assessment system, on balance and mobility in acute stroke patients. [Subjects and Methods] This was a randomized controlled trial in which 52 subjects were assigned randomly into either an experimental group or a control group. The experimental group, which contained 26 subjects, received balance training with a Space Balance 3D exercise program and conventional physical therapy interventions 5 times per week during 3 weeks. Outcome measures were examined before and after the 3-week interventions using the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Postural Assessment Scale for Stroke Patients (PASS). The data were analyzed by a two-way repeated measures ANOVA using SPSS 19.0. [Results] The results revealed a nonsignificant interaction effect between group and time period for both groups before and after the interventions in the BBS score, TUG score, and PASS score. In addition, the experimental group showed more improvement than the control group in the BBS, TUG and PASS scores, but the differences were not significant. In the comparisons within the groups by time, both groups showed significant improvement in BBS, TUG, and PASS scores. [Conclusion] The Space Balance 3D training with conventional physical therapy intervention is recommended for improvement of balance and mobility in acute stroke patients. PMID:26157270

  7. Treatment protocol based on assessment of clot quality during endovascular thrombectomy for acute ischemic stroke using the Trevo stent retriever

    PubMed Central

    Ishikawa, Kojiro; Ohshima, Tomotaka; Nishihori, Masahiro; Imai, Tasuku; Goto, Shunsaku; Yamamoto, Taiki; Nishizawa, Toshihisa; Shimato, Shinji; Kato, Kyozo

    2016-01-01

    ABSTRACT The optional endovascular approach for acute ischemic stroke is unclear. The Trevo stent retriever can be used as first-line treatment for fast mechanical recanalization. The authors developed a treatment protocol for acute ischemic stroke based on the assessment of clot quality during clot removal with the Trevo. This prospective single-center study included all patients admitted for acute ischemic stroke between July 2014 and February 2015, who underwent emergency endovascular treatment. According to the protocol, the Trevo was used for first-line treatment. Immediately after the Trevo was deployed, the stent delivery wire was pushed to open the stent by force (ACAPT technique). Clot quality was assessed on the basis of the perfusion status after deployment of the Trevo; continued occlusion or immediate reopening either reoccluded or maintained after the stent retriever had been in place for 5 min. If there was no obvious clot removal after the first pass with the Trevo, according to the quality of the clot, either a second pass was performed or another endovascular device was selected. Twelve consecutive patients with acute major cerebral artery occlusion were analyzed. Thrombolysis in cerebral infarction score 2b and 3 was achieved in 11 patients (91.7%) and 9 (75%) had a good clinical outcome after 90 days based on a modified Rankin scale score ≤ 2. Symptomatic intracranial hemorrhage occurred in 1 patient (8.3%). The overall mortality rate was 8.3%. Endovascular thrombectomy using the Trevo stent retriever for first-line treatment is feasible and effective. PMID:27578909

  8. Treatment protocol based on assessment of clot quality during endovascular thrombectomy for acute ischemic stroke using the Trevo stent retriever.

    PubMed

    Ishikawa, Kojiro; Ohshima, Tomotaka; Nishihori, Masahiro; Imai, Tasuku; Goto, Shunsaku; Yamamoto, Taiki; Nishizawa, Toshihisa; Shimato, Shinji; Kato, Kyozo

    2016-08-01

    The optional endovascular approach for acute ischemic stroke is unclear. The Trevo stent retriever can be used as first-line treatment for fast mechanical recanalization. The authors developed a treatment protocol for acute ischemic stroke based on the assessment of clot quality during clot removal with the Trevo. This prospective single-center study included all patients admitted for acute ischemic stroke between July 2014 and February 2015, who underwent emergency endovascular treatment. According to the protocol, the Trevo was used for first-line treatment. Immediately after the Trevo was deployed, the stent delivery wire was pushed to open the stent by force (ACAPT technique). Clot quality was assessed on the basis of the perfusion status after deployment of the Trevo; continued occlusion or immediate reopening either reoccluded or maintained after the stent retriever had been in place for 5 min. If there was no obvious clot removal after the first pass with the Trevo, according to the quality of the clot, either a second pass was performed or another endovascular device was selected. Twelve consecutive patients with acute major cerebral artery occlusion were analyzed. Thrombolysis in cerebral infarction score 2b and 3 was achieved in 11 patients (91.7%) and 9 (75%) had a good clinical outcome after 90 days based on a modified Rankin scale score ≤ 2. Symptomatic intracranial hemorrhage occurred in 1 patient (8.3%). The overall mortality rate was 8.3%. Endovascular thrombectomy using the Trevo stent retriever for first-line treatment is feasible and effective. PMID:27578909

  9. The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England

    PubMed Central

    2014-01-01

    Background Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke. Methods We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts. Results We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations. Conclusions This first national prehospital QIC led to significant improvements in ambulance care for AMI and

  10. CT perfusion cerebral blood volume does not always predict infarct core in acute ischemic stroke.

    PubMed

    d'Esterre, Christopher D; Roversi, Gloria; Padroni, Marina; Bernardoni, Andrea; Tamborino, Carmine; De Vito, Alessandro; Azzini, Cristiano; Marcello, Onofrio; Saletti, Andrea; Ceruti, Stefano; Lee, Ting Yim; Fainardi, Enrico

    2015-10-01

    We investigated the practical clinical utility of the CT perfusion (CTP) cerebral blood volume (CBV) parameter for differentiating salvageable from non-salvageable tissue in acute ischemic stroke (AIS). Fifty-five patients with AIS were imaged within 6 h from onset using CTP. Admission CBV defect (CBVD) volume was outlined using previously established gray and white matter CBV thresholds for infarct core. Admission cerebral blood flow (CBF) hypoperfusion and CBF/CBV mismatch were visually evaluated. Truncation of the ischemic time-density curve (ITDC) and hypervolemia status at admission, recanalization at 24-h CT angiography, hemorrhagic transformation (HT) at 24 h and/or 7-day non-contrast CT (NCCT), final infarct volume as indicated by 3-month NCCT defect (NCCTD) and 3-month modified Rankin Score were determined. Patients with recanalization and no truncation had the highest correlation (R = 0.81) and regression slope (0.80) between CBVD and NCCTD. Regression slopes were close to zero for patients with admission hypervolemia with/without recanalization. Hypervolemia underestimated (p = 0.02), while recanalization and ITDC truncation overestimated (p = 0.03) the NCCTD. Among patients with confirmed recanalization at 24 h, 38 % patients had an admission CBF/CBV mismatch within normal appearing areas on respective NCCT. 83 % of these patients developed infarction in admission hypervolemic CBF/CBV mismatch tissue. A reduction in CBV is a valuable predictor of infarct core when the acquisition of ITDC data is complete and hypervolemia is absent within the tissue destined to infarct. Raised or normal CBV is not always indicative of salvageable tissue, contrary to the current definition of penumbra. PMID:25981225

  11. Iodinated Contrast Does Not Alter Clotting Dynamics in Acute Ischemic Stroke as Measured by Thromboelastography

    PubMed Central

    McDonald, Mark M; Archeval-Lao, Joancy M; Cai, Chunyan; Peng, Hui; Sangha, Navdeep; Parker, Stephanie A; Wetzel, Jeremy; Riney, Stephen A; Cherches, Matt F; Guthrie, Greer J; Roper, Tiffany C; Kawano-Castillo, Jorge F; Pandurengan, Renga; Rahbar, Mohammad H; Grotta, James C

    2014-01-01

    Background and Purpose Iodinated contrast agents used for computed tomography angiography (CTA) may alter fibrin fiber characteristics and decrease fibrinolysis by tissue plasminogen activator (tPA). Thromboelastography (TEG™) measures the dynamics of coagulation and correlates with thrombolysis in acute ischemic stroke (AIS) patients. We hypothesized that receiving CTA prior to tPA will not impair thrombolysis as measured by TEG™. Methods AIS patients receiving 0.9 mg/kg tPA within 4.5 hours of symptom onset were prospectively enrolled. For CTA, 350 mg/dL of iohexol or 320 mg/dL of iodixanol at a dose of 2.2 ml/kg was administered. TEG™ was measured prior to tPA and 10-minutes after tPA bolus. CTA timing was left to the discretion of the treating physician. Results Of 136 AIS patients who received tPA, 47 had CTA prior to tPA bolus, and 42 had either CTA following tPA and post-tPA TEG™ draw or no CTA (non-contrast group). The median change in clot lysis (LY30) following tPA was 95.3% in the contrast group vs. 95.0% in the non-contrast group (p = 0.74). Thus, tPA-induced thrombolysis did not differ between contrast and non-contrast groups. Additionally, there was no effect of contrast on any pre-tPA TEG™ value. Conclusions Our data do not support an effect of iodinated contrast agents on clot formation or tPA activity. PMID:24370757

  12. Repurposing an Old Drug to Improve the Use and Safety of Tissue Plasminogen Activator for Acute Ischemic Stroke: Minocycline

    PubMed Central

    Hess, David C.; Fagan, Susan C.

    2015-01-01

    There is only 1 US Food and Drug Administration–approved drug for acute ischemic stroke: tissue plasminogen activator (tPA). Due to a short time window and fear of intracerebral hemorrhage (ICH), tPA remains underutilized. There is great interest in developing combination drugs to use with tPA to improve the odds of a favorable recovery and to reduce the risk of ICH. Minocycline is a broad-spectrum antibiotic that has been found to be a neuroprotective agent in preclinical ischemic stroke models. Minocycline inhibits matrix metalloproteinase-9, a biomarker for ICH associated with tPA use. Minocycline is also an anti-inflammatory agent and inhibits poly (ADP-ribose) polymerase-1. Minocycline has been safe and well tolerated in the clinical trials conducted to date. PMID:20410869

  13. Serum homocysteine as a risk factor for carotid intimal thickening in acute stroke: A cross sectional observational study

    PubMed Central

    Devasia, Anup J.; Joy, Binu; Tarey, Subhash D.

    2016-01-01

    Introduction: The present study aimed to analyse if there is a correlation between carotid intima medial thickening (CIMT) and Hcy in stroke patients. Methodology: We studied 100 consecutive cases of acute anterior circulation strokes at St. John's Medical College, Bangalore, India. Fasting serum samples for homocysteine were sent within 24 hours of admission and all patients underwent a carotid Doppler scan and carotid intima-medial thickness (CIMT) was estimated on both sides. Results: There was significant correlation between serum homocysteine levels and carotid intima-medial thickness (r = 0.409, p = 0.000). Also after controlling for other possible risk factors it was found that elevations in serum homocysteine levels would cause a variation of 60% in the carotid intima-medial thickening. Conclusion: Serum Hcy levels correlate well with CIMT and hence may predict atherothrombotic events. PMID:27011628

  14. Acute free-floating carotid artery thrombus causing stroke in a young patient: unique etiology and management using endovascular approach.

    PubMed

    Tan, Ai Peng; Taneja, Manish; Seah, Boon Heng; Leong, Hoe Nam; Venketasubramanian, Narayanaswamy

    2014-01-01

    Atherosclerotic disease accounts for 20%-30% of strokes in the general population. In young adults, it is an unexpected event and its causes involve diverse pathologies. Herein, we describe a unique case of acute embolic stroke in a young adult patient due to the presence of a large clot in the right common and internal carotid arteries, as a result of an extrinsic cause. Surgical clot retrieval was considered unsafe at that point in time in view of the active inflammatory changes surrounding the affected vessels. This was eventually treated with a novel endovascular technique, a unique alternative to open surgery, with excellent clinical outcome. To our knowledge, the penumbra system has never been used for thrombus removal in a nonacute setting. PMID:25440371

  15. Repurposing an old drug to improve the safety and use of tissue plasminogen activator for acute ischemic stroke: Minocycline

    PubMed Central

    Hess, David C; Fagan, Susan

    2014-01-01

    There is only 1 US Food and Drug Administration-approved drug for acute ischemic stroke: tissue plasminogen activator (tPA). Due to a short time window and fear of intracerebral hemorrhage (ICH), tPA remains underutilized. There is great interest in developing combination drugs to use with tPA to improve the odds of a favorable recovery and to reduce the risk of ICH. Minocycline is a broad spectrum antibiotic that has been found to be a neuroprotective agent in preclinical ischemic stroke models. Minocycline inhibits matrix metalloproteinase-9, a biomarker for ICH associated with tPA use. Minocycline is also an anti-inflammatory agent and inhibits poly (ADP-ribose) polymerase- 1. Minocycline has been safe and well tolerated in the clinical trials conducted to date. PMID:20575623

  16. Effectiveness of Hospital Functions for Acute Ischemic Stroke Treatment on In-Hospital Mortality: Results From a Nationwide Survey in Japan

    PubMed Central

    Iwamoto, Tetsuya; Hashimoto, Hideki; Horiguchi, Hiromasa; Yasunaga, Hideo

    2015-01-01

    Background Though evidence is limited in Japan, clinical controlled studies overseas have revealed that specialized care units are associated with better outcomes for acute stoke patients. This study aimed to examine the effectiveness of hospital functions for acute care of ischemic stroke on in-hospital mortality, with statistical accounting for referral bias. Methods We derived data from a large Japanese claim-based inpatient database linked to the Survey of Medical Care Institutions and Hospital Report data. We compared the mortality of acute ischemic stroke patients (n = 41 476) in hospitals certified for acute stroke treatment with that in non-certified institutions. To adjust for potential referral bias, we used differential distance to hospitals from the patient’s residence as an instrumental variable and constructed bivariate probit models. Results With the ordinary probit regression model, in-hospital mortality in certified hospitals was not significantly different from that in non-certified institutions. Conversely, the model with the instrumental variable method showed that admission to certified hospitals reduced in-hospital mortality by 30.7% (P < 0.001). This difference remained after adjusting for hospital size, volume, staffing, and intravenous use of tissue plasminogen activator. Conclusions Comparison accounting for referral selection found that certified hospital function for acute ischemic stroke care was associated with significantly lower in-hospital mortality. Our results indicate that organized stroke care—with certified subspecialty physicians and around-the-clock availability of personnel, imaging equipment, and emergency neurosurgical procedures in an intensive stroke care unit—is effective in improving outcomes in acute ischemic stroke care. PMID:26165489

  17. Combined Neuroprotective Modalities Coupled with Thrombolysis in Acute Ischemic Stroke: A Pilot Study of Caffeinol and Mild Hypothermia

    PubMed Central

    Martin-Schild, Sheryl; Hallevi, Hen; Shaltoni, Hashem; Barreto, Andrew D.; Gonzales, Nicole R.; Aronowski, Jarek; Savitz, Sean I.; Grotta, James C.

    2009-01-01

    Background Both caffeinol and hypothermia are neuroprotective in preclinical models of transient middle cerebral artery occlusion. We tested whether combining caffeinol and hypothermia with t-PA in acute stroke patients is safe and feasible. Methods 20 patients with acute ischemic stroke were treated with caffeinol (caffeine 8-9 mg/kg + ethanol 0.4g/kg IV X 2 hours, started by 4 hrs after symptom onset) and hypothermia (started by 5 hrs and continued for 24 hrs (target temp 33-35°C) followed by 12 hrs of rewarming). IV t-PA was given to eligible patients. Meperidine and buspirone were used to suppress shivering. Results All patients received caffeinol, and most reached target blood levels. Cooling was attempted in 18 patients via endovascular (n=8) or surface (n=10) approaches. Two patients were not cooled due to catheter or machine failure. Thirteen patients reached target temperature; average time from symptom onset was 9hrs, 43min. The last 5 hypothermia patients received surface cooling with iced saline induction and larger doses of meperidine; all patients reached target temperature, on average within 2hrs 30min from induction and 6hrs 21min from symptom onset. Three patients died: one from symptomatic hemorrhage, one from malignant cerebral edema, and one from unrelated medical complications. No adverse events were attributed to caffeinol. One patient had reduced respiratory drive due to meperidine, requiring BiPAP. Discussion Combining caffeinol with hypothermia in acute stroke patients given IV t-PA is feasible. A prospective placebo-controlled randomized study is needed to further assess safety and to test the efficacy of caffeinol, hypothermia or both. PMID:19251183

  18. Increased Risk of Post-Thrombolysis Intracranial Hemorrhage in Acute Ischemic Stroke Patients with Leukoaraiosis: A Meta-Analysis

    PubMed Central

    Lin, Qianqian; Li, Zhong; Wei, Rui; Lei, Qingfeng; Liu, Yunyun; Cai, Xiaodong

    2016-01-01

    Background Leukoaraiosis is common in patients with acute ischemic stroke. The results from many studies investigating the association between leukoaraiosis and intracranial hemorrhage after thrombolysis remain conflicting. Methods A meta-analysis was performed to compare the risk of post-thrombolytic intracranial hemorrhage in patients with and without leukoaraiosis. Relevant reports were identified by searching PubMed, EmBase, Cochrane Library, and ISI Web of Science through December 2015 using a combination of subjective and random terms. Eligible studies that were original articles with a clear definition of leukoaraiosis and intracranial hemorrhage were selected and analyzed. Funnel plots, Egger’s test, and Begg’s test were conducted to assess the publication bias. Sensitivity analysis was also performed to evaluate the influence of each individual study. Results Eleven trials that enrolled 6912 participants were included. There was a significantly increased risk for acute ischemic stroke patients with leukoaraiosis (odds ratio: 1.89, 95% confidence interval 1.51–2.37, P<0.001). Low heterogeneity and less publication bias was detected among these studies. The results of both computed tomography and magnetic resonance imaging performed on the subgroups of leukoaraiosis were significant. Furthermore, an association between leukoaraiosis and symptomatic intracranial hemorrhage was also confirmed. The odds ratios remained stable with no obvious variations on the sensitivity analysis. The limitations consisted of types of including trials and not matching some baseline variables. Conclusions The results of this meta-analysis show that leukoaraiosis approximately doubles the incidence of intracranial hemorrhage after thrombolytic therapy. However, it does not critically affect decision making regarding thrombolysis for patients with acute ischemic stroke. Additional investigations are required. PMID:27096292

  19. Endovascular therapy including thrombectomy for acute ischemic stroke: A systematic review and meta-analysis with trial sequential analysis.

    PubMed

    Phan, Kevin; Zhao, Dong Fang; Phan, Steven; Huo, Ya Ruth; Mobbs, Ralph J; Rao, Prashanth J; Mortimer, Alex M

    2016-07-01

    One of the primary strategies for the management of acute ischemic stroke is intravenous (IV) thrombolysis with tissue plasminogen activator (t-PA). Over the past decade, endovascular therapies such as the use of stent retrievers to perform mechanical thrombectomy have been found to improve functional outcomes compared to t-PA alone. We aimed to reassess the functional outcomes and complications of IV thrombolysis with and without endovascular treatment for acute ischemic stroke using conventional meta-analysis and trial sequential analysis. Pooled relative risks (RR) and 95% confidence intervals (CI) were calculated for the effect of IV thrombolysis with and without endovascular therapy on functional outcome, mortality and symptomatic intracranial hemorrhage (SICH). Trial sequential analysis was done to strengthen the meta-analysis. We analyzed six randomized controlled trials involving 1943 patients. Patients who received IV thrombolysis with endovascular treatment showed significantly higher rates of excellent functional outcomes (modified Rankin Scale [mRS] 0-1) (RR, 1.75 [95% CI, 1.29-2.39]) compared to those who received IV thrombolysis alone. A similar association was seen for good functional outcomes (mRS 0-2) (RR, 1.56 [95% CI, 1.24-1.96]). Trial sequential analysis demonstrated endovascular treatment increased the RR of a good functional outcome by at least 30% compared to IV thrombolysis alone. There was no significant difference in all-cause mortality for mechanical thrombectomy compared to IV thrombolysis alone or the incidence of SICH at 3month follow-up. Endovascular treatment is more likely to result in a better functional outcome for patients compared to IV thrombolysis alone for acute ischemic stroke. PMID:26947342

  20. Apolipoprotein A1-Unique Peptide as a Diagnostic Biomarker for Acute Ischemic Stroke

    PubMed Central

    Zhao, Xu; Yu, Yue; Xu, Wenlong; Dong, Lei; Wang, Yuan; Gao, Bing; Li, Guangyu; Zhang, Wentao

    2016-01-01

    Clinically-informative biomarkers of ischemic stroke are needed for rapid diagnosis and timely treatment. In the present study, APOA1 unique peptide (APOA1-UP), a novel peptide biomarker, was identified and quantified by multiple reaction monitoring (MRM) using labeled reference peptide (LRP). Serum samples of 94 patients in the ischemic stroke group and 37 patients in the non-stroke group were analyzed for the levels of total APOA1-UP, low density lipoprotein cholesterol (LDL-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and total cholesterol (TC). Median ratio of total APOA1-UP/LRP was 2.14 (interquartile range, 0.40) in the non-stroke group and 1.32 (0.44) in the ischemic stroke group (p < 0.0001). The serum level of total APOA1-UP was independently correlated with the presence of ischemic stroke by multivariate logistic regression analysis (p < 0.0001). From the receiver operating characteristic (ROC) curve, the area under the curve (AUC) was 0.9750 and the optimal cutoff value of the serum APOA1-UP level was 1.80, which yielded a sensitivity of 90.63% and a specificity of 97.14%. The diagnostic efficiency of HDL-C was lower, with an AUC of 0.7488. Therefore, the serum level of APOA1-UP is a diagnostic biomarker candidate for ischemic stroke in the early stage. PMID:27043525

  1. Witness Response at Acute Onset of Stroke: A Qualitative Theory-Guided Study

    PubMed Central

    Dombrowski, Stephan U.; Sniehotta, Falko F.; Mackintosh, Joan; White, Martin; Rodgers, Helen; Thomson, Richard G.; Murtagh, Madeleine J.; Ford, Gary A.; Eccles, Martin P.; Araujo-Soares, Vera

    2012-01-01

    Background Delay in calling emergency medical services following stroke limits access to early treatment that can reduce disability. Emergency medical services contact is mostly initiated by stroke witnesses (often relatives), rather than stroke patients. This study explored appraisal and behavioural factors that are potentially important in influencing witness behaviour in response to stroke. Methods and Findings Semi-structured interviews with 26 stroke witnesses were transcribed and theory-guided content analysed was undertaken based on the Common Sense Self-Regulation Model (appraisal processes) and Theory Domains Framework (behavioural determinants). Response behaviours were often influenced by heuristics-guided appraisal (i.e. mental rules of thumb). Some witnesses described their responses to the situation as ‘automatic’ and ‘instinctive’, rather than products of deliberation. Potential behavioural influences included: environmental context and resources (e.g. time of day), social influence (e.g. prompts from patients) and beliefs about consequences (e.g. 999 accesses rapid help). Findings are based on retrospective accounts and need further verification in prospective studies. Conclusions Witnesses play a key role in patient access to emergency medical services. Factors that potentially influence witnesses’ responses to stroke were identified and could inform behavioural interventions and future research. Interventions might benefit from linking automatic/instinctive threat perceptions with deliberate appraisal of stroke symptoms, prompting action to call emergency medical services. PMID:22911691

  2. Apolipoprotein A1-Unique Peptide as a Diagnostic Biomarker for Acute Ischemic Stroke.

    PubMed

    Zhao, Xu; Yu, Yue; Xu, Wenlong; Dong, Lei; Wang, Yuan; Gao, Bing; Li, Guangyu; Zhang, Wentao

    2016-01-01

    Clinically-informative biomarkers of ischemic stroke are needed for rapid diagnosis and timely treatment. In the present study, APOA1 unique peptide (APOA1-UP), a novel peptide biomarker, was identified and quantified by multiple reaction monitoring (MRM) using labeled reference peptide (LRP). Serum samples of 94 patients in the ischemic stroke group and 37 patients in the non-stroke group were analyzed for the levels of total APOA1-UP, low density lipoprotein cholesterol (LDL-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and total cholesterol (TC). Median ratio of total APOA1-UP/LRP was 2.14 (interquartile range, 0.40) in the non-stroke group and 1.32 (0.44) in the ischemic stroke group (p < 0.0001). The serum level of total APOA1-UP was independently correlated with the presence of ischemic stroke by multivariate logistic regression analysis (p < 0.0001). From the receiver operating characteristic (ROC) curve, the area under the curve (AUC) was 0.9750 and the optimal cutoff value of the serum APOA1-UP level was 1.80, which yielded a sensitivity of 90.63% and a specificity of 97.14%. The diagnostic efficiency of HDL-C was lower, with an AUC of 0.7488. Therefore, the serum level of APOA1-UP is a diagnostic biomarker candidate for ischemic stroke in the early stage. PMID:27043525

  3. Effect of Treatment Delay, Stroke Type, and Thrombolysis on the Effect of Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome after Acute Stroke: A Systematic Review and Meta-Analysis of Individual Patient from Randomised Trials

    PubMed Central

    Bath, Philip M.; Woodhouse, Lisa; Krishnan, Kailash; Anderson, Craig; Berge, Eivind; Ford, Gary A.; Robinson, Thompson G.; Saver, Jeffrey L.; Sprigg, Nikola; Wardlaw, Joanna M.; in Acute Stroke Collaboration (BASC), Blood pressure

    2016-01-01

    Background. Nitric oxide (NO) donors are a candidate treatment for acute stroke and two trials have suggested that they might improve outcome if administered within 4–6 hours of stroke onset. We assessed the safety and efficacy of NO donors using individual patient data (IPD) from completed trials. Methods. Randomised controlled trials of NO donors in patients with acute or subacute stroke were identified and IPD sought from the trialists. The effect of NO donor versus control on functional outcome was assessed using the modified Rankin scale (mRS) and death, by time to randomisation. Secondary outcomes included measures of disability, mood, and quality of life. Results. Five trials (4,197 participants) were identified, all involving glyceryl trinitrate (GTN). Compared with control, GTN lowered blood pressure by 7.4/3.3 mmHg. At day 90, GTN did not alter any clinical measures. However, in 312 patients randomised within 6 hours of stroke onset, GTN was associated with beneficial shifts in the mRS (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.34–0.78) and reduced death (OR 0.32, 95% CI 0.14–0.78). Conclusions. NO donors do not alter outcome in patients with recent stroke. However, when administered within 6 hours, NO donors might improve outcomes in both ischaemic and haemorrhagic stroke. PMID:27190674

  4. Paramedical risk framing during field referral of acute stroke and S-T elevation myocardial infarction patients.

    PubMed

    Campeau, Anthony Gerard

    2016-06-01

    Field referral of emergency ambulance patients by paramedics on a widespread basis is a relatively new aspect of paramedicine. Its implementation involves a significant revision to paramedics' clinical responsibilities and level of interaction with medical specialists. Using grounded theory methodology, this qualitative study uses interviews with paramedics from Ontario, Canada, to explore the framing of risk associated with these referrals in the context of caring for patients with two high-stakes medical conditions: acute stroke and S-T elevation myocardial infarction. The results outline how paramedics have incorporated risk framing into their practice. PMID:26819329

  5. Phase IIB/III Trial of Tenecteplase in Acute Ischemic Stroke: Results of a Prematurely Terminated Randomized Clinical Trial

    PubMed Central

    Haley, E. Clarke; Thompson, John L.P.; Grotta, James C.; Lyden, Patrick D.; Hemmen, Thomas G.; Brown, Devin L.; Fanale, Christopher; Libman, Richard; Kwiatkowski, Thomas G.; Llinas, Rafael H.; Levine, Steven R.; Johnston, Karen C.; Buchsbaum, Richard; Levy, Gilberto; Levin, Bruce

    2010-01-01

    Background: Intravenous alteplase (rt-PA) remains the only approved treatment for acute ischemic stroke, but its use remains limited. In a previous pilot dose-escalation study, intravenous tenecteplase showed promise as a potentially safer alternative. Therefore, a Phase IIB clinical trial was begun to a) choose a best dose of tenecteplase to carry forward, and b) to provide evidence for either promise or futility of further testing of tenecteplase versus rt-PA. If promise was established, then the trial would continue as a Phase III efficacy trial comparing the selected tenecteplase dose to standard rt-PA. Methods: The trial began as a small, multi-center, randomized, double-blind, controlled clinical trial comparing 0.1, 0.25, and 0.4 mg/kg tenecteplase with standard 0.9 mg/kg rt-PA in patients with acute stroke within 3 hours of onset. An adaptive sequential design used an early (24 hour) assessment of major neurological improvement balanced against occurrence of symptomatic intracranial hemorrhage (ICH) to choose a “best” dose of tenecteplase to carry forward. Once a “best” dose was established, the trial was to continue until at least 100 pairs of the selected tenecteplase dose versus standard rt-PA could be compared by 3 month outcome using the modified Rankin Scale in an interim analysis. Decision rules were devised to yield a clear recommendation to either stop for futility or to continue into Phase III. Results: The trial was prematurely terminated for slow enrollment after only 112 patients had been randomized at 8 clinical centers between 2006 and 2008. The 0.4 mg/kg dose was discarded as inferior after only 73 patients were randomized, but the selection procedure was still unable to distinguish between 0.1 mg/kg and 0.25 mg/kg as a propitious dose at the time the trial was stopped. There were no statistically persuasive differences in 3 month outcomes between the remaining tenecteplase groups and rt-PA. Symptomatic ICH rates were highest in the

  6. [The role of nursing in the rehabilitation of acute stroke patients. Towards a unified theoretical perspective].

    PubMed

    Kirkevold, M

    1999-02-01

    A review of existing literature indicates an uncertainty about the specific therapeutic role of nurses in the rehabilitation of stroke patients. Two different conceptualizations of the nursing role exist, but neither is related to specific rehabilitation goals and patient outcomes. A beginning theoretical account of the specific role of nursing in stroke recovery is offered as a structure to integrate the therapeutic aspects of the coordinating, maintenance and training functions of the nurse. Existing research literature is reviewed to substantiate the account. Further research is needed to develop the specific content and focus of nursing in stroke recovery. PMID:10514744

  7. Prevalence, causes and risk factors of hospital readmissions after acute stroke and transient ischemic attack: a systematic review and meta-analysis.

    PubMed

    Zhong, Weibin; Geng, Na; Wang, Pengfei; Li, Zhenguang; Cao, Lili

    2016-08-01

    Acute stroke and transient ischemic attack (TIA) is a great burden not only during hospitalization but also after hospital discharge. The objective of this meta-analysis was to evaluate the hospital readmissions, causes and risk factors after survival of acute stroke and TIA. Pubmed, Web of Science, Cochrane Library, OVID and EMBASE databases were searched to identify studies reporting hospital readmissions after acute stroke and TIA. The primary outcomes were hospital readmission rates during 30 days and 1 year after discharge. The primary causes and risk factors of hospital readmissions were also identified. Ten studies with 253,680 patients were eligible for inclusion. The pooled 30-day and 1-year hospital readmission rates were 17.4 % (95 % CI, 12.7-23.5 %) and 42.5 % (95 % CI, 34.1-51.3 %), respectively. The three major causes of 30-day hospital readmissions were infection (19.9 %), coronary artery disease (CAD) (17.8 %) and recurrent stroke (16.0 %) successively, while the three major causes were recurrent stroke (19.4 %), infection (19.3 %) and CAD (16.3 %) during 1 year's follow-up. There were more patients with CAD in readmits group than that in control group (p = 0.030). The length of index admission, defined as any eligible admission to an acute care hospital assessed in the measure for the outcome, was longer (p = 0.000) and admission National Institutes of Health Stroke Score (NIHSS) was higher (p = 0.002) in readmits group than these in control group. In conclusion, there is high risk of early and long-term hospital readmissions after survival of acute stroke and TIA. These patients with coronary artery disease, longer length of index admission and higher NIHSS deserve deep attention after hospital discharge. PMID:27129874

  8. Postoperative rescue closure of patent foramen ovale in the clinical setting of acute hypoxemic respiratory failure and stroke following coronary artery bypass surgery

    PubMed Central

    Díaz-Gómez, José L.; Rodrigues, Eduardo; Mordecai, Monica; Moss, John; Agnew, Richard C.; Oken, Keith R.

    2015-01-01

    We describe a case of intraoperative diagnosis and successful deferred percutaneous closure of a patent foramen ovale (PFO) in the clinical setting of acute refractory hypoxemic respiratory failure and new-onset ischemic stroke in an elderly patient after coronary artery bypass graft. Perioperative morbidity (i.e. severe hypoxemia, worsening right ventricular dysfunction, and embolic stroke) that is potentially related to intraoperatively diagnosed PFO during cardiac surgery can complicate management in the Intensive Care Unit and perhaps affect the patient's outcome. Although the PFO closure can be challenging in the clinical setting of hypoxemic respiratory failure and stroke following cardiac surgery, it can be a reasonable perioperative option. PMID:25566718

  9. A fast multiparameter MRI approach for acute stroke assessment on a 3T clinical scanner: preliminary results in a non-human primate model with transient ischemic occlusion

    PubMed Central

    Tong, Frank; Li, Chun-Xia; Yan, Yumei; Nair, Govind; Nagaoka, Tsukasa; Tanaka, Yoji; Zola, Stuart; Howell, Leonard

    2014-01-01

    Many MRI parameters have been explored and demonstrated the capability or potential to evaluate acute stroke injury, providing anatomical, microstructural, functional, or neurochemical information for diagnostic purposes and therapeutic development. However, the application of multiparameter MRI approach is hindered in clinic due to the very limited time window after stroke insult. Parallel imaging technique can accelerate MRI data acquisition dramatically and has been incorporated in modern clinical scanners and increasingly applied for various diagnostic purposes. In the present study, a fast multiparameter MRI approach including structural T1-weighted imaging (T1W), T2-weighted imaging (T2W), diffusion tensor imaging (DTI), T2-mapping, proton magnetic resonance spectroscopy, cerebral blood flow (CBF), and magnetization transfer (MT) imaging, was implemented and optimized for assessing acute stroke injury on a 3T clinical scanner. A macaque model of transient ischemic stroke induced by a minimal interventional approach was utilized for evaluating the multiparameter MRI approach. The preliminary results indicate the surgical procedure successfully induced ischemic occlusion in the cortex and/or subcortex in adult macaque monkeys (n=4). Application of parallel imaging technique substantially reduced the scanning duration of most MRI data acquisitions, allowing for fast and repeated evaluation of acute stroke injury. Hence, the use of the multiparameter MRI approach with up to five quantitative measures can provide significant advantages in preclinical or clinical studies of stroke disease. PMID:24834423

  10. Successful Intra-Arterial Thrombolysis for Acute Ischemic Stroke in the Immediate Postpartum Period: Case Report

    SciTech Connect

    Mendez, Jose C. Masjuan, J.; Garcia, N.; Lecinana, M. de

    2008-01-15

    Stroke in pregnancy and the puerperium is a rare but potentially devastating event. We present the case of a previously healthy woman who underwent a cesarean delivery and experienced a middle cerebral artery thrombosis in the immediate postpartum period that was subsequently lysed with intra-arterial urokinase. The patient made a complete neurologic recovery. To the best of our knowledge, this is the first reported case of successful intra-arterial thrombolysis for ischemic stroke in the postpartum period.

  11. Physiologic Reelin does not play a strong role in protection against acute stroke.

    PubMed

    Lane-Donovan, Courtney; Desai, Charisma; Pohlkamp, Theresa; Plautz, Erik J; Herz, Joachim; Stowe, Ann M

    2016-07-01

    Stroke and Alzheimer's disease, two diseases that disproportionately affect the aging population, share a subset of pathological findings and risk factors. The primary genetic risk factor after age for late-onset Alzheimer's disease, ApoE4, has also been shown to increase stroke risk and the incidence of post-stroke dementia. One mechanism by which ApoE4 contributes to disease is by inducing in neurons a resistance to Reelin, a neuromodulator that enhances synaptic function. Previous studies in Reelin knockout mice suggest a role for Reelin in protection against stroke; however, these studies were limited by the developmental requirement for Reelin in neuronal migration. To address the question of the effect of Reelin loss on stroke susceptibility in an architecturally normal brain, we utilized a novel mouse with induced genetic reduction of Reelin. We found that after transient middle cerebral artery occlusion, mice with complete adult loss of Reelin exhibited a similar level of functional deficit and extent of infarct as control mice. Together, these results suggest that physiological Reelin does not play a strong role in protection against stroke pathology. PMID:27146512

  12. Alteration of Thyroid-Related Hormones within Normal Ranges and Early Functional Outcomes in Patients with Acute Ischemic Stroke

    PubMed Central

    Xu, Xiao-yan; Li, Wen-yu; Hu, Xing-yue

    2016-01-01

    This study evaluated the prognostic value of thyroid-related hormones within normal ranges after acute ischemic stroke. This was a retrospective study and we reviewed 1072 ischemic stroke patients consecutively admitted within 72 h after symptom onset. Total triiodothyronine (T3), total thyroxine (T4), free T3, free T4, and thyroid-stimulating hormone (TSH) were assessed to determine their values for predicting functional outcome at the first follow-up clinic visits, which usually occurred 2 to 4 weeks after discharge from the hospital. 722 patients were finally included. On univariate analysis, poor functional outcome was associated with presence of atrial fibrillation as the index event. Furthermore, score of National Institutes of Health Stroke Scale (NIHSS), total T4, free T4, and C-reactive protein at admission were significantly higher in patients with poor functional outcome, whereas free T3 and total T3 were significantly lower. On multiple logistic regression analysis, lower total T3 concentrations remained independently associated with poor functional outcome [odds ratio (OR), 0.10; 95% confidence interval (CI), 0.01–0.84; P = 0.035]. The only other variables independently associated with poor functional outcome were NIHSS scores. In sum, lower total T3 concentrations that were within the normal ranges were independently associated with poor short-term outcomes. PMID:27375741

  13. Alteration of Thyroid-Related Hormones within Normal Ranges and Early Functional Outcomes in Patients with Acute Ischemic Stroke.

    PubMed

    Xu, Xiao-Yan; Li, Wen-Yu; Hu, Xing-Yue

    2016-01-01

    This study evaluated the prognostic value of thyroid-related hormones within normal ranges after acute ischemic stroke. This was a retrospective study and we reviewed 1072 ischemic stroke patients consecutively admitted within 72 h after symptom onset. Total triiodothyronine (T3), total thyroxine (T4), free T3, free T4, and thyroid-stimulating hormone (TSH) were assessed to determine their values for predicting functional outcome at the first follow-up clinic visits, which usually occurred 2 to 4 weeks after discharge from the hospital. 722 patients were finally included. On univariate analysis, poor functional outcome was associated with presence of atrial fibrillation as the index event. Furthermore, score of National Institutes of Health Stroke Scale (NIHSS), total T4, free T4, and C-reactive protein at admission were significantly higher in patients with poor functional outcome, whereas free T3 and total T3 were significantly lower. On multiple logistic regression analysis, lower total T3 concentrations remained independently associated with poor functional outcome [odds ratio (OR), 0.10; 95% confidence interval (CI), 0.01-0.84; P = 0.035]. The only other variables independently associated with poor functional outcome were NIHSS scores. In sum, lower total T3 concentrations that were within the normal ranges were independently associated with poor short-term outcomes. PMID:27375741

  14. Characteristics of Misclassified CT Perfusion Ischemic Core in Patients with Acute Ischemic Stroke

    PubMed Central

    Geuskens, Ralph R. E. G.; Borst, Jordi; Lucas, Marit; Boers, A. M. Merel; Berkhemer, Olvert A.; Roos, Yvo B. W. E. M.; van Walderveen, Marianne A. A.; Jenniskens, Sjoerd F. M.; van Zwam, Wim H.; Dippel, Diederik W. J.; Majoie, Charles B. L. M.; Marquering, Henk A.

    2015-01-01

    Background CT perfusion (CTP) is used to estimate the extent of ischemic core and penumbra in patients with acute ischemic stroke. CTP reliability, however, is limited. This study aims to identify regions misclassified as ischemic core on CTP, using infarct on follow-up noncontrast CT. We aim to assess differences in volumetric and perfusion characteristics in these regions compared to areas that ended up as infarct on follow-up. Materials and Methods This study included 35 patients with >100 mm brain coverage CTP. CTP processing was performed using Philips software (IntelliSpace 7.0). Final infarct was automatically segmented on follow-up noncontrast CT and used as reference. CTP and follow-up noncontrast CT image data were registered. This allowed classification of ischemic lesion agreement (core on CTP: rMTT≥145%, aCBV<2.0 ml/100g and infarct on follow-up noncontrast CT) and misclassified ischemic core (core on CTP, not identified on follow-up noncontrast CT) regions. False discovery ratio (FDR), defined as misclassified ischemic core volume divided by total CTP ischemic core volume, was calculated. Absolute and relative CTP parameters (CBV, CBF, and MTT) were calculated for both misclassified CTP ischemic core and ischemic lesion agreement regions and compared using paired rank-sum tests. Results Median total CTP ischemic core volume was 49.7ml (IQR:29.9ml-132ml); median misclassified ischemic core volume was 30.4ml (IQR:20.9ml-77.0ml). Median FDR between patients was 62% (IQR:49%-80%). Median relative mean transit time was 243% (IQR:198%-289%) and 342% (IQR:249%-432%) for misclassified and ischemic lesion agreement regions, respectively. Median absolute cerebral blood volume was 1.59 (IQR:1.43–1.79) ml/100g (P<0.01) and 1.38 (IQR:1.15–1.49) ml/100g (P<0.01) for misclassified ischemic core and ischemic lesion agreement, respectively. All CTP parameter values differed significantly. Conclusion For all patients a considerable region of the CTP ischemic core

  15. Supplementation of folic acid and vitamin B₁₂ reduces plasma levels of asymmetric dimethylarginine in patients with acute ischemic stroke.

    PubMed

    Xia, Xiao-Shuang; Li, Xin; Wang, Lin; Wang, Ji-Zuo; Ma, Jin-Ping; Wu, Cun-Jin

    2014-09-01

    Increased levels of asymmetric dimethylarginine (ADMA) have been observed in patients with acute ischemic stroke. We aimed to investigate the correlation between ADMA and ischemic stroke, and evaluate the effect of supplementation of folic acid and vitamin B12 on concentrations of ADMA. Patients were randomized into intervention and non-intervention groups within 3 days after symptom onset. Intervention group patients were treated with folic acid (5mg daily) and vitamin B12 (500 μg twice daily) for 12 weeks. ADMA and homocysteine (Hcy) concentrations were measured before treatment (baseline) and 2 and 12 weeks after treatment. The laboratory measures were also collected from healthy controls. Eighty five subjects were enrolled in this study, from whom 72 with complete baseline and follow-up laboratory data were included in the present analysis. Thirty four patients were assigned to the intervention group and 38 patients to the non-intervention group. Sixty people were enrolled as healthy controls. Levels of ADMA and Hcy were raised (p<0.05) in patients with acute ischemic stroke. With supplementation of both folic acid and vitamin B12, the levels of ADMA and Hcy decreased significantly at 2 and 12 weeks (p<0.05). The present study reconfirmed that ADMA can be regarded as a risk biomarker for acute ischemic stroke. We observed that with supplementation of folic acid and vitamin B12, levels of ADMA were decreased in patients with acute ischemic stroke. PMID:24814858

  16. Application of principles of exercise training in sub-acute and chronic stroke survivors: a systematic review

    PubMed Central

    2014-01-01

    Background There is increasing evidence for the beneficial effects of exercise training in stroke survivors. In order to reach the desired training effects, exercise training principles must be considered as this ensures the prescription of adequate exercises at an adequate dose. Moreover, exercise training interventions must be designed in a way that maximizes patients’ adherence to the prescribed exercise regimen. The objectives of this systematic review were (1) to investigate whether training principles for physical exercise interventions are reported in RCTs for sub-acute and chronic stroke survivors, (2) to evaluate whether the RCTs reported the prescription of the FITT components of the exercise interventions as well as (3) patients’ adherence to this prescription, and (4) to assess the risk of bias of the included studies. Methods We performed a systematic review of RCTs with exercise training as the primary intervention and muscular strength and/or endurance as primary outcomes. The Cochrane library’s risk of bias (ROB) tool was used to judge the methodological quality of RCTs. Results Thirty-seven RCTs were included in this systematic review. Eighteen studies (48.7%) focused on aerobic, 8 (21.6%) on resistance and 11 (29.7%) on combined interventions of aerobic and resistive strength exercise. Twenty-nine studies (78.4%) included only chronic stroke survivors, 5 studies (13.5%) only sub-acute stroke survivors whilst 3 studies (8.1%) included both. In terms of principle of exercise training, 89% reported specificity, 75.7% progression, 48.7% overload, 37.8% initial values, 32.4% reversibility and 13.5% diminishing returns. One RCT described all principles of physical exercise training and 19 (51.4%) all FITT components. Patients’ adherence to exercise prescription was accounted for in 3 studies (8.1%). Failure to report blinding in patients and participants and failure to report allocation concealment were the most prevalent methodological

  17. Emergency Care of Patients with Acute Ischemic Stroke in the Kaiser Permanente Southern California Integrated Health System

    PubMed Central

    Sauser-Zachrison, Kori; Shen, Ernest; Ajani, Zahra; Neil, William P; Sangha, Navdeep; Gould, Michael K; Sharp, Adam L

    2016-01-01

    Context: Tissue plasminogen activator (tPA) is underutilized for treatment of acute ischemic stroke. Objective: To determine whether the probability of tPA administration for patients with ischemic stroke in an integrated health care system improved from 2009 to 2013, and to identify predictors of tPA administration. Design: Retrospective analysis of all ischemic stroke presentations to 14 Emergency Departments between 2009 and 2013. A generalized linear mixed-effects model identified patient and hospital predictors of tPA. Main Outcome Measures: Primary outcome was tPA administration; secondary outcomes were door-to-imaging and door-to-needle times and tPA-related bleeding complications. Results: Of the 11,630 patients, 3.9% received tPA. The likelihood of tPA administration increased with presentation in 2012 and 2013 (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.26–2.43; and OR = 2.58; 95% CI = 1.90–3.51), female sex (OR = 1.27; 95% CI = 1.04–1.54), and ambulance arrival (OR = 2.17; 95% CI = 1.76–2.67), and decreased with prior stroke (OR = 0.47; 95% CI = 0.25–0.89) and increased age (OR = 0.98; 95% CI = 0.97–0.99). Likelihood varied by Medical Center (pseudo-intraclass correlation coefficient 13.5%). Among tPA-treated patients, median door-to-imaging time was 15 minutes (interquartile range, 9–23 minutes), and door-to-needle time was 73 minutes (interquartile range, 55–103 minutes). The rate of intracranial hemorrhage was 4.2% and 0.9% among tPA- and non-tPA treated patients (p < 0.001). Conclusion: Acute ischemic stroke care improved over time in this integrated health system. Better understanding of differences in hospital performance will have important quality-improvement and policy implications. PMID:27043833

  18. Acute Stroke and Obstruction of the Extracranial Carotid Artery Combined with Intracranial Tandem Occlusion: Results of Interventional Revascularization

    SciTech Connect

    Lescher, Stephanie Czeppan, Katja; Porto, Luciana; Singer, Oliver C.; Berkefeld, Joachim

    2015-04-15

    PurposeDue to high thrombus load, acute stroke patients with tandem obstructions of the extra- and intracranial carotid arteries or the middle cerebral artery show a very limited response to systemic thrombolysis. Interventional treatment with mechanical thrombectomy—often in combination with acute stenting of underlying atherosclerotic stenosis or dissection—is increasingly used. It has been shown that such complex interventions are technically feasible. The lack of optimal management strategies and clinical data encouraged us to review our acute stroke interventions in patient with anterior circulation tandem lesions to determine lesion patterns, interventional approaches, and angiographic or clinical outcomes.Patients and MethodsWe retrospectively analyzed a series of 39 consecutive patients with intracranial vessel occlusion of the anterior circulation simultaneously presenting with high-grade cervical internal carotid artery (ICA) stenosis or occlusion.ResultsEmergency ICA stent implantation was technically feasible in all patients, and intracranial recanalization with TICI ≥ 2b was reached in a large number of patients (64 %). Good clinical outcomes (mRS ≤ 2 at 3 months) were achieved in one third of the patients (36 %). Symptomatic hemorrhages occurred in four patients (10 %). Mortality was 10 %.ConclusionEndovascular recanalization of acute cervical carotid artery occlusion was technically feasible in all patients, and resulted in high extra- and intracranial revascularization rates. A trend for favorable clinical outcome was seen in a higher TICI score, younger age, good collateral status, and combined IV rTPA and endovascular therapy.

  19. Temporal profiles of blood pressure, circulating nitric oxide, and adrenomedullin as predictors of clinical outcome in acute ischemic stroke patients

    PubMed Central

    SERRANO-PONZ, MARTA; RODRIGO-GASQUÉ, CARMEN; SILES, EVA; MARTÍNEZ-LARA, ESTHER; OCHOA-CALLEJERO, LAURA; MARTÍNEZ, ALFREDO

    2016-01-01

    Stroke remains an important health and social challenge. The present study investigated whether blood pressure (BP) parameters and circulating levels of nitric oxide metabolites (NOx) and adrenomedullin (AM) may predict clinical outcomes of stroke. Patients (n=76) diagnosed with acute ischemic stroke were admitted to the stroke unit and clinical history data and monitored parameters were recorded. Blood plasma was collected at days 1, 2, and 7 to measure NOx and AM levels. Infarct volume, neurological severity [on the National Institutes of Health Stroke Scale (NIHSS)], and functional prognosis (on the Rankin scale) were measured as clinical outcomes. Patients with higher BP had more severe symptoms (NIHSS >3; P<0.01) and BP variability predicted neurological severity and growth of infarct volume. NOx values were significantly lower in stroke patients than in healthy controls (P<0.01). An increase in NOx levels from day 1 to day 2 was beneficial for the patients as measured by NIHSS at 7 days and 3 months, and by Rankin at 3 months [odds ratio (OR), 0.91] whereas a steep increase from day 2 to day 7 was detrimental and associated with an increase in infarct volume (OR, 35.3). AM levels were significantly higher in patients at day 1 and 2 than in healthy individuals (P<0.01) and these levels returned to normal at day 7. Patients with high AM levels at day 2 had significantly higher NIHSS scores measured at day 1 (P<0.05) and 7 (P<0.01). A receiving operating characteristic curve analysis identified that AM levels at day 2 of >522.13 pg/ml predicted increased neurological severity at day 7 (area under the curve=0.721). Multivariate logistic regression indicated that AM levels at day 2 predicted increased neurological severity at 7 days and at 3 months. BP parameters and changing levels for NOx and AM predicted long-term clinical outcomes as measured by infarct volume, neurological severity scale, and functional prognosis. PMID:27035412

  20. Temporal profiles of blood pressure, circulating nitric oxide, and adrenomedullin as predictors of clinical outcome in acute ischemic stroke patients.

    PubMed

    Serrano-Ponz, Marta; Rodrigo-Gasqué, Carmen; Siles, Eva; Martínez-Lara, Esther; Ochoa-Callejero, Laura; Martínez, Alfredo

    2016-05-01

    Stroke remains an important health and social challenge. The present study investigated whether blood pressure (BP) parameters and circulating levels of nitric oxide metabolites (NOx) and adrenomedullin (AM) may predict clinical outcomes of stroke. Patients (n=76) diagnosed with acute ischemic stroke were admitted to the stroke unit and clinical history data and monitored parameters were recorded. Blood plasma was collected at days 1, 2, and 7 to measure NOx and AM levels. Infarct volume, neurological severity [on the National Institutes of Health Stroke Scale (NIHSS)], and functional prognosis (on the Rankin scale) were measured as clinical outcomes. Patients with higher BP had more severe symptoms (NIHSS >3; P<0.01) and BP variability predicted neurological severity and growth of infarct volume. NOx values were significantly lower in stroke patients than in healthy controls (P<0.01). An increase in NOx levels from day 1 to day 2 was beneficial for the patients as measured by NIHSS at 7 days and 3 months, and by Rankin at 3 months [odds ratio (OR), 0.91] whereas a steep increase from day 2 to day 7 was detrimental and associated with an increase in infarct volume (OR, 35.3). AM levels were significantly higher in patients at day 1 and 2 than in healthy individuals (P<0.01) and these levels returned to normal at day 7. Patients with high AM levels at day 2 had significantly higher NIHSS scores measured at day 1 (P<0.05) and 7 (P<0.01). A receiving operating characteristic curve analysis identified that AM levels at day 2 of >522.13 pg/ml predicted increased neurological severity at day 7 (area under the curve=0.721). Multivariate logistic regression indicated that AM levels at day 2 predicted increased neurological severity at 7 days and at 3 months. BP parameters and changing levels for NOx and AM predicted long‑term clinical outcomes as measured by infarct volume, neurological severity scale, and functional prognosis. PMID:27035412

  1. Adjuvant Tirofiban Injection Through Deployed Solitaire Stent As a Rescue Technique After failed Mechanical Thrombectomy in Acute Stroke

    PubMed Central

    Seo, Jung Hwa; Kim, Sung Tae; Kim, Eun-Gyu

    2015-01-01

    Purpose We present our experiences of intra-arterial tirofiban injection through a deployed Solitaire stent as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. Materials and Methods Data on 18 patients treated with adjunctive tirofiban injection through a temporarily deployed Solitaire stent after failed mechanical thrombectomy were retrospectively reviewed. Solitaire stent was used as a primary thrombectomy device in 16 of 18 patients. Two patients received manual aspiration thrombectomy initially. If initial mechanical thrombectomy failed, tirofiban was injected intra-arterially through the deployed Solitaire stent and then subsequent Solitaire thrombectomy was performed. Results Fourteen patients had occlusions in the middle cerebral artery, 2 in the distal internal carotid artery, and 2 in the basilar artery. Successful recanalization was achieved in 14 patients (77.7%) after intra-arterial injection of tirofiban and subsequent Solitaire thrombectomy. Three patients without successful recanalization after rescue method received angioplasty with stenting. Overall, successful recanalization (TICI grades 2b and 3) was achieved in 17 (94.4%) of 18 patients. Periprocedural complications occurred in 5 patients: distal migration of emboli in 5 patients and vessel perforation in 1. Three patients died. Good functional outcome (mRS ≤ 2) was achieved in 9 patients (50.0%) at 3 months. Conclusion Rescue intra-arterial injection of tirofiban through a temporarily deployed Solitaire stent may facilitate further recanalization in cases of failed mechanical thrombectomy in patients with acute ischemic stroke. PMID:25763294

  2. Experience in the use of Actovegin in the treatment of patients with cognitive disorders in the acute period of stroke.

    PubMed

    Derev'yannykh, E A; Bel'skaya, G N; Knoll, E A; Krylova, L G; Popov, D V

    2008-10-01

    Forty-three patients with mild-moderate ischemic stroke were studied in the acute period and were divided into two groups. The experimental group consisted of 32 patients who were given Actovegin; the reference group consisted of 11 patients who were given piracetam. Patients were investigated before treatment and at 10 and 30 days; investigations included examination, points assessments of neurological disorders using the original Gusev-Skvortsova scale, neuropsychological tests using the MMSE scale, rheoencephalography, and electroencephalography. Analysis of changes in clinical features in patients treated with Actovegin during the acute period showed that Actovegin had clear positive effects both on general cerebral and on focal neurological symptoms. By the end of treatment, the extent of recovery of impaired functions, assessed in terms of total ischemic points and cognitive functions, was significantly greater in patients treated with Actovegin than in patients given piracetam. These data lead to the conclusion that Actovegin is effective in the treatment of patients with ischemic stroke. PMID:18802768

  3. The incidence and significance of acute kidney injury following emergent contrast administration in patients with STEMI and stroke.

    PubMed

    Marchick, Michael Robert; Allen, Brandon Russell; Weeks, Emily Cassin; Shuster, Jonathan Jacob; Elie, Marie-Carmelle

    2016-09-01

    The authors have investigated the incidence of acute kidney injury (AKI) and short-term mortality following an activated STEMI and stroke alert at a tertiary referral and academic center. A single center, retrospective chart review of STEMI and stroke activation patients from January 2010 to March 2012. Data was collected and reviewed from an institutional database following IRB-approval. Inclusion criteria were STEMI patients taken for cardiac catheterization, excluding patients receiving hemodialysis due to end-stage renal disease (ESRD). Primary outcome measures were the incidence of AKI using the RIFLE criteria and short-term mortality. 745 patients were included (488 stroke, 257 STEMI). The median age was 65, and 39 % were female. Overall inpatient mortality was 7.0 %. 5.4 % (40/745) of patients experienced some degree of AKI (8.6 % of STEMI, 3.7 % of stroke patients). Overall, 30 % of patients with AKI died during their hospitalization. AKI was associated with a 7.1-fold (95 % CI 3.4-15.1) increase in mortality in the entire cohort. Among STEMI patients, AKI was associated with a 66.6-fold (95 % CI 12.9-343.4) increase in mortality. These findings follow similar trends published among critically ill patients with AKI. The risk of death with concomitant AKI in this hospital population is significant and deserves future study. Early recognition and awareness in the emergency department is paramount to the patient's survival. Future studies should focus on modalities to improve early recognition and preventative therapies. PMID:26910240

  4. Outcomes of Patients Requiring Blood Pressure Control Before Thrombolysis with tPA for Acute Ischemic Stroke

    PubMed Central

    Darger, Bryan; Gonzales, Nicole; Banuelos, Rosa C.; Peng, Hui; Radecki, Ryan P.; Doshi, Pratik B.

    2015-01-01

    Introduction The purpose of this study was to assess safety and efficacy of thrombolysis in the setting of aggressive blood pressure (BP) control as it compares to standard BP control or no BP control prior to thrombolysis. Methods We performed a retrospective review of patients treated with tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) between 2004–2011. We compared the outcomes of patients treated with tPA for AIS who required aggressive BP control prior to thrombolysis to those requiring standard or no BP control prior to thrombolysis. The primary outcome of interest was safety, defined by all grades of hemorrhagic transformation and neurologic deterioration. The secondary outcome was efficacy, determined by functional status at discharge, and in-hospital deaths. Results Of 427 patients included in the analysis, 89 received aggressive BP control prior to thrombolysis, 65 received standard BP control, and 273 required no BP control prior to thrombolysis. Patients requiring BP control had more severe strokes, with median arrival National Institutes of Health Stroke Scale of 10 (IQR [6–17]) in patients not requiring BP control versus 11 (IQR [5–16]) and 13 (IQR [7–20]) in patients requiring standard and aggressive BP lowering therapies, respectively (p=0.048). In a multiple logistic regression model adjusting for baseline differences, there were no statistically significant differences in adverse events between the three groups (P>0.10). Conclusion We observed no association between BP control and adverse outcomes in ischemic stroke patients undergoing thrombolysis. However, additional study is necessary to confirm or refute the safety of aggressive BP control prior to thrombolysis. PMID:26759644

  5. Progesterone in the treatment of neonatal arterial ischemic stroke and acute seizures: Role of BDNF/TrkB signaling.

    PubMed

    Atif, Fahim; Yousuf, Seema; Stein, Donald G

    2016-08-01

    Neonatal stroke is among the top ten causes of childhood death and permanent disability in survivors, but no safe and effective acute treatments exist. To advance understanding of its neuroprotective mechanisms, we examined the effects of progesterone (PROG) on local and systemic inflammation (IL-1β, IL-6, TNFα), brain derived neurotrophic factor/Tropomyosin receptor kinase B (BDNF/TrkB) signaling, vascular damage (vascular endothelial growth factor (VEGF), matrix metalloproteinase-9 (MMP-9)), acute behavioral seizures and brain infarction size following neonatal arterial ischemic stroke in mice. CD1 mouse pups (postnatal day 12, mixed gender) received permanent unilateral right common carotid ligation (pUCCL) or sham surgery. Pups showing seizure activity during the first hour post-pUCCL were randomly assigned to receive PROG (8 mg/kg) or vehicle injections. PROG treatment significantly (p < 0.05) reduced seizure occurrence by ∼44% compared to vehicle and attenuated the expression of pro-inflammatory cytokines in serum and brain at different time-points. PROG differentially regulated the expression of BDNF and TrkB and the activity of VEGF and MMP-9 over the 7d period. Permanent UCCL resulted in severe hemispheric damage measured at 7 days post-pUCCL but PROG treatment produced a significant (p < 0.05) reduction in infarct volume (∼70%) compared to vehicle. A gender-based comparison of data revealed significantly greater seizure activity in males compared to females. However, we did not observe significant sex differences on any other markers of the injury at this early stage of development. PROG treatment is neuroprotective through a number of signaling pathways and can be beneficial in treating neonatal arterial ischemic stroke in CD1 mice. PMID:27039043

  6. Prostaglandin D2 DP1 receptor is beneficial in ischemic stroke and in acute exicitotoxicity in young and old mice

    PubMed Central

    Ahmad, Abdullah Shafique; Ahmad, Muzamil; Maruyama, Takayuki; Narumiya, Shuh

    2010-01-01

    The cardiovascular complications reported to be associated with cyclooxygenase inhibitor use have shifted our focus toward prostaglandins and their respective receptors. Prostaglandin D2 and its DP1 receptor have been implicated in various normal and pathologic conditions, but their role in stroke is still poorly defined. Here, we tested whether DP1 deletion aggravates N-methyl-d-aspartic acid (NMDA)-induced acute toxicity and whether DP1 pharmacologic activation protects mice from acute excitotoxicity and transient cerebral ischemia. Moreover, since the elderly are more vulnerable to stroke-related damage than are younger patients, we tested the susceptibility of aged DP1 knockout (DP1−/−) mice to brain damage. We found that intrastriatal injection of 15 nmol NMDA caused significantly larger lesion volumes (27.2 ± 6.4%) in young adult DP1−/− mice than in their wild-type counterparts. Additionally, intracerebroventricular pretreatment of wild-type mice with 10, 25, and 50 nmol of the DP1-selective agonist BW245C significantly attenuated the NMDA-induced lesion size by 19.5 ± 5.0%, 39.6 ± 7.7%, and 28.9 ± 7.0%, respectively. The lowest tested dose of BW245C also was able to reduce middle cerebral artery occlusion-induced brain infarction size significantly (21.0 ± 5.7%). Interestingly, the aggravated NMDA-induced brain damage was persistent in older DP1−/− mice as well. We conclude that the DP1 receptor plays an important role in attenuating brain damage and that selective targeting of this receptor could be considered as an adjunct therapeutic tool to minimize stroke damage. PMID:20640551

  7. Preliminary findings on the reliability and validity of the Cantonese Birmingham Cognitive Screen in patients with acute ischemic stroke

    PubMed Central

    Pan, Xiaoping; Chen, Haobo; Bickerton, Wai-Ling; Lau, Johnny King Lam; Kong, Anthony Pak Hin; Rotshtein, Pia; Guo, Aihua; Hu, Jianxi; Humphreys, Glyn W

    2015-01-01

    Background There are no currently effective cognitive assessment tools for patients who have suffered stroke in the People’s Republic of China. The Birmingham Cognitive Screen (BCoS) has been shown to be a promising tool for revealing patients’ poststroke cognitive deficits in specific domains, which facilitates more individually designed rehabilitation in the long run. Hence we examined the reliability and validity of a Cantonese version BCoS in patients with acute ischemic stroke, in Guangzhou. Method A total of 98 patients with acute ischemic stroke were assessed with the Cantonese version of the BCoS, and an additional 133 healthy individuals were recruited as controls. Apart from the BCoS, the patients also completed a number of external cognitive tests, including the Montreal Cognitive Assessment Test (MoCA), Mini Mental State Examination (MMSE), Albert’s cancellation test, the Rey–Osterrieth Complex Figure Test, and six gesture matching tasks. Cutoff scores for failing each subtest, ie, deficits, were computed based on the performance of the controls. The validity and reliability of the Cantonese BCoS were examined, as well as interrater and test–retest reliability. We also compared the proportions of cases being classified as deficits in controlled attention, memory, character writing, and praxis, between patients with and without spoken language impairment. Results Analyses showed high test–retest reliability and agreement across independent raters on the qualitative aspects of measurement. Significant correlations were observed between the subtests of the Cantonese BCoS and the other external cognitive tests, providing evidence for convergent validity of the Cantonese BCoS. The screen was also able to generate measures of cognitive functions that were relatively uncontaminated by the presence of aphasia. Conclusion This study suggests good reliability and validity of the Cantonese version of the BCoS. The Cantonese BCoS is a very promising

  8. Intravenous thrombolysis guided by a telemedicine consultation system for acute ischaemic stroke patients in China: the protocol of a multicentre historically controlled study

    PubMed Central

    Yuan, Ziwen; Wang, Bo; Li, Feijiang; Wang, Jing; Zhi, Jin; Luo, Erping; Liu, Zhirong; Zhao, Gang

    2015-01-01

    Introduction The rate of intravenous thrombolysis with tissue-type plasminogen activator or urokinase for stroke patients is extremely low in China. It has been demonstrated that a telestroke service may help to increase the rate of intravenous thrombolysis and improve stroke care quality in local hospitals. The aim of this study, also called the Acute Stroke Advancing Program, is to evaluate the effectiveness and safety of decision-making concerning intravenous thrombolysis via a telemedicine consultation system for acute ischaemic stroke patients in China. Methods and analysis This is a multicentre historically controlled study with a planned enrolment of 300 participants in each of two groups. The telestroke network consists of one hub hospital and 14 spoke hospitals in underserved regions of China. The usual stroke care quality in the spoke hospitals without guidance from the hub hospital will be used as the historical control. The telemedicine consultation system is an interactive, two-way, wireless, audiovisual system accessed on portable devices. The primary outcome is the percentage of patients treated with intravenous thrombolysis within 4.5 h of stroke onset. Ethics and dissemination The project has been approved by the Institutional Review Board of Xijing Hospital. The results will be published in scientific journals and presented to local government and relevant institutes. Trial registration number NCT02088346 (12 March 2014). PMID:25979867

  9. The neuroprotective role of erythropoietin in the management of acute ischaemic stroke: from bench to bedside.

    PubMed

    Ntaios, G; Savopoulos, C; Chatzinikolaou, A; Hatzitolios, A I

    2008-12-01

    Recombinant human erythropoietin was produced soon after the discovery of the erythropoietin gene in 1985 and since then, it is used in various clinical conditions such as chronic renal failure. Moreover, experimental studies have shown that erythropoietin exerts neuroprotective action as well. Recently, a clinical trial yielded promising results concerning the use of erythropoietin in stroke management. In this review, we summarize the main data which suggest that recombinant human erythropoietin and its analogues may indeed have a role in stroke treatment. PMID:18513348

  10. Assessment of the Needs of Caregivers of Stroke Patients at State-Owned Acute-Care Hospitals in Southern Vietnam, 2011

    PubMed Central

    Hai, Hoang Hoa; Tai, Nguyen Anh

    2013-01-01

    Introduction Care for stroke patients has improved steadily in southern Vietnam. Medical treatments such as thrombolytic therapy have been implemented at several hospitals, and stroke-care units composed of a team of various health professionals have been created. However, little attention has been focused on providing support to caregivers of stroke patients. This study aimed to characterize the caregivers of stroke patients who were treated in state-owned acute-care hospitals and to learn about their needs when patients are discharged. Such information can be used to enhance the caregiver’s support system. Methods We used questionnaires to conduct a descriptive study in 2011 at a state-owned acute-care hospital in southern Vietnam. We recruited study participants from among caregivers of stroke patients who had been informed of their hospital discharge date. We assessed 8 caregiver characteristics, and caregiver participants selected their needs from the survey’s list of 15 possible needs. We analyzed the data by using the independent sample t test and logistic regression. Results Of the 93 caregivers who consented to participate, 86 (92.5%) completed the survey and indicated their concerns at discharge. The most frequently cited need was information on how to prevent stroke recurrence (72, 83.7%), followed by which drugs are most effective in preventing a relapse (62, 72.1%), how long recovery would take (61, 70.9%), and availability of hospitals in the patient’s hometown (60, 69.8%). A little over half of caregivers indicated financial concerns. A caregiver’s need for information on diet for a stroke survivor increased with the caregiver’s education level. Conclusions This study revealed several needs among caregivers of stroke survivors in southern Vietnam that are similar to those found by studies of caregivers of stroke survivors in high-income countries. Our findings suggest that comprehensive stroke care that includes caregiver education about

  11. Penumbra Pattern Assessment in Acute Stroke Patients: Comparison of Quantitative and Non-Quantitative Methods in Whole Brain CT Perfusion

    PubMed Central

    Baumann, Alena B.; Meinel, Felix G.; Helck, Andreas D.; Opherk, Christian; Straube, Andreas; Reiser, Maximilian F.; Sommer, Wieland H.

    2014-01-01

    Background And Purpose While penumbra assessment has become an important part of the clinical decision making for acute stroke patients, there is a lack of studies measuring the reliability and reproducibility of defined assessment techniques in the clinical setting. Our aim was to determine reliability and reproducibility of different types of three-dimensional penumbra assessment methods in stroke patients who underwent whole brain CT perfusion imaging (WB-CTP). Materials And Methods We included 29 patients with a confirmed MCA infarction who underwent initial WB-CTP with a scan coverage of 100 mm in the z-axis. Two blinded and experienced readers assessed the flow-volume-mismatch twice and in two quantitative ways: Performing a volumetric mismatch analysis using OsiriX imaging software (MMVOL) and visual estimation of mismatch (MMEST). Complementarily, the semiquantitative Alberta Stroke Programme Early CT Score for CT perfusion was used to define mismatch (MMASPECTS). A favorable penumbral pattern was defined by a mismatch of ≥30% in combination with a cerebral blood flow deficit of ≤90 ml and an MMASPECTS score of ≥1, respectively. Inter- and intrareader agreement was determined by Kappa-values and ICCs. Results Overall, MMVOL showed considerably higher inter-/intrareader agreement (ICCs: 0.751/0.843) compared to MMEST (0.292/0.749). In the subgroup of large (≥50 mL) perfusion deficits, inter- and intrareader agreement of MMVOL was excellent (ICCs: 0.961/0.942), while MMEST interreader agreement was poor (0.415) and intrareader agreement was good (0.919). With respect to penumbra classification, MMVOL showed the highest agreement (interreader agreement: 25 agreements/4 non-agreements/κ: 0.595; intrareader agreement 27/2/0.833), followed by MMEST (22/7/0.471; 23/6/0.577), and MMASPECTS (18/11/0.133; 21/8/0.340). Conclusion The evaluated approach of volumetric mismatch assessment is superior to pure visual and ASPECTS penumbra pattern assessment in WB

  12. Feasibility of Delivering a Dance Intervention for SubAcute Stroke in a Rehabilitation Hospital Setting

    PubMed Central

    Demers, Marika; McKinley, Patricia

    2015-01-01

    Dance can be a promising treatment intervention used in rehabilitation for individuals with disabilities to address physical, cognitive and psychological impairments. The aim of this pilot study was to determine the feasibility of a modified dance intervention as an adjunct therapy designed for people with subacute stroke, in a rehabilitation setting. Using a descriptive qualitative study design, a biweekly 45-min dance intervention was offered to individuals with a subacute stroke followed in a rehabilitation hospital, over 4 weeks. The dance intervention followed the structure of an usual dance class, but the exercises were modified and progressed to meet each individual’s needs. The dance intervention, delivered in a group format, was feasible in a rehabilitation setting. A 45-min dance class of moderate intensity was of appropriate duration and intensity for individuals with subacute stroke to avoid excessive fatigue and to deliver the appropriate level of challenge. The overall satisfaction of the participants towards the dance class, the availability of space and equipment, and the low level of risks contributed to the feasibility of a dance intervention designed for individuals in the subacute stage of post-stroke recovery. PMID:25785497

  13. The comparison of two physiotherapeutic approaches for gait improvement in sub-acute stroke patients.

    PubMed

    Krawczyk, Maciej; Szczerbik, Ewa; Syczewska, Małgorzata

    2014-01-01

    The functional gait problems encountered by stroke patients include impaired balance, abnormal gait pattern with marked asymmetry, pathological trunk and spinal motion. Many different methods of physiotherapy are used to improve functional ability (especially gait) in stroke patients, but their efficacy and outcome are often not objectively assessed. The goal of this paper is to compare two therapeutic programs: one that is traditionally used in our rehabilitation facilities (exercises in lying position, "open chain" exercises, isolated movements of extremities with trunk stabilization) and the new one (exercises in vertical position, sitting or standing, "closed chain" exercises involving whole paretic side of the body). Fifty one stroke patients, aged 34 to 79 years, participated in the study. Patients were randomly allocated to one of the two groups. Patients underwent clinical assessment (Fugl-Meyer, Rivermead Motor Assessment, Berg Balance Scale) and instrumented gait analysis (using six-camera VICON 460 system) simultaneously three times: prior to the beginning of the rehabilitation program, after 6 weeks of the program, and after another 6 weeks of physiotherapy, at the end of rehabilitation program. Results demonstrated that both rehabilitation programs improved the gait function and clinical status in patients suffering from stroke. Despite the differences between the two programs the progress achieved by the patients in locomotor function is similar. Two equivalent physiotherapy programs could be applied during rehabilitation process depending on the patient's individual preferences and needs, as the amount of functional improvement provided by them is comparable. PMID:24708038

  14. Herpes simplex encephalitis initially presented with parietal cortex lesions mimicking acute ischemic stroke: A case report.

    PubMed

    Hara, Yoshine; Ishii, Nobuyuki; Sakai, Katsuya; Mochizuki, Hitoshi; Shiomi, Kazutaka; Nakazato, Masamitsu

    2016-03-01

    A 73-year-old woman was admitted to our hospital due to a decreased conscious level and a high fever. Six days before her admission, she felt transient numbness in her right lower limb. Brain MRI taken by her local doctor revealed only right parietal cortex lesions. She was diagnosed with transient ischemic attack and started on anti-platelet therapy. One day before her admission, she became drowsy, and left-side weakness developed. She was admitted to a community hospital for treating stroke. On the next day, she was referred to our hospital because of a high fever. Our brain MRI showed new lesions in her right temporal lobe. She had no stroke risk factors, and embolic sources were not detected. Cerebrospinal fluid analysis detected herpes simplex virus DNA. She was diagnosed with herpes simplex encephalitis (HSE). HSE is common encephalitis which develops fever, headache and alteration in mental status. It often involves temporal lobe, but extratemporal lesions alone are not uncommon. Diffusion-weighted images (DWI) of brain are of importance to differentiate HSE from stroke. When it is questionable to diagnose with stroke for patients with cerebral cortex lesions, they must be monitored with close observation. There is the possibility of initial presentation of HSE in that situation even if patients have no typical symptoms. PMID:26797480

  15. Recanalization and Mortality Rates of Thrombectomy With Stent-Retrievers in Octogenarian Patients with Acute Ischemic Stroke

    SciTech Connect

    Parrilla, G.; Carreón, E.; Zamarro, J.; Espinosa de Rueda, M.; García-Villalba, B.; Marín, F.; Hernández-Fernández, F.; Morales, A.; Fernández-Vivas, M.; Núñez, R.; Moreno, A.

    2015-04-15

    BackgroundOur objective was to evaluate the effect of treatment with stent-retrievers in octogenarians suffering an acute ischemic stroke.MethodsA total of 150 consecutive patients with acute stroke who were treated with stent-retrievers between April 2010 and June 2012 were retrospectively reviewed. Patients were divided into those <80 years old (n = 116) and those ≥80 (n = 34). Baseline characteristics, procedure data, and endpoints (postprocedural NIHSS, death, and mRS at 3 months) were compared.ResultsHigh blood pressure, atrial fibrillation, and anticoagulation were more frequent in octogenarians (p = 0.01, 0.003, and 0.04 respectively). There were no differences between both groups regarding previous intravenous thrombolysis (32.4 vs. 48.3 %, p = 0.1), preprocedural NIHSS (18.1 vs. 16.8, p = 0.3), procedure time (74.5 (40–114) min vs. 63 (38–92) min, p = 0.2), revascularization time (380.5 (298–526.3) min vs. 350 (296.3–452.8), p = 0.3), TICI ≥ 2B (88.2 vs. 93.9 %, p = 0.1), and symptomatic haemorrhage (5.9 vs. 2.6 %, p = 0.3). Discharge NIHSS was higher in octogenarians (9.7 vs. 6.5, p = 0.03). Death and 3-month mRS ≥3 were more frequent in octogenarians (35.3 vs. 17.2 %, p = 0.02 and 73.5 vs. 37.1 %, p = 0.02). ICA-involvement and prolonged revascularization involved higher mortality (66.7 vs. 27.6 %, p = 0.03) and worse mRS (50 vs. 24.4 %, p = 0.06) in octogenarians.ConclusionsIn our series, treatment with stent-retrievers in octogenarians with acute ischemic stroke achieved good rates of recanalization but with a high mortality rate. ICA involvement and revascularization times beyond 6 hours associated to a worse prognosis. These data might be of value in the design of prospective studies evaluating the clinical efficacy of the endovascular treatments in octogenarians.

  16. Factors Associated with Early Hospital Arrival in Patients with Acute Ischemic Stroke

    PubMed Central

    Song, Dongbeom; Tanaka, Eijirou; Lee, Kijeong; Sato, Shoichiro; Koga, Masatoshi; Kim, Young Dae; Nagatsuka, Kazuyuki; Toyoda, Kazunori

    2015-01-01

    Background and Purpose Factors associated with early arrival may vary according to the characteristics of the hospital. We investigated the factors associated with early hospital arrival in two different stroke centers located in Korea and Japan. Methods Consecutive patients with ischemic stroke arrived hospital within 48 hours of onset between January 2011 and December 2012 were identified and the clinical and time variables were retrieved from the prospective stroke registries of Severance Hospital of Yonsei University Health System (YUHS; Seoul, Korea) and National Cerebral and Cardiovascular Center (NCVC; Osaka, Japan). Subjects were dichotomized into early (time from onset to arrival ≤4.5 hours) and late (>4.5 hours) arrival groups. Univariate and multivariate analyses were performed to evaluate factors associated with early hospital arrival. Results A total of 1,966 subjects (992 from YUHS; 974 from NCVC) were included in this study. The median time from onset to arrival was 6.1 hours [interquartile range, 1.7-17.8 hours]. In multivariate analysis, the factors associated with early arrival were atrial fibrillation (Odds ratio [OR], 1.505; 95% confidence interval [CI], [1.168-1.939]), higher initial National Institute of Health Stroke Scale scores (OR, 1.037; 95% CI [1.023-1.051]), onset during daytime (OR, 2.799; 95% CI [2.173-3.605]), and transport by an emergency medical service (OR, 2.127; 95% CI [1.700-2.661]). These factors were consistently associated with early arrival in both hospitals. Conclusions Despite differences between the hospitals, there were common factors related to early arrival. Efforts to identify and modify these factors may promote early hospital arrival and improve stroke outcome. PMID:26060803

  17. Increased Epicardial Fat Thickness Correlates with Aortic Stiffness and N-Terminal Pro-Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Patients

    PubMed Central

    Unal, Yasemin; Basaran, Ozcan; Akin, Fatih; Emir, Gulser Karadaban; Kutlu, Gulnihal; Biteker, Murat

    2016-01-01

    Epicardial fat, a metabolically active tissue, has emerged as a risk factor and active player in metabolic and cardiovascular diseases. We investigated epicardial fat thickness in patients who had sustained an acute ischemic stroke, and we evaluated the relationship of epicardial fat thickness with other prognostic factors. We enrolled 61 consecutive patients (age, ≥18 yr) who had sustained a first acute ischemic stroke and had been admitted to our hospital within 24 hours of the onset of stroke symptoms. The control group comprised 82 consecutive sex- and age-matched patients free of past or current stroke who had been admitted to our cardiology clinics. Blood samples were taken for measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at admission. Aortic stiffness indices and epicardial fat thickness were measured by means of transthoracic echocardiography within the first 48 hours. In comparison with the control group, the patients with acute ischemic stroke had significantly higher epicardial fat thickness (4.8 ± 0.9 vs 3.8 ± 0.7 mm; P <0.001), lower aortic distensibility (2.5 ± 0.8 vs 3.4 ± 0.9 cm2·dyn−1; P <0.001) and lower aortic strain (5.5% ± 1.9% vs 6.4% ± 1.8%; P=0.003). We found a significant association between epicardial fat thickness, NT-proBNP levels, and arterial dysfunction in patients who had sustained acute ischemic stroke. Increased epicardial fat thickness might be a novel risk factor and might enable evaluation of subclinical target-organ damage in these patients. PMID:27303237

  18. Cerebral hemodynamics in human acute ischemic stroke: a study with diffusion- and perfusion-weighted magnetic resonance imaging and SPECT.

    PubMed

    Liu, Y; Karonen, J O; Vanninen, R L; Ostergaard, L; Roivainen, R; Nuutinen, J; Perkiö, J; Könönen, M; Hämäläinen, A; Vanninen, E J; Soimakallio, S; Kuikka, J T; Aronen, H J

    2000-06-01

    Nineteen patients with acute ischemic stroke (<24 hours) underwent diffusion-weighted and perfusion-weighted (PWI) magnetic resonance imaging at the acute stage and 1 week later. Eleven patients also underwent technetium-99m ethyl cysteinate dimer single-photon emission computed tomography (SPECT) at the acute stage. Relative (ischemic vs. contralateral control) cerebral blood flow (relCBF), relative cerebral blood volume, and relative mean transit time were measured in the ischemic core, in the area of infarct growth, and in the eventually viable ischemic tissue on PWI maps. The relCBF was also measured from SPECT. There was a curvilinear relationship between the relCBF measured from PWI and SPECT (r = 0.854; P < 0.001). The tissue proceeding to infarction during the follow-up had significantly lower initial CBF and cerebral blood volume values on PWI maps (P < 0.001) than the eventually viable ischemic tissue had. The best value for discriminating the area of infarct growth from the eventually viable ischemic tissue was 48% for PWI relCBF and 87% for PWI relative cerebral blood volume. Combined diffusion and perfusion-weighted imaging enables one to detect hemodynamically different subregions inside the initial perfusion abnormality. Tissue survival may be different in these subregions and may be predicted. PMID:10894174

  19. Association between i.v. thrombolysis volume and door-to-needle times in acute ischemic stroke.

    PubMed

    Groot, Adrien E; van Schaik, Ivo N; Visser, Marieke C; Nederkoorn, Paul J; Limburg, Martien; Aramideh, Majid; de Beer, Frank; Zwetsloot, Caspar P; Halkes, Patricia; de Kruijk, Jelle; Kruyt, Nyika D; van der Meulen, Willem; Spaander, Fianne; van der Ree, Taco; Kwa, Vincent I H; Van den Berg-Vos, Renske M; Roos, Yvo B; Coutinho, Jonathan M

    2016-04-01

    Centralization of intravenous thrombolysis (IVT) for acute ischemic stroke in high-volume centers is believed to improve the door-to-needle times (DNT), but limited data support this assumption. We examined the association between DNT and IVT volume in a large Dutch province. We identified consecutive patients treated with IVT between January 2009 and 2013. Based on annualized IVT volume, hospitals were categorized as low-volume (≤ 24), medium-volume (25-49) or high-volume (≥ 50). In logistic regression analysis, low-volume hospitals were used as reference category. Of 17,332 stroke patients from 11 participating hospitals, 1962 received IVT (11.3 %). We excluded 140 patients because of unknown DNT (n = 86) or in-hospital stroke (n = 54). There were two low-volume (total 101 patients), five medium-volume (747 patients) and four high-volume hospitals (974 patients). Median DNT was shorter in high-volume hospitals (30 min) than in medium-volume (42 min, p < 0.001) and low-volume hospitals (38 min, p < 0.001). Patients admitted to high-volume hospitals had a higher chance of DNT < 30 min (adjusted OR 3.13, 95 % CI 1.70-5.75), lower risk of symptomatic intracerebral hemorrhage (adjusted OR 0.39, 95 % CI 0.16-0.92), and a lower mortality risk (adjusted OR 0.45, 95 % CI 0.21-1.01), compared to low-volume centers. There was no difference in DNT between low- and medium-volume hospitals. Onset-to-needle times (ONT) did not differ between the groups. Hospitals in this Dutch province generally achieved short DNTs. Despite this overall good performance, higher IVT volumes were associated with shorter DNTs and lower complication risks. The ONT was not associated with IVT volume. PMID:26946499

  20. Cost-Effectiveness of Intraarterial Treatment as an Adjunct to Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

    PubMed Central

    Leppert, Michelle H; Campbell, Jonathan D; Simpson, Jennifer R; Burke, James F

    2015-01-01

    Background and Purpose The objective of this study was to determine the cost-effectiveness of intraarterial treatment within the 0- to 6- hour window after intravenous (IV) tissue plasminogen activator (tPA) within 0- to 4.5-hours compared to IV tPA alone, in the US setting and from a social perspective. Methods A decision analytic model estimated the lifetime costs and outcomes associated with the additional benefit of intraarterial therapy compared to standard treatment with IV tPA alone. Model inputs were obtained from published literature, the MR CLEAN study, and claims databases in the United States. Health outcomes were measured in quality adjusted life years (QALYs). Treatment benefit was assessed by calculating the cost per QALY gained. One-way and probabilistic sensitivity analyses were performed to estimate the overall uncertainty of model results. Results The addition of intraarterial therapy compared with standard treatment alone yielded a lifetime gain of 0.7 QALY for an additional cost of $9,911, which resulted in a cost of $14,137 per QALY. Multivariable sensitivity analysis predicted cost-effectiveness (≤$50,000 per QALY) in 97.6% of simulation runs. Conclusion Intraarterial treatment after IV tPA for patients with anterior circulation strokes within the 6 hour window is likely cost effective. From a societal perspective, increased investment in access to intraarterial treatment for acute stroke may be justified. PMID:26012639