Abstract only Background: Tele-stroke has been an efficient cost-effective way to standardize care and improve access to immediate neurologic care for rural hospitals and other areas underserved by ...neurologists. Virtual telestroke support is commonly used in the Emergency Department. Hands-free wearable technology allows for seamless communication and faster more informed decisions. It can advance the triage of stroke patients into the pre-hospital setting at the scene or in the ambulance and facilitate the routing of patients to comprehensive stroke centers. Objective: To assess the feasibility and reliability of Xpert Eye TM solution, a Google Glass- based wearable solution in evaluating patients with suspected acute stroke. Methods: Consecutive patients with suspected stroke were evaluated concurrently by an on-site neurologist wearing Xpert Eye TM solution and a remotely located neurologist through Xpert Eye TM platform. Inter-rater reliability in calculating the NIH Stroke Scale (NIHSS) scores was evaluated. Results: Seventeen patients were included. There was a high degree of correlation in total NIHSS score (ICC 0.99 and weighted kappa 0.88) and across all NIHSS sub-items (ICC 0.81-1 and weighted kappa 0.68-1) between the two examiners. The maximum difference between the two NIHSS scores was 3. Conclusion: The use of Xpert Eye TM solution in tele-stroke is feasible and reliable. Using wearable solutions in tele-stroke can advance the care faster to the pre-hospital setting, at the scene or in the ambulance and can potentially facilitate triaging patients to appropriate stroke centers in the community.
OBJECTIVETo compare the functional outcomes and health-related quality of life metrics of restarting vs not restarting antiplatelet therapy (APT) in patients presenting with intracerebral hemorrhage ...(ICH) in the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study.
METHODSAdult patients aged 18 years and older who were on APT before ICH and were alive at hospital discharge were included. Patients were dichotomized based on whether or not APT was restarted after hospital discharge. The primary outcome was a modified Rankin Scale score of 0–2 at 90 days. Secondary outcomes were excellent outcome (modified Rankin Scale score 0–1), mortality, Barthel Index, and health status (EuroQol–5 dimensions EQ-5D and EQ-5D visual analog scale scores) at 90 days.
RESULTSThe APT and no APT cohorts comprised 127 and 732 patients, respectively. Restarting APT was associated with lower rates of good functional outcome (36.5% vs 40.8%; p = 0.021) and lower Barthel Index scores at 90 days (p = 0.041). The 2 cohorts were then matched in a 1:1 ratio, and the matched cohorts each comprised 107 patients. No difference in primary outcome was observed between restarting vs not restarting APT (35.5% vs 43.9%; p = 0.105). There were also no differences between the secondary outcomes of the 2 cohorts.
CONCLUSIONRestarting APT in patients with ICH of mild to moderate severity after acute hospitalization is not associated with worse functional outcomes or health-related quality of life at 90 days. In patients with significant cardiovascular risk factors who experience an ICH, restarting APT remains the decision of the treating practitioner.
Abstract only Background: In acute cerebral ischemia, there is an imbalance between oxygen tissue consumption and delivery and oxygen extraction fraction (OEF) from the circulation increases to ...maintain normal oxygen metabolism and neuronal function. Detecting such metabolic changes may provide important data to inform decisions on therapeutic interventions such as patient selection for reperfusion or identification of futile therapeutic situations. We used serial OEF MRI to assess metabolic changes in brain tissue associated with reperfusion interventions. Methods: Serial OEF acquired in 10 consecutive cases of acute anterior circulation ischemic stroke at a single center during a 12 month period. Transverse relaxation and static magnetic field inhomogeneity driven relaxation was mapped using multislice gradient echo planar imaging. Data are fitted on a voxel-by-voxel basis to the Yablonskiy and Haacke model to map deoxyhemoglobin concentration and cerebral blood volume. Results: 10 cases (median age 72 years (IQR 62-77), 5 women) were studied. Median NIHSS score 15.5 (IQR 9-25). 3 patients received no intervention as last known well time exceeded a treatment window. 3 patients received intravenous thrombolysis (IV), 3 patients received IV and mechanical thrombectomy (MT), and 1 patient received MT only. In the IV treated patients, median time to therapy 110. 5 minutes (IQR 80-132). In the MT treated patients, median time to therapy 257 minutes (IQR 234-331). In the untreated patients, the OEF was elevated in the ischemic territory and this appeared to persist at 24 hours. In the treated patients, those who had at least partial recanalization, demonstrated improved OEF in the ischemic territory at 24 hours. Conclusions: OEF provides a novel method for non-invasive detection of tissue with impaired oxygen delivery in acute stroke patients and is a novel tool for imaging metabolic changes in pathophysiology and disclosing therapeutic opportunities.
Abstract only Background: In clinical practice, when no consent provider is immediately available to authorize start of thrombolytic stroke therapy, acute stroke physicians face a fundamental ...conflict between the ethical principles of autonomy (respect for persons) and beneficence (maximizing benefit). Delaying therapy to reach a consent provider maximizes autonomy but reduces benefit. Physician attitudes toward resolving this conflict have not previously been delineated. Methods: A 6 item internet-based survey was administered to US academic stroke neurologists. Respondents were asked to indicate how much time (minutes), patients (number who fail to benefit due to delay), and brain (neurons lost due to delay) they would spend trying to reach consent provider for an aphasic acute stroke patient before proceeding with treatment under the doctrine of presumed consent. Results: Survey responses were received from 103 of 332 academic stroke neurologists. All respondents were engaged in stroke clinical care, with cerebrovascular disease accounting for more than half of practice time in over 70%. Career duration was substantial, with over 72% having been in practice for more than 5 years. In the time tradeoff framework, respondents indicated they would spend a median of 1.75 minutes (interquartile range, IQR, 0 - 10.0 minutes) trying to contact a consent provider before proceeding with thrombolysis. In the patient tradeoff framework, they would accept a median of 0 (IQR 0-0) per 1000 treated patients failing to benefit from therapy before proceeding. In the brain tradeoff scenario, they would accept a median of 0 (IQR 0-1) neurons lost before proceeding. Converting all choices to time, respondents indicated they would trade off shorter times in the patient framework (0 minutes) and the neuron framework (0 minutes) than in the time framework (1.75 minutes). Conclusion: Vascular neurologists indicate they emphasize beneficence over autonomy in deciding when to forego further attempts to reach consent providers to proceed with thrombolytic therapy under the doctrine of presumed consent. Their preference for rapid intervention is magnified when decisions are framed in person failure to benefit and neuron loss, compared with simple chronologic time.
Sleep-disordered breathing and stroke Ali, Latisha K; Avidan, Alon Y
Reviews in neurological diseases,
2008-Fall, Letnik:
5, Številka:
4
Journal Article
Sleep and stroke have an important and fascinating interaction. Patients with sleep-disordered breathing present with cardiovascular heart disease, cognitive decline, and increased risk of stroke. ...Stroke adversely affects sleep and factors such as prolonged immobilization, chronic pain, nocturnal hypoxia, and depression, which can also adversely impact sleep quality. Obstructive sleep apnea (OSA), one of the most common and serious sleep disturbances, manifests itself in almost 50% of all stroke patients. Sleep apnea patients who experience a stroke may be at a greater impairment in their rehabilitation potential and have increased risk of secondary stroke and mortality. Given these factors, the practicing neurologist should possess the skills to appropriately recognize, rapidly diagnose, and properly manage stroke patients with OSA.
Abstract only Background: Considering the recent advances in endovascular thrombectomy and advances in neurocritical care of patients with intracranial hemorrhage (ICH), there is an urgent need to ...develop tools for paramedics to identify patients likely to benefit from direct routing to comprehensive stroke centers (CSC). We report prospective validation of the Los Angeles Motor Scale (LAMS) performed by paramedics in the field, and compare its performance with other proposed prehospital LVO-identification scales. Methods: We analyzed all subjects enrolled in the NIH Field Administration of Stroke Therapy -Magnesium (FAST-MAG) trial transported directly to an academic center with a policy of performing immediate CTA or MRA imaging for all likely strokes. Prehospital LAMS was performed by paramedics prior to field enrollment. Hospital arrival (HA) LAMS and NIHSS were performed by trained study nurses after ED arrival. RACE, PASS, and 3i SS scales were calculated from NIHSS items. LVO in a proximal cerebral artery (ICA, MCA M1 & M2, Vertebral, Basilar and PCA P1 & 2) was determined by 3 vascular neurologists with expertise in neuroimaging. An LVO or ICH were considered as CSC appropriate patients. Results: Among 94 patients, age was 68 (±13) and 49% were female. Final diagnoses were acute cerebral ischemia in 71 (76%), intracranial hemorrhage in 18 (19%), mimic in 5 (5%). Overall, 48 patients (68%) had LVO, including MCA (30), ICA (14), basilar (1), vertebral (1) and PCA (2), and 66 (70%) were CSC-appropriate (LVO or ICH). In prediction of LVO, prehospital LAMS had the highest sensitivity (71%) and moderate specificity (54%). 3i-SS had the highest specificity (83%) but lowest sensitivity (40%). In prediction of CSC-appropriate patients, prehospital LAMS had the highest sensitivity (69%) and 3i-SS had the highest specificity (93%) but lowest sensitivity (37%). When comparing receiver operating curves, PM LAMS had AUC of 0.761, HA RACE 0.752, HA 3i SS 0.732, and HA PASS 0.712. Conclusions: Prehospital LAMS score of 4 or higher identified CSC-appropriate patients with good sensitivity and moderate specificity, and performed similar to or better than other proposed scales. LAMS is easy to administer and reproducible, and widely used currently by paramedics nationwide.
OBJECTIVE:To assess race-ethnic differences in acute blood pressure (BP) following intracerebral hemorrhage (ICH) and the contribution to disparities in ICH outcome.
METHODS:BPs in the field ...(emergency medical services EMS), emergency department (ED), and at 24 hours were compared and adjusted for group differences between non-Hispanic black (black), non-Hispanic white (white), and Hispanic participants in the Ethnic Racial Variations of Intracerebral Hemorrhage case-control study. Outcome was obtained by modified Rankin Scale (mRS) score at 3 months. We analyzed race-ethnic differences in good outcome (mRS ≤ 2) and mortality after adjusting for baseline differences and included BP recordings in this model.
RESULTS:Of 2,069 ICH cases enrolled, 30% were white, 37% black, and 33% Hispanic. Black and Hispanic patients had higher EMS and ED systolic and diastolic BPs compared with white patients (p = 0.0001). Although attenuated, at 24 hours after admission, black patients had higher systolic and diastolic BPs. After adjusting for baseline differences, significant race/ethnic differences persisted for EMS systolic, ED systolic and diastolic, and 24-hours diastolic BP. Only ED systolic and diastolic BP was associated with poor functional outcome, and no BP predicted mortality. We found no race-ethnic differences in 3-month functional outcome or mortality after adjusting for group differences, including acute BPs.
CONCLUSIONS:Although black and Hispanic patients had higher BPs than white patients at presentation, we did not find race-ethnic disparities in 3-month functional outcome or mortality. ED systolic and diastolic BP was associated with poor functional outcome, but not mortality, in this race-ethnically diverse population.
Abstract only Background & Purpose: Children were excluded from the recent positive mechanical thrombectomy trials and the literature on endovascular therapy in this population needs to be built. We ...report here case series of pediatric patients who received mechanical thrombectomy at our institution. Methodology: Our prospectively collected UCLA acute stroke database from 2000 to present was retrospectively reviewed. Only patients <18 years old with large vessel occlusion who underwent acute endovascular therapy were included in this study. Demographic, clinical, pre- and post-intervention imaging, and the interventional procedure data were analyzed. The Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score at presentation and at discharge, as well as pediatric-modified Rankin Scale (Ped-mRS) up-to 90 days were used. Results: All five patients (ages 2-15) suffered an embolic stroke. Three of them had congenital heart disease and one had repeated episodes of syncope and bradycardia. No risk factors other than PFO were identified in the fifth patient. Occlusion sites were ICA-M1 (n=2), M1 (n=2), and M1-M2 (n=1). IV tPA was used in one case. Time from last known well to reperfusion ranged from 3h to 9h 28min and the patients’ initial collaterals were scored between grades 2 - 3. AOL score of 3 was achieved in all cases, TICI 2a in two and TICI 2b in three cases. Merci was used in two cases, Penumbra, Solitaire and Mindframe Capture were used each in one case. One patient developed intracerebral hemorrhage that required hemicraniectomy. The PedNIHSS score at discharge ranged from 0 to 8 and the Ped-mRS score up-to 90 days ranged from 0 to 4, with 80% of children having Ped-mRS ≤ 3. Conclusion: Mechanical thrombectomy may be a safe and feasible treatment option in pediatric stroke patients with large vessel occlusion.
Abstract only Introduction: In acute arterial occlusion, the FLAIR vascular hyperintensity (FVH) sign have been linked to slow flow in leptomeningeal collaterals and cerebral hypoperfusion, but the ...impact on clinical outcome is still controversial. In this study, we aimed to investigate the association between FVH-ASPECTS pattern and outcome in acute M1-MCA occlusion patients with endovascular treatment. Methods: We included acute M1-MCA occlusion patients treated with endovascular therapy. All patients had DWI and FLAIR before endovascular therapy. Distal FVH ASPECT score was evaluated according to distal MCA-ASPECT area (M1-M6) and acute DWI lesion was also reviewed. Presence of FVH inside DWI positive lesion and outside DWI positive lesion was separately analyzed. We analyzed clinical outcome after endovascular therapy based on these different FVH-ASPECTS patterns. Results: Among 101 patients that met inclusion criteria for the study, mean age was 66.2±17.8 and median NIHSS was 17.0 (IQR 12.0-21.0). FVH-ASPECTS measured outside of the DWI lesion was significantly higher in patients with good outcome (mRS 0-2), (8.0 vs 4.0, p<0.001). Logistic regression demonstrated that FVH-ASPECTS outside of the DWI lesion was independently associated with clinical outcome of these patients (OR 1.3, p=0.013). FVH-ASPECTS inside the DWI lesion was associated with hemorrhage transformation (OR 1.3, p=0.019). Conclusion: Higher FVH-ASPECTS measured outside the DWI lesion is associated with good clinical outcomes in patients undergoing endovascular therapy. FVH-ASPECTS measured inside the DWI lesion was predictive of hemorrhage transformation. FVH pattern, not number, can predict outcome of acute M1-MCA occlusion patients after endovascular therapy.
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