Hemorrhagic transformation can occur as a complication of endovascular treatment for acute ischemic stroke. This study aimed to determine whether ischemia depth as measured by admission CTP metrics ...can predict the development of hemorrhagic transformation at 24 hours.
Patients with baseline CTP and 24-hour follow-up imaging from the ESCAPE-NA1 trial were included. RAPID software was used to generate CTP volume maps for relative CBF, CBV, and time-to-maximum at different thresholds. Hemorrhage on 24-hour imaging was classified according to the Heidelberg system, and volumes were calculated. Univariable and multivariable regression analyses assessed the association between CTP lesion volumes and hemorrhage/hemorrhage subtypes.
Among 408 patients with baseline CTP, 142 (35%) had hemorrhagic transformation at 24-hour follow-up, with 89 (63%) classified as hemorrhagic infarction (HI1/HI2), and 53 (37%), as parenchymal hematoma (PH1/PH2). Patients with HI or PH had larger volumes of low relative CBF and CBV at each threshold compared with those without hemorrhage. After we adjustied for baseline and treatment variables, only increased relative CBF <30% lesion volume was associated with any hemorrhage (adjusted OR, 1.14; 95% CI, 1.02-1.27 per 10 mL), as well as parenchymal hematoma (adjusted OR, 1.23; 95% CI, 1.06-1.43 per 10 mL). No significant associations were observed for hemorrhagic infarction.
Larger "core" volumes of relative CBF <30% were associated with an increased risk of PH following endovascular treatment. This particular metric, in conjunction with other clinical and imaging variables, may, therefore, help estimate the risk of post-endovascular treatment hemorrhagic complications.
Abstract only Background: Early infarct growth after endovascular therapy (EVT) may lead to unfavorable outcomes despite successful reperfusion. The REPERFUSE-NA1 study replicated the preclinical NA1 ...experiment by investigating the effect of NA1 on early DWI infarct growth in acute ischemic stroke patients receiving EVT. Methods: REPERFUSE-NA1 was a sub-study of the randomized controlled trial ESCAPE-NA1 (ClinicalTrialGov NCT02930018). Patients received MRI within 5 hours and 24 hours of EVT. The primary outcome was early diffusion weighted (DWI) infarct growth. The secondary outcome was region-specific DWI infarct growth in the white matter, cortical grey matter and basal ganglia. Results: A total of 71 patients was included, of whom 67 had sufficient MR imaging at 5h and 24h post-EVT. For patients who received NA1 compared to placebo, the median age (68.8 v 67.5), baseline NIHSS (15.5 v 16), time from symptom onset to reperfusion (161 v 167 minutes) and mTICI 2b-3 (94.4% v 94.3%) were statistically not different. Median DWI volumes post-EVT (5h) were 13.0 mL (IQR, 5.9-28.1) in NA1 and 13.3 mL (IQR, 3.1-27.0) in placebo. At 24h median DWI volumes increased to 22.6 mL (IQR, 11.2-63.4) in the NA1 group and 22.4 mL (IQR, 7.4-52.3) in the placebo group, equating to a 48.4% DWI volume growth in the NA1 group and a 66.0% growth in the placebo group. Median DWI volume growth was 55.1% for NA1 patients who received alteplase compared to 41.3% for NA1 patients who did not receive alteplase (p=0.65). In terms of region-specific infarct volumes, absolute growth was 2.27mL (IQR, 0.70-6.19) in the white matter, 3.93 mL (IQR, 0.18-12.40) in cortical grey matter, and 1.20 mL (IQR, 0.31-2.62) in basal ganglia in the overall cohort. Between the NA1 and the placebo groups, lesion growth in the white matter (1.96 mL v 2.77mL), cortical gray matter (3.93 mL v 4.07 mL) and basal ganglia (1.62 mL v 0.89 mL) did not differ significantly. Conclusion: There was substantial infarct growth early after EVT, with the largest absolute growth in cortical grey matter. No significant effect of NA1 on early infarct growth was observed.
Background Prehospital delay reduces the proportion of patients with stroke treated with recanalization therapies. We aimed to identify novel and modifiable risk factors for prehospital delay. ...Methods and Results We included patients with an ischemic stroke confirmed by diffusion-weighted magnetic resonance imaging, symptom onset within 24 hours and hospitalized in the Stroke Center of the University Hospital Basel, Switzerland. Trained study nurses interviewed patients and proxies along a standardized questionnaire. Prehospital delay was defined as >4.5 hours between stroke onset-or time point of wake-up-and admission. Overall, 336 patients were enrolled. Prehospital delay was observed in 140 patients (42%). The first healthcare professionals to be alarmed were family doctors for 29% of patients (97/336), and a quarter of these patients had a baseline National Institute of Health Stroke Scale score of 4 or higher. The main modifiable risk factor for prehospital delay was a face-to-face visit to the family doctor (adjusted odds ratio, 4.19; 95% CI, 1.85-9.46). Despite transport by emergency medical services being associated with less prehospital delay (adjusted odds ratio, 0.41; 95% CI, 0.24-0.71), a minority of patients (39%) who first called their family doctor were transported by emergency medical services to the hospital. The second risk factor was lack of awareness of stroke symptoms (adjusted odds ratio, 4.14; 95% CI, 2.36-7.24). Conclusions Almost 1 in 3 patients with a diffusion-weighted magnetic resonance imaging-confirmed ischemic stroke first called the family doctor practice. Face-to-face visits to the family doctor quadrupled the odds of prehospital delay. Efforts to reduce prehospital delay should address family doctors and their staffs as important partners in the prehospital pathway. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02798770.
Objectives:
To present a patient with acute hemorrhagic leukoencephalitis (AHLE) and a systematic review of the literature analyzing diagnostic procedures, treatment, and outcomes of AHLE.
Methods:
...PubMed and Cochrane databases were screened. Papers published since 01/01/2000 describing adult patients are reported according to the PRISMA-guidelines.
Results:
A 59-year old male with rapidly developing coma and cerebral biopsy changes compatible with AHLE is presented followed by 43 case reports from the literature including males in 67% and a mean age of 38 years. Mortality was 47%. Infectious pathogens were reported in 35%, preexisting autoimmune diseases were identified in 12%. Neuroimaging revealed uni- or bihemispheric lesions in 65% and isolated lesions of the cerebellum, pons, medulla oblongata or the spinal cord without concomitant hemispheric involvement in 16%. Analysis of the cerebrospinal fluid showed an increased protein level in 87%, elevated white blood cells in 65%, and erythrocytes in 39%. Histology (reported in 58%) supported the diagnosis of AHLE in all cases. Glucocorticoids were used most commonly (97%), followed by plasmapheresis (26%), and intravenous immunoglobulins (12%), without a clear temporal relationship between treatment and the patients' clinical course.
Conclusions:
Although mortality was lower than previously reported, AHLE remains a life-threatening neurologic emergency with high mortality. Diagnosis is challenging as the level of evidence regarding the diagnostic yield of clinical, neuroimaging and laboratory characteristics remains low. Hence, clinicians are urged to heighten their awareness and to prompt cerebral biopsies in the context of rapidly progressive neurologic decline of unknown origin with the concurrence of the compiled characteristics. Future studies need to focus on treatment characteristics and their effects on course and outcome.
Background and aim
Loss of time is a major obstacle to efficient stroke treatment. Our telestroke path intends to optimize prehospital triage using a video link connecting ambulance personnel and a ...stroke physician. The objectives were as follows: (1) To identify patients suffering a stroke and (2) in particular large vessel occlusion (LVO) strokes as candidates for endovascular treatment. We have chosen the Rapid Arterial Occlusion Evaluation (RACE) scale for this purpose.
Methods
This analysis aimed to verify the feasibility of prehospital stroke identification by video assessment. In this prospective telestroke cohort study, we included 97 subjects, in which the RACE score (items: facial palsy, arm and leg motor function, head and gaze deviation, and aphasia or agnosia) was applied, and the assessment videotaped by a trained member of the Emergency Medical Services (EMS) in the field using a mobile device. Each recorded patient video was independently assessed by three experienced stroke physicians from a certified stroke center and compared to the neuroimaging gold standard. Within this feasibility study, the stroke code was not altered by the outcome of the RACE assessment, and all patients underwent the standard procedures within the emergency unit.
Results
We analyzed 97 patients (median age 78 years, 53% women), of whom 51 (52.6%) suffered an acute stroke, 12 (23.5%) of which were due to an LVO and 46 patients had symptoms mimicking a stroke. The sensitivity of stroke identification was 77.8%, and specificity was 53.6%. In regard to the identification of an LVO, sensitivity was 69.4% and specificity was 84.3%. The inter-rater agreement in the RACE-score assessment was ICC = 0.82 (intraclass-correlation coefficient).
Conclusion
These results confirm our hypothesis that the local telestroke concept is feasible. It allows correct (i) stroke and (ii) LVO identification in the majority of the cases and thus has the potential to assist in efficient prehospital triage.
Background Patients with white matter disease (WMD) – a key marker of cerebral small vessel disease – may have less brain reserve to cope with ischemic injury. The relationship of WMD to functional ...recovery after endovascular thrombectomy is uncertain. We aim to explore the association between WMD and functional outcome, assessed at multiple time‐points postendovascular thrombectomy. Methods In this post hoc analysis, we analyzed noncontrast computed tomography‐imaging from the ESCAPE‐NA1 (Safety and Efficacy of Nerinetide NA‐1 in Subjects Undergoing Endovascular Thrombectomy for Stroke) trial and assessed WMD by using the total Fazekas‐score (score range: 0–6). The primary outcome was repeated measurements of the modified Rankin scale (mRS) scores (i.e., day‐5/discharge, day‐30, and day‐90). Secondary outcome measures were the ordinal‐mRS at 90‐days, 90‐day‐mRS0–2, and 90‐day‐mortality. Mixed‐linear and binary/ordinal logistic regressions were performed, adjusting for age, sex, baseline National Institutes of Health Stroke Scale, cortical atrophy, chronic infarctions, stroke laterality, follow‐up infarct volume, and alteplase–nerinetide interaction. Sensitivity analyses were done including only those patients for whom magnetic resonance imaging was available. Results We included 1102 patients with noncontrast computed tomography (median age 71, interquartile range: 61–80; median National Institutes of Health Stroke Scale 17, interquartile range: 12–21). The median total Fazekas‐score was 1(interquartile range: 0–2). Out of 1202 patients, 566 had follow‐up magnetic resonance imaging. We observed heterogeneity in functional recovery with varying degrees of WMD‐burden ( P <0.001). Patients with Fazekas=3–6 fared worse at every time‐point after endovascular thrombectomy, compared with patients with Fazekas=0–1. At 30‐days, the adjusted difference of the mean mRS=0.47; 95% CI, 0.22–0.72 and at 90‐days: adjusted difference=0.60 (95% CI, 0.36–0.85). Higher WMD‐burdens were also associated with worse 90‐day mRS (adjusted common odds ratio for Fazekas=3–6 versus 0–1: 1.42; 95% CI, 1.03–1.96). Similar results were found in magnetic resonance imaging‐only sensitivity analyses. Conclusion Patients with more WMD showed worse functional recovery after endovascular thrombectomy, compared with patients without WMD, even after adjusting for age and chronic disease markers like atrophy and chronic infarctions. These data may further help inform treatment expectations and recovery‐related planning, by using simple visual ratings on routinely acquired noncontrast computed tomography.
Background
Cerebral microbleeds (CMBs) may have a differential impact on clinical outcome in stroke patients with atrial fibrillation (AF) treated with different types of oral anticoagulation (OAC).
...Methods
Observational single-center study on AF-stroke-patients treated with OAC. Magnetic-resonance-imaging was performed to assess CMBs. Outcome measures consisted of recurrent ischemic stroke (IS), intracranial hemorrhage (ICH), death, and their combined analysis. Functional disability was assessed by mRS. Using adjusted logistic regression and Cox proportional-hazards models, we assessed the association of the presence of CMBs and OAC type (vitamin K antagonists VKAs vs. direct oral anticoagulants DOACs) with clinical outcome.
Results
Of 310 AF-stroke patients treated with OAC DOACs:
n
= 234 (75%); VKAs:
n
= 76 (25%), CMBs were present in 86 (28%) patients; of these, 66 (77%) received DOACs. In both groups, CMBs were associated with an increased risk for the composite outcome: VKAs: HR 3.654 1.614; 8.277;
p
= 0.002; DOACs: HR 2.230 1.233; 4.034;
p
= 0.008. Patients with CMBs had ~50% higher absolute rates of the composite outcome compared to the overall cohort, with a comparable ratio between treatment groups VKAs 13/20(65%) vs. DOACs 19/66(29%);
p
< 0.01. The VKA-group had a 2-fold higher IS VKAs:4 (20%) vs. DOACs:6 (9%);
p
= 0.35 and a 10-fold higher ICH rate VKAs: 3 (15%) vs. DOACs: 1 (1.5%);
p
= 0.038. No significant interaction was observed between type of OAC and presence of CMBs. DOAC-patients showed a significantly better functional outcome (OR 0.40 0.17; 0.94;
p
= 0.04).
Conclusions
In AF-stroke patients treated with OAC, the presence of CMBs was associated with an unfavorable composite outcome for both VKAs and DOACs, with a higher risk for recurrent IS than for ICH. Strokes were numerically higher under VKAs and increased in the presence of CMBs.
Clinical trial registration
http://www.clinicaltrials.gov
, Unique identifier: NCT03826927.
Abstract only Introduction The current neurovascular research funding environment is highly competitive, stifling collaboration and hindering progress. Further, specific groups of ...researchers/research topics are disproportionately affected, resulting in inequity in the funding process. These include early‐career researchers, women, and researchers from low‐middle income countries. Certain conditions, e.g., rare, stroke‐related diseases are due to their low prevalence not suitable for clinical trials, and therefore even less likely to receive funding. Currently, there is no easy way for people working on such topics to come together and collaborate. To address this problem, a novel internet‐based platform, Collavidence (www.collavidence.com), was designed. The idea is to complement current systems of neurovascular research collaboration and funding for more inclusive, efficient, and impactful research results. The aim of this study is to present the initial performance of the platform in achieving this goal. Methods Analytics on pre‐defined user‐, project‐, and interaction‐based metrics will be performed to describe the level of platform engagement in the initial months following launch. These include the number of users and projects posted, the amount of funding accumulated, the proportion of successfully funded projects, and the iterative improvement of the proposals. Further, the relative engagement of early‐career, female researchers, and researchers from low‐middle‐income countries will be assessed. Results A qualitative assessment of the value of the overall platform, the process of iterative review, and possibilities for collaboration will be presented. Further, trends in platform engagement during the initial 3 months, including the relative distribution of specific user demographics to assess the platform’s success in encouraging equity, diversity, and inclusion, will be presented. Conclusions This study will assess the feasibility and initial success of Collavidence as a unique platform for neurovascular research collaboration and funding.
Over the past decades, continuous technological advances and the availability of novel therapies have enabled treatment of more acute medical conditions than ever before. Many of these treatments, ...such as intravenous thrombolysis and mechanical thrombectomy for acute ischemic stroke, are highly time sensitive. This has raised interest in shifting advanced acute care from hospitals to the prehospital setting. Key objectives of advanced prehospital stroke care may include (1) early targeted treatments in the prehospital setting, for example, intravenous thrombolysis for acute stroke, and (2) advanced prehospital diagnostics such as prehospital large vessel occlusion and intracranial hemorrhage detection, to help inform patient triage and potentially reduce subsequent workload in emergency departments. Major challenges that may hamper a swift transition to more advanced prehospital care are related to conducting clinical trials in the prehospital setting to provide sufficient evidence for emergency interventions, as well as ambulance design, infrastructure, emergency medical service personnel training and workload, and cost barriers. Utilizing new technologies such as telemedicine, mobile stroke units and portable diagnostic devices, customized software applications, and smart storage space management may help surmount these challenges and establish efficient, targeted care strategies that are achievable in the prehospital setting. In this article, we delineate the paradigm of shifting advanced stroke care to the prehospital setting and outline future directions in providing evidence-based, patient-centered prehospital care. While we use acute stroke as an illustrative example, these principles are not limited to stroke patients and can be applied to prehospital triage for any time-critical disease.
Abstract only Background: Stroke research is underfunded, but there is a paucity of data on the perspectives of researchers, funders, patients and the public about current funding paradigms. ...Understanding their priorities and opinions is important to guide meaningful innovation. Methods: The PERSPECT (Priorities & Expectations of Researchers, Donors, Patients and the Public Regarding the Funding & Conduct of Stroke Research) study involved in-depth, semi-structured one-on-one interviews with stroke researchers, funding organization representatives/philanthropists, patients, and members of the public. Participants were sampled using three axes (age, sex, ethnicity) to ensure diversity. They were asked to discuss thoughts about the state of stroke research funding and any potential or desired alternatives to current funding models. Qualitative analyses of transcripts included constant comparison and grounded theory content analysis. The study ended when the standard of thematic saturation was attained. Results: Forty-one interviews were completed (11 researchers, 10 research funders/philanthropists, 10 patients, 10 lay citizens). Researchers, philanthropists, patients, and public participants expressed a desire for greater transparency with grant funding processes, and voiced concerns that current models fostered bias towards certain topics and researchers. Patients and donors felt that conventional processes at times seemed disconnected from their interests. Crowdfunding was identified as an alternative strategy that could facilitate democratization in terms of topics studied, exploration of new frontiers, integration of diverse methods, and capacity building for less established researchers/centers. However, participants emphasized the importance of expert review, as in current processes, in building trust in proposal quality. They noted that successful crowdfunding strategies would require innovative approaches from researchers to promote their work. Conclusions: Our findings revealed stakeholder concerns about transparency and equity with current research funding paradigms. Stakeholders recognize crowdfunding as a useful alternative approach, but incorporation of expert review will be important to engender trust.
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