OBJECTIVES: Delayed cerebral ischemia (DCI) is a major driver of morbidity after aneurysmal subarachnoid hemorrhage (aSAH). Quantitative pupillometry has been shown to be of prognostic value after ...acute neurological injury. However, the evidence for the use of pupillometric features for the detection of DCI has been conflicting. The aim of this study was to investigate the prognostic value of frequent pupillometric monitoring for DCI detection. DESIGN: Observational cohort study from a prospective aSAH registry. SETTING: Tertiary referral center. PATIENTS: Adult patients with confirmed aSAH admitted to the ICU between March 2019 and December 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred fourteen patients were included, of which 31 (27.2%) suffered from DCI. All patients underwent frequent pupillometry (every 3 hr). We determined the absolute value of the neurological pupil index (NPi) and constriction velocity (CV), and their value normalized to the maximal recorded value between the admission and the pupillometry measure to account for personalized baselines. The association between pupillometry values and the occurrence of DCI within 6–24 hours was investigated. Normalized CV had the best discriminative performance to identify DCI within 8 hours, with an area under the receiver operating characteristic curve of 0.82 (95% CI, 0.69–0.91). NPi, as well as non-normalized metrics, were not significantly associated with DCI. CONCLUSIONS: Normalized CV has a clinically and statistically significant association with the occurrence of DCI after aSAH. Frequent quantitative pupillometry could improve the multimodal monitoring of patients after aSAH with the goal of improving the identification of patients likely to benefit from therapeutic interventions.
Central retinal artery occlusion (CRAO) often leads to permanent monocular blindness. Hence, early recognition and rapid re-perfusion is of paramount importance. This study aims to describe ...prehospital pathways in CRAO compared to stroke and study the knowledge about CRAO.
(1) Description of baseline characteristics, prehospital pathways/delays, and acute treatment (thrombolysis/thrombectomy vs. standard of care) of patients with CRAO and ischemic stroke registered in the Swiss Stroke Registry. (2) Online survey about CRAO knowledge amongst population, general practitioners (GPs) and ophthalmologists in Eastern Switzerland.
Three hundred and ninety seven CRAO and 32,816 ischemic stroke cases were registered from 2014 until 2019 in 20 Stroke Centers/Units in Switzerland. In CRAO, 25.6% arrived at the hospital within 4 h of symptom onset and had a lower rate of emergency referrals. Hence, the symptom-to-door time was significantly longer in CRAO compared to stroke (852 min. vs. 300 min). The thrombolysis/thrombectomy rate was 13.2% in CRAO and 30.9% in stroke. 28.6% of the surveyed population recognized CRAO-symptoms, 55.4% of which would present directly to the emergency department in contrast to 90.0% with stroke symptoms. Almost 100% of the ophthalmologist and general practitioners recognized CRAO as a medical emergency and 1/3 of them considered IV thrombolysis a potentially beneficial therapy.
CRAO awareness of the general population and physician awareness about the treatment options as well as the non-standardized prehospital organization, seems to be the main reason for the prehospital delays and impedes treating CRAO patients. Educational efforts should be undertaken to improve awareness about CRAO.
BackgroundWe investigated outcomes in patients with intracerebral haemorrhage (ICH) according to prior anticoagulation treatment with Vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs) ...or no anticoagulation.MethodsThis is an individual patient data study combining two prospective national stroke registries from Switzerland and Norway (2013–2019). We included all consecutive patients with ICH from both registries. The main outcomes were favourable functional outcome (modified Rankin Scale 0–2) and mortality at 3 months.ResultsAmong 11 349 patients with ICH (mean age 73.6 years; 47.6% women), 1491 (13.1%) were taking VKAs and 1205 (10.6%) DOACs (95.2% factor Xa inhibitors). The median percentage of patients on prior anticoagulation was 23.7 (IQR 22.6–25.1) with VKAs decreasing (from 18.3% to 7.6%) and DOACs increasing (from 3.0% to 18.0%) over time. Prior VKA therapy (n=209 (22.3%); adjusted ORs (aOR), 0.64; 95% CI, 0.49 to 0.84) and prior DOAC therapy (n=184 (25.7%); aOR, 0.64; 95% CI, 0.47 to 0.87) were independently associated with lower odds of favourable outcome compared with patients without anticoagulation (n=2037 (38.8%)). Prior VKA therapy (n=720 (49.4%); aOR, 1.71; 95% CI, 1.41 to 2.08) and prior DOAC therapy (n=460 (39.7%); aOR, 1.28; 95% CI, 1.02 to 1.60) were independently associated with higher odds of mortality compared with patients without anticoagulation (n=2512 (30.2%)).ConclusionsThe spectrum of anticoagulation-associated ICH changed over time. Compared with patients without prior anticoagulation, prior VKA treatment and prior DOAC treatment were independently associated with lower odds of favourable outcome and higher odds of mortality at 3 months. Specific reversal agents unavailable during the study period might improve outcomes of DOAC-associated ICH in the future.
After stroke, penumbral salvage determines clinical recovery. However, the rescued penumbra may be affected by selective neuronal loss, as documented both histopathologically in animals and using the ...validated in vivo positron emission tomography marker (11)C-flumazenil in humans. However, whether the non-infarcted penumbra is capable of neuronal activation, and how selective neuronal loss may interfere, is unknown. Here we prospectively mapped the topographical relationships between functional magnetic resonance imaging responses and non-infarcted penumbra, and tested the hypothesis that the former do take place in the latter, but only in its subsets spared selective neuronal loss. Seven patients (mean age 74 years; three thrombolysed) with first-ever acute anterior circulation stroke, presence of penumbra on computed tomography perfusion performed within 6 h of onset, and substantial deficit on admission but good outcome at 1-3 months (National Institute of Health Stroke Score range 6-13 and 0-1, respectively, P = 0.001), were studied. At follow-up, patients underwent structural magnetic resonance imaging to map the infarct, functional magnetic resonance imaging (three tasks selected to probe the right or left hemisphere), and (11)C-flumazenil positron emission tomography generating binding potential maps. Patients with significant carotid or middle-cerebral artery disease or impaired vasoreactivity were excluded. Following image coregistration, the non-infarcted penumbra comprised all acutely ischaemic voxels (identified on acute computed tomography perfusion using previously validated thresholds) not part of the final infarct. To test our hypotheses, the overlap between functional magnetic resonance imaging activation clusters and non-infarcted penumbra was mapped, and binding potential values then computed both within and outside this overlap. In addition, the overlap between functional magnetic resonance imaging activation clusters and areas of significantly reduced binding potential (determined using Statistical Parametric Mapping against 16 age-matched control subjects) was assessed in each patient. An overlap between non-infarcted penumbra and functional magnetic resonance imaging clusters was present in seven of seven patients, substantial in four. Binding potential was significantly reduced in the whole non-infarcted penumbra (P < 0.01) but not within the functional magnetic resonance imaging overlap. Clusters with significantly reduced binding potential showed virtually no overlap with functional magnetic resonance imaging activation compared with 12 age-matched controls (P = 0.04).The results from this proof of principle study suggest that 1-3 months after stroke the non-infarcted penumbra is capable of neuronal activation, consistent with its established role in recovery of neurological functions. However, although the non-infarcted penumbra as a whole was affected by selective neuronal loss, activations tended to occur within portions spared selective neuronal loss, suggesting the latter impedes neuronal activation. Although its clinical correlates are still elusive, selective neuronal loss may represent a novel therapeutic target in the aftermath of ischaemic stroke.
The National Institutes of Health Stroke Scale (NIHSS) is commonly used to triage and monitor the evolution of stroke victims. Data regarding NIHSS knowledge in nurses and physicians working with ...stroke patients are scarce, and a progressive decline in specific knowledge regarding this challenging scale is to be expected even among NIHSS certified personnel. This protocol was designed according to the CONSORT-eHealth (Consolidated Standards of Reporting Trials) guidelines. It describes the design of a randomized controlled trial whose primary objective is to determine if nurses and physicians who work in stroke units improve their NIHSS knowledge more significantly after following a highly interactive e-learning module than after following the traditional didactic video. Univariate and multivariable linear regression will be used to analyze the primary outcome, which will be the difference between the score on a 50-question quiz answered before and immediately after following the allocated learning material. Secondary outcomes will include knowledge retention at one month, assessed using the same 50-question quiz, user satisfaction, user course duration perception, and probability of recommending the allocated learning method. The study is scheduled to begin during the first semester of 2022.
Background
Acute ischemic stroke attributed to basilar artery occlusion (BAO) results in high rates of death and significant morbidity. Endovascular thrombectomy an effective treatment for BAO, but ...imaging parameters that predict a favorable response to thrombectomy are not well defined. We determined which imaging parameters were associated with poor outcome in patients with BAO treated by thrombectomy.
Methods
We performed a retrospective cohort study of patients with BAO who underwent thrombectomy at multiple international stroke centers. All patients underwent computed tomography or magnetic resonance perfusion imaging before treatment. Clinical and imaging variables were measured and correlated to poor functional outcomes (modified Rankin scale score ≥4) after thrombectomy. Imaging variables included the following: Critical Area Perfusion Score, Posterior Circulation Alberta Stroke Program Early Computed Tomography Score, ischemic core volume (30% cerebral blood flow on computed tomography perfusion or diffusion‐weighted imaging), and volume of time to maximum >10 seconds. Clinical and imaging variables associated with poor functional outcome were assessed by a multivariable binary logistic regression analysis.
Results
A total of 102 patients were included in the study. Median patient age was 66.5 years (interquartile range IQR, 55–78), median presentation National Institutes of Health Stroke Scale score was 14 (IQR, 7–23), and the median time from last seen normal was 4 hours (IQR, 1:52–9:20). Patient age (odds ratio OR, 1.37 per 5‐year increment 95% CI, 1.08–1.72; P=0.008), presentation National Institutes of Health Stroke Scale score (OR, 1.11 95% CI, 1.04–1.18; P=0.001), successful reperfusion after thrombectomy (OR, 0.03 95% CI, 0.003–0.25; P=0.002), Posterior Circulation Alberta Stroke Program Early Computed Tomography Score ≤6 (OR, 11.40 95% CI, 1.73–75; P=0.011), and Critical Area Perfusion Score >3 (OR, 26.22 95% CI, 1.07–642;
P
=0.045) independently predicted poor outcome after BAO thrombectomy. Ischemic core volume (30% cerebral blood flow) and volume of time to maximum >10 seconds did not predict poor outcome.
Conclusion
Age, National Institutes of Health Stroke Scale presentation, unsuccessful reperfusion, Critical Area Perfusion Score >3, and Posterior Circulation Alberta Stroke Program Early Computed Tomography Score ≤6 are independently associated with poor outcome after BAO thrombectomy.
Depicting the salvageable tissue is increasingly used in the clinical setting following stroke. As absolute cerebral blood flow (CBF) is difficult to measure using perfusion magnetic resonance or ...computed tomography and has limitations as a penumbral marker, time-based variables, particularly the mean transit time (MTT), are routinely used as surrogates. However, a direct validation of MTT as a predictor of the penumbra threshold using gold-standard positron emission tomography (PET) is lacking. Using 15O-PET data sets obtained from two independent acute stroke samples (N=7 and N=30, respectively), we derived areas under the curve (AUCs), optimal thresholds (OTs), and 90%-specificity thresholds (90%-Ts) from receiver operating characteristic curves for absolute MTT, MTT delay, and MTT ratio to predict three penumbra thresholds (‘classic’: CBF <20 mL/100 g per min; ‘normalized’: CBF ratio <0.5; and ‘stringent’: both CBF <20 mL/100 g per min and oxygen extraction fraction >0.55). In sample 1, AUCs ranged from 0.79 to 0.92, indicating good validity; OTs ranged from 7.8 to 8.3 seconds, 2.8 to 4.7 seconds, and 151% to 267% for absolute MTT, MTT delay, and MTT ratio, respectively, while as expected, 90%-Ts were longer. There was no significant difference between sample 1 and sample 2 for any of the above measurements, save for a single MTT parameter with a single penumbra threshold. These consistent findings from gold-standard PET obtained in two independent cohorts document that MTT is a very good surrogate to CBF for depicting the penumbra threshold.
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