Prompt and accurate identification of stroke victims is essential to reduce time from symptom onset to adequate treatment and to improve neurological outcomes. Most neurologists evaluate the extent ...of neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), but the use of this scale by paramedics, the first healthcare providers to usually take care of stroke victims, has proven unreliable. This might be, at least in part, due to the teaching method. The video used to teach NIHSS lacks interactivity, while more engaging electronic learning (e-learning) methods might improve knowledge acquisition.
This study was designed to evaluate whether a highly interactive e-learning module could enhance NIHSS knowledge acquisition in paramedics.
A randomized controlled trial comparing a specially designed e-learning module with the original NIHSS video was performed with paramedics working in Geneva, Switzerland. A registration number was not required as our study does not come into the scope of the Swiss federal law on human research. The protocol was nevertheless submitted to the local ethics committee (Project ID 2017-00847), which issued a "Declaration of no objection." Paramedics were excluded if they had prior knowledge of or previous training in the NIHSS, or if they had worked in a neurology or neurosurgery ward. The primary outcome was overall performance in the study quiz, which contained 50 questions. Secondary outcomes were performance by NIHSS item, time to course and quiz completion, user satisfaction regarding the learning method, user perception of the course duration, and probability the user would recommend the course to a colleague.
The study was completed by 39 paramedics. There was a better overall median score (36/50 vs 33/50, P=.04) and a higher degree of satisfaction regarding the learning method in the e-learning group (90% vs 37%, P=.002). Users who had followed the e-learning module were more likely to recommend the course to a colleague (95% vs 63%, P=.02). Paramedics in the e-learning group took more time to complete the course (93 vs 59 minutes, P<.001), but considered the duration to be more adequate (75% vs 32%, P=.01). Time to quiz completion was similar between groups (25 vs 38 minutes, P=.12).
Use of an e-learning module shows promising results in teaching the NIHSS to paramedics.
Objective
Hippocampal sclerosis (HS) is a prominent biomarker of epilepsy. If acquired later in life, it usually occurs in the context of degenerative or acute inflammatory-infectious disease. ...Conversely, acute symptomatic seizures (ASS) are considered a risk factor for developing post-stroke epilepsy, but other factors remain unrecognized. Here, we hypothesize that silent hippocampal injury contributes to the development of post-stroke epilepsy.
Methods
We performed a retrospective observational study of patients hospitalized between 1/2007 and 12/2018 with an acute stroke in the Stroke Center of the Geneva University Hospital. Patients were included if they had a documented normal hippocampal complex at onset and a control MRI at ≥ 2 year interval without new lesion in the meantime.
Results
162 patients fulfilled our inclusion criteria. ASS during the first week (
p
< 0.0001) and epileptiform abnormalities in electroencephalography (EEG;
p
= 0.02) were more frequently associated with the development of epilepsy. Hemorrhagic stroke was strongly associated to both ASS and future focal epilepsy (
p
= 0.00097). Three patients (1.8%) developed hippocampal sclerosis ipsilateral to the cerebrovascular event between 2 and 5 years, all with ASS and hemorrhagic stroke.
Interpretation
ASS and epileptiform EEG abnormalities are strong predictors of post-stroke epilepsy. HS develops in a minority of patients after hemorrhagic lesions, leading to focal epilepsy. Prospective studies are required, including follow-up with EEG and if characterized by epileptiform discharges, with MRI, to determine the true frequency of HS and to better understand predictors of post-stroke epilepsy (AAS, stroke type, and HS), and their impact on stroke recovery.
IMPORTANCE: Thrombosis with thrombocytopenia syndrome (TTS) has been reported after vaccination with the SARS-CoV-2 vaccines ChAdOx1 nCov-19 (Oxford–AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & ...Johnson). OBJECTIVE: To describe the clinical characteristics and outcome of patients with cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination with and without TTS. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from an international registry of consecutive patients with CVST within 28 days of SARS-CoV-2 vaccination included between March 29 and June 18, 2021, from 81 hospitals in 19 countries. For reference, data from patients with CVST between 2015 and 2018 were derived from an existing international registry. Clinical characteristics and mortality rate were described for adults with (1) CVST in the setting of SARS-CoV-2 vaccine–induced immune thrombotic thrombocytopenia, (2) CVST after SARS-CoV-2 vaccination not fulling criteria for TTS, and (3) CVST unrelated to SARS-CoV-2 vaccination. EXPOSURES: Patients were classified as having TTS if they had new-onset thrombocytopenia without recent exposure to heparin, in accordance with the Brighton Collaboration interim criteria. MAIN OUTCOMES AND MEASURES: Clinical characteristics and mortality rate. RESULTS: Of 116 patients with postvaccination CVST, 78 (67.2%) had TTS, of whom 76 had been vaccinated with ChAdOx1 nCov-19; 38 (32.8%) had no indication of TTS. The control group included 207 patients with CVST before the COVID-19 pandemic. A total of 63 of 78 (81%), 30 of 38 (79%), and 145 of 207 (70.0%) patients, respectively, were female, and the mean (SD) age was 45 (14), 55 (20), and 42 (16) years, respectively. Concomitant thromboembolism occurred in 25 of 70 patients (36%) in the TTS group, 2 of 35 (6%) in the no TTS group, and 10 of 206 (4.9%) in the control group, and in-hospital mortality rates were 47% (36 of 76; 95% CI, 37-58), 5% (2 of 37; 95% CI, 1-18), and 3.9% (8 of 207; 95% CI, 2.0-7.4), respectively. The mortality rate was 61% (14 of 23) among patients in the TTS group diagnosed before the condition garnered attention in the scientific community and 42% (22 of 53) among patients diagnosed later. CONCLUSIONS AND RELEVANCE: In this cohort study of patients with CVST, a distinct clinical profile and high mortality rate was observed in patients meeting criteria for TTS after SARS-CoV-2 vaccination.
Abstract
BACKGROUND:
It has been postulated that the Gosling pulsatility index (PI) assessed with transcranial Doppler (TCD) has a diagnostic value for noninvasive estimation of intracranial pressure ...(ICP) and cerebral perfusion pressure (CPP).
OBJECTIVE:
To revisit this hypothesis with the use of a database of digitally stored signals from a cohort of head-injured patients.
METHODS:
We analyzed prospectively collected data of patients admitted to the Cambridge Neuroscience critical care unit who had continuous recordings of arterial blood pressure, ICP, and cerebral blood flow velocities (FVs) using TCD. PI was calculated (FVsys − FVdia)/FVmean over each recording session. Statistical analysis was performed using Spearman rank correlation, receiver-operator-characteristics methods, and modeling of a nonlinear PI-ICP/CPP graph.
RESULTS:
Seven hundred sixty-two recorded daily sessions from 290 patients were analyzed with a total recording time of 499.9 hours. The correlation between PI and ICP was 0.31 (P < .001) and for PI and CPP -0.41 (P < .001). The 95% prediction interval of ICP values for a given PI was more than ±15 mm Hg and for CPP more than ±25 mm Hg. The diagnostic value of PI to assess ICP area under the curve ranged from 0.62 (ICP >15 mm Hg) to 0.74 (ICP >35 mm Hg). For CPP, the area under the curve ranged from 0.68 (CPP <70 mm Hg) to 0.81 (CPP <50 mm Hg). Probability charts for elevated ICP/lowered CPP depending on PI were created.
CONCLUSION:
Overall, the value of TCD-PI to assess ICP and CPP noninvasively is very limited. However, extreme values of PI can still potentially be used in support of a decision for invasive ICP monitoring.
Abstract only Introduction: Imaging studies are used to guide patient selection for acute stroke treatment. Perfusion CT (pCT) is widely used to identify the acute ischemic core and penumbra, but the ...prediction of the final infarct remains challenging. With the advent of machine learning, algorithms learning the prediction of the final lesion from imaging data collected in the acute phase have been proposed. We aimed to investigate whether machine learning methods that integrate prior ischemic core segmentation improve the prediction of the final infarct after stroke. Methodology: We retrospectively included all stroke patients admitted to the Geneva University Hospital for intravenous and/or endovascular treatment from 01.2016 to 12.2017. All patients had acute pCT and follow-up MRI. An Attention-Gated 3D Unet was used as the baseline model on which the effect of access to a threshold-based ischemic core segmentation was tested. To ensure the efficient integration of information contained in voxels from the ischemic core, we extended the baseline model with a bayesian skip connection allowing only the prior to bypass most of the network. This modifies the model’s task to predict divergence from the prior representation. All models were evaluated for the prediction of the final infarct on follow-up MRI, given acute pCT maps as input. The output of each model was compared to finals lesions manually delineated by expert neurologists. Dice score was used to assess performance. Results: A total of 144 patients were included. Median hypoperfused tissue volume (Tmax > 6s) was 60 ml 17-134, median ischemic core (relative CBF < 38%) volume was 23 ml 17-33 and median final infarct volume was 13 ml 3-38. Dice score for the threshold based ischemic core segmentation was 0.1. The baseline model with and without prior segmentation as input achieved a Dice score of 0.19. Adding the proposed bayesian skip connection lead to a more efficient integration of the prior segmentation ensuring faster convergence and better performance with a final Dice score of 0.21. Conclusion: The evaluated deep learning model can effectively leverage the information contained in a prior segmentation of the ischemic core to enhance the learning process and improve the prediction of the final infarct after stroke.
Abstract only Background and Purpose: After stroke restricted to the primary motor cortex (M1), it is uncertain whether network reorganization associated with motor recovery involves the periinfarct ...or more remote brain regions. In humans, the challenge is to recruit patients with similar lesions in size and location. Methods: We studied 16 patients with focal M1 stroke and hand paresis. Motor function and resting-state MRI functional connectivity (FC) were studied at three time points: acute (<10 days), early subacute (3 weeks), and late subacute (3 months). FC correlates of motor recovery were investigated at three spatial scales, i) ipsilesional non-infarcted M1, ii) core motor network (including M1, premotor cortex (PMC), supplementary motor area (SMA), and primary somatosensory cortex), and iii) extended motor network including all regions structurally connected to the upper limb representation of M1. Results: Hand dexterity was impaired only in the acute phase ( P =0.036). At a small spatial scale, improved dexterity was associated with increased FC involving mainly the ipsilesional non-infarcted M1 and contralesional motor regions (cM1: rho=0.732; P =0.004; cPMC: rho=0.837, P <0.001; cSMA: rho=0.736; P =0.004). At a larger scale, motor recovery correlated with the relative increase in total FC strength in the core motor network compared to the extended motor network (rho=0.71; P =0.006). Conclusions: FC changes associated with motor improvement involve the perilesional M1 and do not extend beyond the core motor network. The ipsilesional non-infarcted M1 and core motor regions could hence be primary targets for future restorative therapies.
Abstract only Introduction: Endovascular treatment (EVT) is the therapy of choice, in patients with unknown stroke onset (unwitnessed and wake-up strokes) and large vessel occlusion (LVO) with a ...favorable perfusion pattern. Whether bridging therapy (intravenous thrombolysis (IVT) and EVT) is superior to EVT alone remains unknown. Material and Methods: We retrospectively included all patients admitted to the Geneva University Hospital from 01.2016 to 06.2020 with i) stroke of unknown onset, due to ii) anterior circulation occlusion, with iii) favorable CT perfusion pattern based on the DEFUSE criteria (ischemic core volume< 70ml; mismatch ratio >= 1.8 and mismatch volume >= 15ml), and iv) treated < 4.5 hours after symptom recognition. As a standard of care, the patients fulfilling these inclusion criteria were treated with EVT and IVT or EVT alone when IVT was contraindicated. Outcome measures were any intracerebral bleeding (symptomatic or asymptomatic), mortality and favorable outcome (mRS 0-1) at three months. Results: 32 patients were included (17 treated with EVT alone and 15 with EVT and IVT). Mean age was 69±18 yo. Median NIHSS was 16 (IQR 12-20) and median time from symptom recognition to treatment was 184 (146-226) minutes. Median hypoperfused tissue volume (Tmax > 6s) was 119 ml (80-151) and infarcted core (CBF ratio <30%) 8 ml (0-27). After propensity score weighting, bridging therapy was not associated with an increased risk of intracerebral bleeding (p=0.72) or mortality (p=0.55). The proportion of favorable outcomes at three months was similar between treatment groups (p=0.78). Conclusion: These results suggest that IVT before EVT is a safe therapeutic option in patients with unknown stroke onset selected on perfusion imaging and treated <4.5 hours after symptom recognition. Early administration of IVT may be particularly relevant before interhospital transfer to a comprehensive stroke center for EVT.
Cerebral amyloid angiopathy (CAA) is a common and well-defined small vessel disease characterized by the deposition of amyloid β in the vascular wall. CAA causes devastating outcomes related to ...intracerebral hemorrhage and cognitive decline in older adults. The shared pathogenic pathway between CAA and Alzheimer's disease, co-occuring frequently in the same subject, has important implications for cognitive outcomes and novel anti-amyloid-β immunotherapies. In this review, we present the epidemiology, pathophysiology, current diagnostic criteria of CAA, and future developments in the field.
Objective
The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral ...anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3‐month outcomes.
Methods
This was a cohort study of consecutive patients (2014–2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0–2) at 3 months.
Results
Of 8,179 patients (mean SD age, 79.8 9.6 years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, interquartile range 2–11) compared with VKA (6, 2–14) and controls (7, 3–15, p < 0.001; quantile regression: β −2.1, 95% confidence interval CI −2.6 to −1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 63%; adjusted odds ratio aOR 0.67; 95% CI 0.50–0.90) and particularly in patients on DOACs (69 of 464 15%; aOR 0.06; 95% CI 0.05–0.08) compared with controls (1,544 of 2,504 74%). sICH after IVT occurred in 3.6% (2.6–4.7%) of controls, 9 of 195 (4.6%; 1.9–9.2%; aOR 0.93; 95% CI 0.46–1.90) patients on VKA and 2 of 65 (3.1%; 0.4–10.8%, aOR 0.56; 95% CI 0.28–1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3‐month outcome (aOR 1.24; 1.01–1.51).
Interpretation
Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2021;89:42–53
The COVID-19 pandemic has considerably altered the regular medical education curriculum while increasing the need for health care professionals. Senior medical students are being incrementally ...deployed to the front line to address the shortage of certified physicians. These students, some of whom will be fast-tracked as physicians, may lack knowledge regarding the initial management of time-critical emergencies such as stroke.
Our aim was to determine whether an e-learning module could improve asynchronous distance knowledge acquisition of the National Institutes of Health Stroke Scale (NIHSS) in senior medical students compared to the traditional didactic video.
A randomized, data analyst-blinded web-based trial was conducted at the University of Geneva Faculty of Medicine between April and June 2020. Fifth year medical students followed a distance learning path designed to teach the NIHSS. The control group followed the traditional didactic video created by Patrick Lyden, while the e-learning group followed the updated version of a previously tested, highly interactive e-learning module. The main outcome was the score on a 50-question quiz displayed upon completion of the learning material. The difference in the proportion of correct answers for each specific NIHSS item was also assessed.
Out of 158 potential participants, 88 started their allocated learning path and 75 completed the trial. Participants who followed the e-learning module performed better than those who followed the video (38 correct answers, 95% CI 37-39, vs 35 correct answers, 95% CI 34-36, P<.001). Participants in the e-learning group scored better on five elements than the video group: key NIHSS concepts (P=.02), the consciousness - global item (P<.001), the facial palsy item (P=.04), the ataxia item (P=.03), and the sensory item (P=.04).
Compared to the traditional didactic video, a highly interactive e-learning module enhances asynchronous distance learning and NIHSS knowledge acquisition in senior medical students.
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