Clotilde Balucani

Streamlining of prehospital stroke management: the golden hour.

Thrombolysis with alteplase administered within a narrow therapeutic window provides an effective therapy for acute ischaemic stroke. However, mainly because of prehospital delay, patients often arrive too late for treatment, and no more than 1-8% of patients with stroke obtain this treatment. We recommend that all links in the prehospital stroke rescue chain must be optimised so that in the future more than a small minority of patients can profit from time-sensitive acute stroke therapy. Measures for improvement include continuous public awareness campaigns, education of emergency medical service personnel, the use of standardised, validated scales for recognition of stroke symptoms and for triaging to the appropriate institution, and advance notification to the receiving hospital. In the future, use of telemedicine technologies for interaction between the emergency site and hospital, and the strategy of treatment directly at the emergency site (mobile stroke unit concept), could contribute to more efficient use of resources and reduce the time taken to instigate treatment to within 60 min--the golden hour--of the onset of the symptoms of stroke.

Blood pressure variability and stroke outcome in patients with internal carotid artery occlusion

PURPOSE The aim of this study was to evaluate the relationship between arterial blood pressure (BP) variability during the acute phase and the 3-month outcome in ischemic stroke patients with internal carotid artery (ICA) occlusion. METHODS At least 10 BP measurements during the first 48 h after stroke onset were obtained in 89 patients with ICA occlusion. BP profile was described using various parameters: average of recordings, maximum (max), minimum (min), difference between max and min (max-min), standard deviation (SD) and coefficient of variation (CV) for both systolic and diastolic BP. Outcome at 3 months was defined using the modified Rankin Scale (mRS) score corrected for baseline stroke severity. RESULTS Fifty-five patients had a good and 34 a poor outcome. Max values, max-min, SD and CV of both systolic and diastolic BP resulted significantly higher in patients with poor outcome compared to those with good outcome (p<0.05, multivariate adjusted model). CONCLUSIONS In a cohort of acute ischemic stroke patients with ipsilateral ICA occlusion BP variability, assessed in the acute phase, was associated with poor clinical outcome. These preliminary exploratory findings are worthy of further study to be conducted to confirm or confute the role of BP variability in predicting stroke outcome. In order to obtain more comprehensive information, it would also be appropriate to consider the possibility of acquiring data related to the pathophysiology of stroke and to cerebral hemodynamic changes.

Is Prehospital Treatment of Acute Stroke too Expensive An Economic Evaluation Based on the First Trial

Background: Recently, a strategy for treating stroke directly at the emergency site was developed. It was based on the use of an ambulance equipped with a scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit). Despite demonstrating a marked reduction in the delay to thrombolysis, this strategy is criticized because of potentially unacceptable costs. Methods: We related the incremental direct costs of prehospital stroke treatment based on data of the first trial on this concept to one year direct cost savings taken from published research results. Key parameters were configuration of emergency medical service personnel, operating distance, and population density. Model parameters were varied to cover 5 different relevant emergency medical service scenarios. Additionally, the effects of operating distance and population density on benefit-cost ratios were analyzed. Results: Benefits of the concept of prehospital stroke treatment outweighed its costs with a benefit-cost ratio of 1.96 in the baseline experimental setting. The benefit-cost ratio markedly increased with the reduction of the staff and with higher population density. Maximum benefit-cost ratios between 2.16 and 6.85 were identified at optimum operating distances in a range between 43.01 and 64.88 km (26.88 and 40.55 miles). Our model implies that in different scenarios the Mobile Stroke Unit strategy is cost-efficient starting from an operating distance of 15.98 km (9.99 miles) or from a population density of 79 inhabitants per km2 (202 inhabitants per square mile). Conclusion: This study indicates that based on a one-year benefit-cost analysis that prehospital treatment of acute stroke is highly cost-effective across a wide range of possible scenarios. It is the highest when the staff size of the Mobile Stroke Unit can be reduced, for example, by the use of telemedical support from hospital experts. Although efficiency is positively related to population density, benefit-cost ratios can be greater than 1 even in rural settings.

Mild Stroke and Rapidly Improving Symptoms It's Not Always a Happy Ending

Despite the substantial benefit of intravenous recombinant tissue-type plasminogen activator (IV rtPA) in improving neurologic outcomes in acute ischemic stroke (AIS) patients,1,2 only about half of those patients who arrive at the hospital in time receive it.3,4 In 2009, 3.4% to 5.2% of AIS patients in the United States received thrombolytics, approximately double the rate of treatment in 2005.5 Rapid recognition and transport and quick treatment in the Emergency Department are clear goals for further improving treatment rates.5 There have been more controversial barriers to the use of IV rtPA treatment. Prior studies6–10 have estimated that 29% to 43% of AIS patients arriving within 3 hours of symptom onset are not treated with IV rtPA because of “mild stroke” or “rapidly improving stroke symptoms” (RISS). In this issue of Stroke , Smith et al11 have reported important results from the American Heart Association Get With The Guidelines (GWTG) nationwide program11,12 involving 1290 participating hospitals, the largest data set to date analyzing outcomes of mild stroke and RISS. During the last 6 years, among 93 517 AIS patients arriving within 2 hours of symptom onset, almost one third (29 200 patients) were excluded from IV rtPA treatment solely because they presented with mild stroke or RISS. This would not be of concern if the outcomes of AIS patients with mild stroke or RISS were invariably benign. However, data have suggested that this is frequently not true.9,13 Their outcome is indeed unpredictable, as confirmed by Smith et al.11 In the GWTG population, ≈28% went to inpatient rehabilitation or skilled-nursing facilities and 1% died; almost 30% were not fully functionally independent at hospital discharge. These outcomes were worse than those of patients diagnosed with …

Cerebrovascular Assessment for the Risk Prediction of Alzheimer's Disease

Increasing evidence is emerging that vascular disease and its risk factors play a role in the development of Alzheimers disease (AD) and affect the probability of an adverse outcome. The aims of this review are to explore the relationship between vascular risk factors and AD and to discuss the potential use of vascular markers in the clinical approach to cognitive impairment. Moreover, we present evidence about the potential use of ultrasonographic and neuroradiologic markers of cognitive impairment in order to establish possible treatment strategies in subjects with a clinical profile at risk of developing AD.

Intracerebral Hemorrhage Associated with Oral Phenylephrine Use: A Case Report and Review of the Literature

BACKGROUND Prior reports have linked both ischemic and hemorrhagic stroke to use of sympathomimetic drugs including phenylephrine. The purpose of this study is to describe the first case, to our knowledge of intracerebral hemorrhage (ICH) after oral use of phenylephrine and to systematically review the literature on phenylephrine and acute stroke. METHODS A case report and review of the literature. RESULTS A 59-year-old female presented with thunderclap headache, right hemiparesis, aphasia, and left gaze deviation. Head computed tomography (CT) showed a left frontal ICH with intraventricular and subarachnoid extension. She had no significant past medical history. For the previous 30 days, the patient was taking multiple common cold remedies containing phenylephrine to treat sinusitis. CT and magnetic resonance angiography showed no causative vascular abnormality. Catheter cerebral angiography supported reversible cerebral vasoconstriction syndrome (RCVS). Phenylephrine was determined to be the most likely etiology for her hemorrhage. A review of the literature, found 7 cases describing phenylephrine use with acute stroke occurrence: female, 5 of 7 (71%); route of administration, nasal (n = 3), ophthalmic (n = 2), intravenous (n = 1), intracorporeal injection (n = 1). Stroke types were subarachnoid hemorrhage (n = 5), ICH (n = 4), and ischemic (n = 1). One case reported RCVS after phenylephrine use. CONCLUSIONS It is scientifically plausible that phenylephrine may cause strokes, consistent with the pharmacologic properties and adverse event profiles of similar amphetamine-like sympathomimetics. As RCVS has been well described in association with over-the-counter sympathomimetics, a likely, although not definitive, causal relationship between phenylephrine and ICH is proposed.

First translational 'Think Tank' on cerebrovascular disease, cognitive impairment and dementia.

Abstract and introduction to the workshopAs the human population continues to age, an increasing number of people will exhibit significant deficits in cognitive function and dementia. It is now recognized that cerebrovascular, metabolic and neurodegenerative diseases all play major roles in the evolution of cognitive impairment and dementia. Thus with our more recent recognition of these relationships and our need to understand and more positively impact on this world health problem, “The Leo and Anne Albert Charitable Trust” (Gene Pranzo, Trustee with significant support from Susan Brogan, Meeting Planner) provided generous support for this inaugural international workshop that was held from April 13–16, 2015 at the beautiful Ritz Carlton Golf Resort in North Naples, Florida. Researchers from SUNY Downstate Medical Center, Brooklyn, NY organized the event by selecting the present group of translationally inclined preclinical, clinical and population scientists focused on cerebrovascular disease (CVD) risk and its progression to vascular cognitive impairment (VCI) and dementia. Participants at the workshop addressed important issues related to aging, cognition and dementia by: (1) sharing new data, information and perspectives that intersect vascular, metabolic and neurodegenerative diseases, (2) discussing gaps in translating population risk, clinical and preclinical information to the progression of cognitive loss, and (3) debating new approaches and methods to fill these gaps that can translate into future therapeutic interventions. Participants agreed on topics for group discussion prior to the meeting and focused on specific translational goals that included promoting better understanding of dementia mechanisms, the identification of potential therapeutic targets for intervention, and discussed/debated the potential utility of diagnostic/prognostic markers. Below summarizes the new data-presentations, concepts, novel directions and specific discussion topics addressed by this international translational team at our “First Leo and Anne Albert Charitable Trust ‘Think Tank’ VCI workshop”.

Expansion of Intravenous Tissue Plasminogen Activator Eligibility Beyond National Institute of Neurological Disorders and Stroke and European Cooperative Acute Stroke Study III Criteria.

Intravenous tPA is the standard treatment for acute ischemic stroke. Multiple contraindications for thrombolysis developed during the design of the clinical trials may be overly cautious and limit the number of patients who may be eligible and potentially benefit from treatment. As clinicians have become more comfortable with off-label use of tPA, new data on the safety of thrombolysis have become available and shaped the current guidelines. This article updates our knowledge on the evidence available for these contraindications to help guide the clinician in choosing the optimal approach to some of the most commonly encountered clinical scenarios.

Increased Common Carotid Artery Wall Thickness Is Associated with Rapid Progression of Asymptomatic Carotid Stenosis

This study aimed to identify clinical and ultrasound imaging predictors of progression of carotid luminal narrowing in subjects with asymptomatic moderate internal carotid artery (ICA) stenosis.

A tonsillomedullary stroke causing supranuclear lingual paresis

The anatomy of the cortico-hypoglossal projections and the clinical effect of lesions on them are not clear-cut. Lesions close to the midline of the ventral pons typically impair only the contralateral cortico-hypoglossal projections, while lesions extending to the lateral part of the basal pons, or dorsolateral and mediolateral medulla, affect the ipsilateral projections.1 ,2 This suggests that these fibres decussate close to the pontomedullary junction. However, Chang and Cho3 reported a case of contralateral supranuclear glossoplegia due to an ischaemic lesion on the ventromedial part of the rostral medulla, suggesting the fibres cross caudal to the pontomedullary junction. We report a case of ischaemic stroke involving the tonsillomedullary segment of the right posterior inferior cerebellar artery that affected …