David N. Alexander

Interactions Within Stroke Systems of Care A Policy Statement From the American Heart Association/American Stroke Association

In the United States and other parts of the world, various cities, states, and regions are developing multitiered systems for the care of patients with acute stroke. These systems often involve a range of healthcare components supported by various rules and regulations. The present policy statement will put forth concepts and elements for stroke systems of care that are intended to optimize patient care and management processes and improve patient outcomes, are practical to implement, and are supported by existing clinical data or expert consensus opinion. We will also make policy recommendations for the key elements of a stroke system of care. The public health implications of stroke care in the United States and worldwide are profound. Stroke is currently the fourth-leading cause of death in the United States and a major cause of long-term disability. Advancing age is a major risk factor for stroke, and the demographics of the US population and elsewhere reflect a continued growth of the aging population, with a resulting increase in the absolute incidence and prevalence of stroke.1 Improved stroke systems of care can ensure proper treatment of these patients and a reduction in death and disability. This is consistent with current American Heart Association and Centers for Disease Control and Prevention Healthy People 2020 public health goals and initiatives.2 There are several new care paradigms and technologies that are emerging as important elements of a stroke system of care. These include the development and proliferation of various levels of stroke centers; the expanded use of telemedicine technologies; advanced medical, endovascular, and surgical interventions; and comprehensive rehabilitation strategies and programs. Prehospital care and triage and the efficient transfer of patients between hospitals are also key components of stroke systems. The present …

Ideomotor apraxia: Behavioral dimensions and neuroanatomical basis

Ideomotor apraxia, disordered movement execution to command, commonly follows left-hemisphere damage, implying left-hemisphere dominance for certain kinds of movements. To delineate this dominance we used different command modalities to elicit meaningful movements and tested imitation of nonsense movements. Twenty-seven patients with unilateral hemispheric stroke and 10 age-matched controls were evaluated. Patients with left-hemisphere damage performed both meaningful and nonsense movements poorer than the other study groups; thus, the meaningfulness of the movements is irrelevant for the left-hemisphere motor dominance. The performance varied, however, with the command modality and movement type. Based on this and earlier studies we posit that the left-hemisphere motor dominance is determined by the artificiality of the test situation (it concerns movements performed to command and out of the natural context) and increased spatial and temporal complexity of the demanded movements. No association between the lesion locus within the left hemisphere and the severity of the ideomotor apraxia was found.

Clinical Performance Measures for Adults Hospitalized With Acute Ischemic Stroke Performance Measures for Healthcare Professionals From the American Heart Association/American Stroke Association

To work toward the goal of building healthier lives, free of cardiovascular diseases and stroke, the American Heart Association (AHA) and American Stroke Association (ASA) have developed a multifaceted strategy for improving the quality of care for stroke. A key feature of this strategy is the development of professional guidelines for evidence-based stroke care. Recommendations are provided for acute management, primary and secondary prevention, rehabilitation, stroke systems of care, and other domains of stroke care.1–4 The strength of the evidence supporting these recommendations is given, according to a specified grading system. For many aspects of care, there is widespread consensus that the intervention is beneficial, usually supported by strong scientific evidence including randomized controlled trials. Professional guidelines improve the delivery of evidence-based care; however, despite these guidelines, gaps between best evidence-based practice and actual practice persist.5 To close these gaps in quality of care, several organizations have developed systems to allow practitioners and healthcare organizations such as hospitals to quantify the quality of their care through performance measures. A performance measure is defined by the Agency for Healthcare Research and Quality as a “mechanism for assessing the degree to which a provider competently and safely delivers the appropriate clinical services to the patient within the optimal time period.”6 The AHA and American College of Cardiology Foundation have additionally suggested that performance measures should be based on the highest level of supportive evidence and have the greatest impact on health outcomes.7 Performance measures, in addition to supporting quality improvement activities, are specifically suitable for public reporting, external comparisons, and possibly pay-for-performance programs. As steward of the professional guidelines for stroke care, with a large group of volunteer expert clinicians with expertise in guideline creation and performance measurement, the AHA/ASA is uniquely positioned to develop high-quality …

Erratum to: PRISM II: An open-label study to assess effectiveness of dextromethorphan/quinidine for pseudobulbar affect in patients with dementia, stroke or traumatic brain injury [BMC Neurol., 16 (2016) 89], DOI:10.1186/s12883-016-0609-0

Erratum After publication of the original article [1], the authors noticed that there were errors in the caption of Fig. 3, and the y-axis of Fig. 6 itself. The following statement should not have been included in the caption of Fig. 3: “CNS-LS scores were not normalized.” The CNS-LS is a rank-order scale, and is not normalized. This statement was included erroneously and the authors intended on removing it prior to resubmission, but this was unfortunately overlooked. Similarly, the y-axis within Fig. 6 was mislabelled. The CNS-LS scale ranges from 7 to 35, so the y-axis for Fig. 6 should start at a base score of 7 and not zero. The correct and updated version of Fig. 6, in which the data presented remain accurate and are unchanged, is published in this erratum.

Dextromethorphan/Quinidine for Pseudobulbar Affect Following Stroke: Safety and Effectiveness in the PRISM II Trial

Dextromethorphan (DM) / quinidine (Q) was approved for pseudobulbar affect (PBA) treatment based on efficacy and safety trials in patients with PBA caused by amyotrophic lateral sclerosis or multiple sclerosis. The PRISM II trial evaluated DM/Q as PBA treatment in patients with stroke, dementia, or traumatic brain injury.