Dulka Manawadu

An Observational Study of Thrombolysis Outcomes in Wake-Up Ischemic Stroke Patients

Background and Purpose— Wake-up ischemic stroke (WUIS) patients are not eligible for thrombolysis; the a priori hypothesis was that thrombolysis of selected WUIS patients who meet clinical and imaging criteria for treatment is associated with better outcomes. Methods— The sample consisted of consecutive WUIS patients who fulfilled predefined criteria: (1) were last seen normal >4.5 hours and <12 hours before presentation; (2) National Institute of Health Stroke Scale score ≥5; (3) No or early ischemic changes <1/3 middle cerebral artery territory on computed tomography imaging; (4) No absolute contraindications to thrombolysis. The primary outcome measure was the modified Rankin Scale of 0 to 2 at 90 days. Other outcome measures were mortality and symptomatic intracerebral hemorrhage. Results— WUIS patients constituted 10.5% (193/1836) of all stroke admissions. Inclusion criteria were fulfilled by 122 (63%) patients, of whom 68 (56%) were thrombolysed. Thrombolysed and nonthrombolysed patients were comparable for baseline characteristics, but the median baseline National Institute of Health Stroke Scale score was higher in thrombolysed patients (9 versus 11.5; P=0.034). There was no difference in modified Rankin Scale 0 to 2 (25 [37%] versus 14 [26%]; P=0.346), death (10 [15%] versus 14 [26%]; P=0.122), and symptomatic intracerebral hemorrhage (2 versus 0; P=0.204) between thrombolysed and nonthrombolysed patients. After adjusting for age, sex, and baseline National Institute of Health Stroke Scale score thrombolysis was associated with odds ratio of 5.2 (95% confidence interval 1.3–20.3), P=0.017 for modified Rankin Scale 0 to 2 at 90 days and odds ratio of 0.09 (95% confidence interval 0.02–0.44), P=0.003 for death. Conclusions— Thrombolysis in selected WUIS patients is feasible and may have potential of benefit.

A Case-Controlled Comparison of Thrombolysis Outcomes Between Wake-Up and Known Time of Onset Ischemic Stroke Patients

Background and Purpose— Wake-up ischemic stroke (WUIS) patients are not thrombolysed even if they meet other criteria for treatment. We hypothesized that patients with WUIS showing no or early ischemic changes on brain imaging will have thrombolysis outcomes comparable with those with known time of symptom onset. Methods— Consecutive sampling of a prospective registry of patients with stroke between January 2009 and December 2010 identified 394 thrombolysed patients meeting predefined inclusion criteria, 326 presenting within 0 to 4.5 hours of symptom onset (Reference Group) and 68 WUIS patients. Inclusion criteria were last seen normal <12 hours or >4.5 hours (WUIS) or presented <4.5 hours (Reference Group), had National Institutes of Health Stroke Scale score ≥5, and no or early ischemic changes on imaging at presentation. The primary outcome measure was the modified Rankin Scale of 0 to 2 at 90 days measured by trained assessors blinded to patient grouping. Other outcome measures were symptomatic intracerebral hemorrhage, modified Rankin Scale 0 to 1, and mortality at 90 days. Results— The groups were comparable for mean age (72.8 versus 73.9 years; P=0.58) and baseline median National Institutes of Health Stroke Scale score (median 13 versus 12; P=0.34). The proportions of patients with modified Rankin Scale 0 to 2 (38% versus 37%; P=0.89) and modified Rankin Scale 0 to 1 (24% versus 16%; P=0.18) at 90 days, any ICH (20% versus 22%; P=0.42) and symptomatic intracerebral hemorrhage (3.4% versus 2.9%; P=1.0) were comparable after adjusting for age, stroke severity, and imaging changes. Only 9/394 (2%) patients were lost to follow-up. Conclusions— Thrombolysis in selected patients with WUIS is feasible, and its outcomes are comparable with those thrombolysed with 0 to 4.5 hours.

Hemicraniectomy for Massive Middle Cerebral Artery Infarction: A Review

Hemicraniectomy and opening underlying dura mater permits the expansion of infarcted, swollen brain outwards, reversing dangerous intracranial pressure elevations and the risk of fatal transtentorial temporal lobe or diencephalic herniation. Recently published randomized controlled trials have proven this procedure a powerful life-saving measure in the setting of malignant middle cerebral artery infarction and allayed concerns that a reduction in mortality is accompanied by an unacceptable increase in patients suffering severe neurological impairments. Appropriate patients are relatively young, in the first five decades of life, suffering infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere, and decompression should be performed prior to progression to coma or two dilated, fixed pupils. Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention. Families and, when possible, patients themselves, should be informed of the certainty of at least moderate to mild permanent deficits, and the possibility of worse. To be successful decompression must be extensive, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cm lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture. An augmentation duraplasty is mandatory.

Safety and clinical outcome of thrombolysis in ischaemic stroke using a perfusion CT mismatch between 3 and 6 hours.

OBJECTIVE It may be possible to thrombolyse ischaemic stroke (IS) patients up to 6 h by using penumbral imaging. We investigated whether a perfusion CT (CTP) mismatch can help to select patients for thrombolysis up to 6 h. METHODS A cohort of 254 thrombolysed IS patients was studied. 174 (69%) were thrombolysed at 0-3 h by using non-contrast CT (NCCT), and 80 (31%) at 3-6 h (35 at 3-4.5 h and 45 at 4.5-6 h) by using CTP mismatch criteria. Symptomatic intracerebral haemorrhage (SICH), the mortality and the modified Rankin Score (mRS) were assessed at 3 months. Independent determinants of outcome in patients thrombolysed between 3 and 6 h were identified. RESULTS The baseline characteristics were comparable in the two groups. There were no differences in SICH (3% v 4%, p = 0.71), any ICH (7% v 9%, p = 0.61), or mortality (16% v 9%, p = 0.15) or mRS 0-2 at 3 months (55% v 54%, p = 0.96) between patients thrombolysed at 0-3 h (NCCT only) or at 3-6 h (CTP mismatch). There were no significant differences in outcome between patients thrombolysed at 3-4.5 h or 4.5-6 h. The NIHSS score was the only independent determinant of a mRS of 0-2 at 3 months (OR 0.89, 95% CI 0.82-0.97, p = 0.007) in patients treated using CTP mismatch criteria beyond 3 h. CONCLUSIONS The use of a CTP mismatch model may help to guide thrombolysis decisions up to 6 h after IS onset.

Detection of patent foramen ovale by 3D echocardiography.

TECHNICAL ADVANCES IN PATENT FORAMEN OVALE (PFO) DEVICE CLOSURE RESULTED IN GREATER CLINICAL IMPORTANCE TO OPTIMALLY DIAGNOSE INTRACARDIAC SHUNTS. Two-dimensional transesophageal echocardiography (2DTEE) with agitated saline contrast is currently the gold standard for diagnosing PFO. However, direct

Influence of Age on Thrombolysis Outcome in Wake-Up Stroke

Background and Purpose— Thrombolysis in patients >80 years remains controversial; we hypothesized that >80-year-old patients with wake-up ischemic stroke (WUIS) will benefit from thrombolysis despite risks because of poor outcomes with no treatment. Methods— The study included 68 thrombolysed patients with WUIS (33 [48%] >80 years), 54 nonthrombolysed patients with WUIS (21 [39%] >80 years), and 117 patients (>80 years old) thrombolysed within 4.5 hours of symptom onset (reference group). Mortality and modified Rankin Scale (mRS) were assessed at 90 days. Results— Baseline characteristics of thrombolysed and nonthrombolysed >80 and ⩽80-year-old patients with WUIS were comparable. Thrombolysis outcomes in >80-year-old patients with WUIS were better than in nonthrombolysed >80-year-old patients with WUIS (90-day mortality: 24% versus 47%, P=0.034; mRS 0–2: 30% versus 5%, P=0.023; mRS 0–1: 15% versus 5%, P=0.24) and comparable with thrombolysed ⩽80-year-old patients with WUIS. Thrombolysis was associated with odds ratio 0.27 (95% confidence interval, 0.05–0.97) for mortality and odds ratio 28.6 (95% confidence interval, 1.8–448) for mRS 0 to 2 at 90 days in >80-year-old patients with WUIS after adjusting for stroke severity and risk factors. Conclusions— Thrombolysis may be associated with greater benefit in >80-year-old patients with WUIS but a selection bias favoring thrombolysis in those most likely to benefit may significantly reduce interpretability of these findings.

The Impact of Early Specialist Management on Outcomes of Patients with In-Hospital Stroke

Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis eligibility, 90-day functional outcomes and all-cause mortality were compared between IHS patients referred for specialist stroke management within 3 hours of symptom onset (early referrals) and later referrals. Patients were identified from a prospective stroke registry between January 2009 and December 2010. Inclusion criteria were primary admission with a non-stroke diagnosis, onset of new neurological deficits after admission and early ischaemic changes on CT or MR imaging. Eighty four (4.6%) of 1836 stroke patients had IHS (mean age 74 year; 51% male, median NIHSS score 10). There were no significant differences in baseline characteristics between 53 (63%) early and 31 (37%) late referrals. Thrombolysis was performed in 29 (76%) of the 37/78 (47%) potentially eligible patients; 7 patients were excluded because specialist referral was delayed beyond 4.5 hours despite symptom recognition within 3 hours of onset. Early referral improved functional outcomes (modified Rankin Scale 0–2 at 90 days 40% v 7%, p = 0.001) and was an independent predictor of mRS 0–2 at 90 days after adjusting for age, pre-morbid function, primary cause for hospital admission and stroke severity [OR 1.13 (95% C.I.  = 1.10–1.27), p = 0.002]. Early referral and specialist management of IHS patients that includes thrombolysis is associated with better functional outcomes at 90 days.

Smoking and common mental disorders in patients with chronic conditions: An analysis of data collected via a web-based screening system

OBJECTIVE Smoking is the largest preventable cause of death and disability in the UK and remains pervasive in people with mental disorders and in general hospital patients. We aimed to quantify the prevalence of mental disorders and smoking, examining associations between mental disorders and smoking in patients with chronic physical conditions. METHOD Data were collected via routine screening systems implemented across two London NHS Foundation Trusts. The prevalence of mental disorder, current smoking, nicotine dependence and wanting help with quitting smoking were quantified, and the relationships between mental disorder and smoking were examined, adjusting for age, gender and physical illness, with multiple regression models. RESULTS A total of 7878 patients were screened; 23.2% screened positive for probable major depressive disorder, and 18.5% for probable generalised anxiety disorder. Overall, 31.4% and 29.2% of patients with probable major depressive disorder or generalised anxiety disorder respectively were current smokers. Probable major depression and generalised anxiety disorder were associated with 93% and 44% increased odds of being a current smoker respectively. Patients with depressive disorder also reported higher levels of nicotine dependence, and the presence of common mental disorder was not associated with odds of wanting help with quitting smoking. CONCLUSION Common mental disorder in patients with chronic physical health conditions is a risk factor for markedly increased smoking prevalence and nicotine dependence. A general hospital encounter represents an opportunity to help patients who may benefit from such interventions.

Health professionals' knowledge of driving restrictions following stroke and TIA: experience from a hyperacute stroke centre.

Background and purpose Assessment of fitness to drive (FTD) is important after stroke or transient ischaemic attack (TIA) to ensure that neither patients nor public are at risk. This is particularly important in patients with TIAs or minor stroke as many are discharged directly from emergency departments by a range of health professionals. We assessed stroke-related FTD knowledge among physicians’ and allied health professionals’ (AHPs) treating patients with stroke at a hyperacute stroke centre. Methods Knowledge of FTD restrictions following a stroke or TIA for domestic and commercial use was assessed in 195 physicians and 45 AHPs using a multiple-choice questionnaire between January and December 2009. The effect of discipline, seniority, previous instruction in FTD restrictions and experience in stroke medicine on FTD was assessed. Results The correct driving restriction following stroke with domestic and commercial license was known to 29% and 73% of physicians, respectively. For AHPs, these figures were 36% and 20%. For TIA with domestic and commercial license, this was 37% and 43% for physicians, and 44% and 11% for AHPs. 25% of physicians and 11% of AHPs believed that no driving restrictions applied after a TIA. The correct office for reporting FTD was known to 180 (92%) doctors and 31 (69%) AHPs (p=0.0001); 160 (82%) physicians and 27 (60%) AHPs correctly identified that reporting was the patients’ responsibility (p=0.001). FTD knowledge correlated with post in stroke (OR 3.2 (95% CI 1.6 to 6.2, p=0.001)) but not with seniority or previous FTD education. Conclusions Health professionals providing stroke care showed limited knowledge of FTD regulations after minor stroke or TIA. Imparting accurate information on driving restrictions is an important but neglected part of stroke management.

Transcranial Doppler and Cerebral Augmentation in Acute Ischemic Stroke

Collateral flow augmentation using partial aortic occlusion may improve cerebral perfusion in acute stroke. We assessed the effect of partial aortic occlusion on arterial flow velocities of acute stroke patients.