Patricia Fearon

Cognitive and Mood Assessment in Stroke Research Focused Review of Contemporary Studies

Background and Purpose— International guidelines recommend cognitive and mood assessments for stroke survivors; these assessments also have use in clinical trials. However, there is no consensus on the optimal assessment tool(s). We aimed to describe use of cognitive and mood measures in contemporary published stroke trials. Methods— Two independent, blinded assessors reviewed high-impact journals representing: general medicine (n=4), gerontology/rehabilitation (n=3), neurology (n=4), psychiatry (n=4), psychology (n=4), and stroke (n=3) January 2000 to October 2011 inclusive. Journals were hand-searched for relevant, original research articles that described cognitive/mood assessments in human stroke survivors. Data were checked for relevance by an independent clinician and clinical psychologist. Results— Across 8826 stroke studies, 488 (6%) included a cognitive or mood measure. Of these 488 articles, total number with cognitive assessment was 408 (83%) and mood assessment tools 247 (51%). Total number of different assessments used was 367 (cognitive, 300; mood, 67). The most commonly used cognitive measure was Folsteins Mini-Mental State Examination (n=180 articles, 37% of all articles with cognitive/mood outcomes); the most commonly used mood assessment was the Hamilton Rating Scale of Depression(n=43 [9%]). Conclusions— Cognitive and mood assessments are infrequently used in stroke research. When used, there is substantial heterogeneity and certain prevalent assessment tools may not be suited to stroke cohorts. Research and guidance on the optimal cognitive/mood assessment strategies for clinical practice and trials is required.

The 2010 British Association of Stroke Physicians Survey of interventional treatments for stroke in the United Kingdom

Introduction The UK National Stroke Strategy (Department of Health 2007) states that patients should have access to a stroke service with neurointerventional capacity. This survey was conducted by the Clinical Standards Committee of the British Association of Stroke Physicians to get a snapshot of the availability of interventional treatments for stroke in the United Kingdom. Methods Questionnaires covering availability of endovascular treatments for stroke, e.g. intra-arterial thrombolysis and mechanical thrombectomy, were emailed to all British Association of Stroke Physicians members in October 2010. Where more than one response was received from the same hospital, the data were only entered once. If there was a discrepancy between different respondents for the same hospital, details were cross-checked with the respondents to ensure accuracy. Results Responses were received from 58 hospitals in England, Scotland, Wales, and Northern Ireland. Intra-arterial thrombolysis and/or mechanical thrombectomy were available in 23 hospitals. Of these, three had not performed any procedures in 2010. Twenty centres had conducted a mean (range) of eight (2–20) procedures during the 10-month period. Thirty-five hospitals were not offering endovascular treatments. Sixteen of these were not referring patients to centres which could provide interventional treatments. Hospitals offering endovascular treatments had a mean (range) of 5·2 (2–12) stroke physicians, 2·3 (0–4) interventional neuroradiologists, and 3·6 (0–9) noninterventional neuroradiologists. Only two hospitals providing interventions had four or more interventional neuroradiologists. Conclusions Only a small number of hospitals in the United Kingdom provide interventional treatments for stroke. Almost 50% of hospitals not providing interventions had no processes in place for referral to providers.

Stop the clots, but at what cost? Pharmacoeconomics of dabigatran etexilate for the prevention of stroke in subjects with atrial fibrillation: a systematic literature review

Dabigatran etexilate is a newly approved agent for prophylaxis of stroke in atrial fibrillation. Through narrative review, the authors assess evidence of the efficacy of dabigatran in stroke prevention, focusing on the multicenter, randomized trial RE-LY. The authors complement this with a review of the clinical efficacy of standard treatments (antiplatelet and warfarin). Finally, the authors present a systematic review of published studies describing the economics of dabigatran. Our systematic search gave six economic reviews from a variety of healthcare systems (the USA, Canada and the UK) and utilizing different economic models. Analyses suggest economic benefit of high- or sequential-dose dabigatran, particularly when stroke risk is high; intracerebral hemorrhage risk is high or warfarin control is poor. However, questions remain around dabigatran tolerability, compliance and possible unexpected adverse events.

Making the call: is telestroke cost effective?

Evaluation of: Nelson RE, Saltzman GM, Skalabrin EJ, Demaerschalk BM, Majersik JJ. The cost–effectiveness of telestroke in the treatment of acute ischaemic stroke. Neurology 77, 1590–1598 (2011). The clinical efficacy of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is proven, and the cost-efficacy of tPA is realized through reduction in disability and associated long-term care. Only a modest proportion of eligible stroke patients receive tPA. Potential barriers include distance from treatment centers and lack of local expertise and infrastructure. Nelson and colleagues describe a telecommunications strategy to facilitate increased delivery of thrombolysis. The analysis used a model based on an expert stroke-center ‘hub’ offering video-based liaison with several peripheral hospital ‘spokes’. Economic modeling suggested cost efficacy of this approach, albeit with all the caveats that come with long-term economic analyses of an acute stroke intervention. There is a clinical, ethical and economical imperative to increase uptake of evidence-based acute stroke therapies. These encouraging data suggest that use of audiovisual technologies may facilitate greater access to thrombolysis.

Response to Letter Regarding Article, “Prestroke Modified Rankin Stroke Scale Has Moderate Interobserver Reliability and Validity in an Acute Stroke Setting”

We thank Bruno and Switzer for their comments on our manuscript describing the reliability and validity of prestroke modified Rankin Scale (mRS).1 We agree with all the points made in their letter, and it is reassuring that other centers are also giving some consideration to the clinimetric properties of mRS when used to describe functional ability prestroke. Bruno and Switzer make the valid point that the structure and wording of the various mRS grades are not suited to retrospective assessment of a subject’s function before the stroke event. This may be especially pertinent for mRS grades 0 to 2, where the descriptors place an emphasis on symptoms and …