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Purpose: In the treatment of intracranial arterial stenosis (ICAS), controversies remain regarding the optimal treatment strategy. Our study aims to conduct an individual patient-level data meta-analysis of existing RCTs comparing PTAS versus best medical therapy and to identify differences in outcomes such as incidence of ischemic stroke or death. Methods: Randomised controlled trials comparing the outcomes of stenting versus best medical therapy for patients who had symptomatic ICAS of >50%. Excluded studies included case reports, case series, reviews, observational studies, letters or studies evaluating isolated angioplasty techniques without stenting. Data was extracted in accordance with PRISMA guidelines. Results: 7 studies involving 1425 participants were included. There was an increased risk in the incidence of stroke and death within the first 30 days post-procedure for patients treated with PTAS over best medical therapy (RR = 2.22 [1.28–3.86], I² = 0%). Patients who underwent stenting also had a significantly higher risk of intracranial haemorrhage (RR = 12.66 [2.41–66.45], I² = 0%) and death (RR = 5.41 [1.20–24.28], I² = 0%). Under the shared frailty model, stenting when compared to medical therapy has a HR of 1.81 (95% CI:1.25–2.6) of stroke or death across 1 year. Under the parametric Royston-Parmar model, stenting has a significant decrease in the RMST(–0.83 months; 95% CI: –1.30–0.37). Stenting continued to show worse outcomes up to the 3 year mark with a HR of 1.60 (95% CI: 1.11–2.32). Conclusions and Relevance: There is an increased risk of peri- and post-procedural stroke and death over best medical therapy in patients with symptomatic ICAS who undergo PTAS. Further work is required to refine patient selection and mitigate peri-procedural risks. [ABSTRACT FROM AUTHOR]

Background: To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke. Methods: Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0–1), functional independence (mRS 0–2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model. Results: Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67–1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64–1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06–1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10–1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment. Conclusion: The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings. [ABSTRACT FROM AUTHOR]

Stroke, a leading cause of death and long-term disability, has a considerable social and economic impact. It is imperative to investigate stroke-related costs. The main goal was to conduct a systematic literature review on the described costs associated with stroke care continuum to better understand the evolution of the economic burden and logistic challenges. This research used a systematic review method. We performed a search in PubMed/MEDLINE, ClinicalTrial.gov, Cochrane Reviews, and Google Scholar confined to publications from January 2012 to December 2021. Prices were adjusted using consumer price indices of the countries in the studies in the years the costs were incurred to 2021 Euros using the World Bank and purchasing power parity exchange rate in 2020 from the Organization for Economic Co-operation and Development with the XE Currency Data API. The inclusion criteria were all types of publications, including prospective cost studies, retrospective cost studies, database analyses, mathematical models, surveys, and cost-of-illness (COI) studies. Were excluded studies that (a) were not about stroke, (b) were editorials and commentaries, (c) were irrelevant after screening the title and abstract,(d) grey literature and non-academic studies, (e) reported cost indicators outside the scope of the review, (f) economic evaluations (i.e., cost-effectiveness or cost–benefit analyses); and (g) studies not meeting the population inclusion criteria. There may be risk of bias because the effects are dependent on the persons delivering the intervention. The results were synthetized by PRISMA method. A total of 724 potential abstracts were identified of which 25 articles were pulled for further investigation. The articles were classified into the following categories: 1)stroke primary prevention, 2) expenditures related to acute stroke care, 3) expenditures for post-acute strokes, and 4) global average stroke cost. The measured expenditures varied considerably among these studies with a global average cost from €610-€220,822.45. Given the great variability in the costs in different studies, we can conclude that we need to define a common system for assessing the costs of strokes. Possible limitations are related to clinical choices exposed to decision rules that trigger decisions alerts within stroke events in a clinical setting. This flowchart is based on the guidelines for acute ischemic stroke treatment but may not be applicable to all institutions. [ABSTRACT FROM AUTHOR]

Background: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a genetic small vessel disease responsible for recurrent ischemic strokes, often with a progressive course leading to dementia and disability. On MRI, lacunes, microbleeds, and severe white matter alterations are typical features of the disease. In case of acute stroke, because of the bleeding risk associated with the disease and the doubtful efficacy of fibrinolytic treatment in a disease with poor evidence of thrombosis, the efficacy of intravenous thrombolysis remains unproven. Nevertheless, stroke is a frequent occurrence in CADASIL patients, and clinicians not unlikely may face in the emergency room the situation of a CADASIL patient with an acute stroke within the time window for thrombolysis. Objective: We report on two CADASIL patients treated with intravenous alteplase for acute ischemic stroke, and we present a review of literature aimed to report epidemiological data, efficacy and safety of intravenous thrombolysis in CADASIL patients. Methods: We performed a systematic review of medical literature published until August 2, 2022. Case reports and series in English language reporting on CADASIL patients and acute stroke were included. Results: Both patients were treated with intravenous thrombolysis without complications and had a good clinical outcome. The systematic review identified three case reports of CADASIL patients who were treated with intravenous alteplase for acute ischemic stroke; no bleedings complications were described. Conclusions: Available data on intravenous thrombolysis in CADASIL patients are scarce but suggest that this treatment can be taken into consideration for these patients. [ABSTRACT FROM AUTHOR]

Transient ischemic attack (TIA) is a neurologic emergency characterized by cerebral ischemia eliciting a temporary focal neurological deficit. Many clinical prediction scores have been proposed to assess the risk of stroke after TIA; however, studies on their clinical validity and comparisons among them are scarce. The objective is to compare the accuracy of ABCD2, ABCD2-I, and OTTAWA scores in the prediction of a stroke at 7, 90 days, and 1 year in patients presenting with TIA. Single-centre, retrospective study including patients with TIA admitted to the Emergency Department of our third-level, University Hospital, between 2018 and 2019. Five hundred three patients were included. Thirty-nine (7.7%) had a stroke within 1 year from the TIA: 9 (1.7%) and 24 (4.7%) within 7 and 90 days, respectively. ABCD2, ABCD2-I, and OTTAWA scores were significantly higher in patients who developed a stroke. AUROCs ranged from 0.66 to 0.75, without statistically significant differences at each time-point. Considering the best cut-off of each score, only ABCD2 > 3 showed a sensitivity of 100% only in the prediction of stroke within 7 days. Among clinical items of each score, duration of symptoms, previous TIA, hemiparesis, speech disturbance, gait disturbance, previous cerebral ischemic lesions, and known carotid artery disease were independent predictors of stroke. Clinical scores have moderate prognostic accuracy for stroke after TIA. Considering the independent predictors for stroke, our study indicates the need to continue research and prompts the development of new tools on predictive scores for TIA. [ABSTRACT FROM AUTHOR]

Background: The infectious disease phenotype of acute stroke associated with COVID-19 has been poorly characterized.Objective: We investigated the neurovascular and infectious disease phenotype of stroke patients with and without COVID-19 infection, and their effect on in-hospital mortality.Methods: This is a retrospective cohort study of consecutive patients with acute stroke, admitted to any ward of a hub hospital for stroke in Lombardy, Italy, during the first wave of COVID-19. Demographic, neurovascular, infectious disease, and respiratory characteristics were collected. The effect of clinical variables on survival was evaluated using logistic regression models.Results: One hundred thirty-seven patients with acute stroke were recruited; 30 (21.9%) patients had COVID-19 and represented 2.5% of the 1218 COVID-19 patients hospitalized in the study period. Demographics, comorbidities, stroke type, stroke severity, and etiology did not differ between COVID + stroke patients and non-COVID stroke patients, except for an excess of multi-embolic ischemic stroke in the COVID + group. Most COVID + stroke patients had symptomatic infection (60%) and interstitial pneumonia (70%). COVID + stroke patients required more frequently respiratory support (77% versus 29%; p < 0.0001) and had higher in-hospital mortality (40% versus 12%; p = 0.0005) than non-COVID stroke patients. Mortality was independently associated with symptomatic interstitial pneumonia (aOR 6.7; 95% CI 2.0-22.5; p = 0.002) and, to a lesser extent, with NIHSS on admission (aOR 1.1; 95% CI 1.03-1.2; p = 0.007) and recanalization therapies (aOR 0.2; 95% CI 0.04-0.98; p = 0.046).Conclusion: Symptomatic interstitial pneumonia was the major driver of in-hospital mortality in COVID + stroke patients. [ABSTRACT FROM AUTHOR]

Objectives: Artif icial intelligence (AI)–based image analysis is increasingly applied in the acute stroke field. Its implementation for the detection and quantification of hemorrhage suspect hyperdensities in non-contrast-enhanced head CT (NCCT) scans may facilitate clinical decision-making and accelerate stroke management. Methods: NCCTs of 160 patients with suspected acute stroke were analyzed regarding the presence or absence of acute intracranial hemorrhages (ICH) using a novel AI-based algorithm. Read was performed by two blinded neuroradiology residents (R1 and R2). Ground truth was established by an expert neuroradiologist. Specificity, sensitivity, and area under the curve were calculated for ICH and intraparenchymal hemorrhage (IPH) detection. IPH-volumes were segmented and quantified automatically by the algorithm and semi-automatically. Intraclass correlation coefficient (ICC) and Dice coefficient (DC) were calculated. Results: In total, 79 of 160 patients showed acute ICH, while 47 had IPH. Sensitivity and specificity for ICH detection were 0.91 and 0.89 for the algorithm; 0.99 and 0.98 for R1; and 1.00 and 0.98 for R2. Sensitivity and specificity for IPH detection were 0.98 and 0.89 for the algorithm; 0.83 and 0.99 for R1; and 0.91 and 0.99 for R2. Interreader reliability for ICH and IPH detection showed strong agreements for the algorithm (0.80 and 0.84), R1 (0.96 and 0.84), and R2 (0.98 and 0.92), respectively. ICC indicated an excellent (0.98) agreement between the algorithm and the reference standard of the IPH-volumes. The mean DC was 0.82. Conclusion: The AI-based algorithm reliably assessed the presence or absence of acute ICHs in this dataset and quantified IPH volumes precisely. Key Points: • Artificial intelligence (AI) is able to detect hyperdense volumes on brain CTs reliably. • Sensitivity and specificity are highest for the detection of intraparenchymal hemorrhages. • Interreader reliability for hemorrhage detection shows strong agreement for AI and human readers. [ABSTRACT FROM AUTHOR]

Objective: Cold and warm water ear irrigation, also known as bithermal caloric testing, has been considered for over 100 years the 'Gold Standard' for the detection of peripheral vestibular hypofunction. Its discovery was awarded a Nobel Prize. We aimed to investigate the diagnostic accuracy of Caloric Testing when compared to the video head impulse test (vHIT) in differentiating between vestibular neuritis and vestibular strokes in acute dizziness. Design: Prospective cross-sectional study (convenience sample). Setting: All patients presenting with signs of an acute vestibular syndrome at the emergency department of a tertiary referral center. Participants: One thousand, six hundred seventy-seven patients were screened between February 2015 and May 2020 for Acute Vestibular Syndrome (AVS), of which 152 met the inclusion criteria and were enrolled. Inclusion criteria consisted of a state of continuous dizziness, associated with nausea or vomiting, head-motion intolerance, new gait or balance disturbance and nystagmus. Patients were excluded if they were younger than 18 years, if symptoms lasted < 24 h or if the index ED visit was > 72 h after symptom onset. Of the 152 included patients 85 completed testing. We assessed 58 vestibular neuritis and 27 stroke patients. Main outcome measures: All patients underwent calorics and vHIT followed by a delayed MRI which served as a gold standard for vestibular stroke confirmation. Results: The overall sensitivity and specificity for detecting stroke with a caloric asymmetry cut-off of 30.9% was 75% and 86.8%, respectively [negative likelihood ratio (NLR) 0.29] compared to 91.7% and 88.7% for vHIT (NLR 0.094). Best VOR gain cut-off was 0.685. Twenty-five percent of vestibular strokes were misclassified by calorics, 8% by vHIT. Conclusions: Caloric testing proved to be less accurate than vHIT in discriminating stroke from vestibular neuritis in acute dizziness. Contrary to classic teaching, asymmetric caloric responses can also occur with vestibular strokes and might put the patient at risk for misdiagnosis. We, therefore, recommend to abandon caloric testing in current practice and to replace it with vHIT in the acute setting. Caloric testing has still its place as a diagnostic tool in an outpatient setting. [ABSTRACT FROM AUTHOR]

Purpose of Review: This article provides an overview of acute treatments in stroke which are widely studied and available for adults and their applicability in the pediatric population. Recent Findings: Arterial ischemic stroke is an important cause of morbidity and mortality in the pediatric population. Neurological deficits and etiologies are age-dependent and more challenging to diagnose than in the adult population. Advancements in imaging and treatment modalities including increased treatment windows in acute stroke have led to improvement in the diagnosis and management of pediatric arterial ischemic disease. Accordingly, hyperacute treatments, such as endovascular therapy, are becoming increasingly available in an attempt to improve outcomes in children. Summary: Significant scientific and technological advances have transformed the hyperacute treatment of stroke in the recent years, allowing for improvement in the diagnosis and treatment of cerebrovascular pathologies in children. Optimization in the approach and validation of existing stroke pathways/protocols are expected to further advance acute stroke therapy in pediatric patient care. Given that the lifelong individual, family, and societal burden of acute stroke is likely to be greater than in adults because infants and children surviving stroke live more years with disability, we must be knowledgeable about this pathology and the medical and therapeutic options available for this unique population as detailed in this review. [ABSTRACT FROM AUTHOR]

COVID-19 (Coronavirus disease 2019) caused by SARS-CoV-2 has a diverse constellation of neurological manifestations that include encephalopathy, stroke, Guillain–Barré syndrome, myelitis, and encephalitis. Intraluminal carotid thrombi (ILT) are infrequent lesions seen in only 1.6% of patients with acute ischemic stroke. Underlying atherosclerosis is the most common lesion associated with ILT formation. However, with COVID-19, we have encountered ILT in patients without significant atherosclerotic disease. The endothelial inflammation and hypercoagulable state associated with COVID-19 pose a risk of arterial and venous thromboembolism and could have contributed to this presentation although the exact pathophysiology and optimal treatment of ILT in COVID-19 remain elusive. Herein, we present a series of ischemic stroke patients with carotid ILT in the setting of a recent SARS-CoV-2 infection. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to study the relationship between air pollution and stroke (especially emergency stroke) in different regions and determine which air pollutant is the most significantly associated with stroke. Methods: The number of patients with emergency stroke, air pollutant data and related meteorological indicators were collected from December 2013 to May 2018 for large comprehensive hospitals in Chongqing. The generalized additive model was used to analyse the relationship between air pollution and emergency stroke. Results: After analysis and adjusting for meteorological indicators and day-of-the-week effects, in the one-pollutant model, every 10 μg/m3 increase in ozone(O3) was associated with a 2.482% (95% CI 1.044%, 3.919%) change in emergency strokes within lag0. For males, every 10 μg/m3 increase of O3 contributed to a 0.77% percent greater change compared with females. For the group younger than 60 years, we observed a 1.14% increase in risk with every 10 μg/m3 increase in O3. The group with pre-existing hypertension had a 0.26% higher risk than the group with no pre-existing hypertension with every 10 μg/m3 increase in O3. In two-pollutant model, when O3 was combined with a 10 μg/m3 increase of NO2, it increased the most significant risk of emergency stroke by 0.22%. Conclusion: These findings suggest that short-term exposure to O3 within 0 days is associated with emergency outpatient strokes, and younger people (age < 60 years) males and people with hypertension are more sensitive than older people, females and people without pre-existing hypertension. [ABSTRACT FROM AUTHOR]

Background: In acute stroke, distal cerebrovascular occlusions can be linked to severe clinical symptoms, and treatment by mechanical thrombectomy may have an important clinical impact. When intravenous fibrinolytic therapy is firmly contraindicated, it remains the only treatment option. Methods: A total of 42 patients with isolated distal arterial occlusions and absolute contraindication for intravenous fibrinolytic therapy were retrospectively included. Mechanical thrombectomy was performed using Penumbra 4MAX or 3MAX aspiration catheters. When aspiration alone did not result in successful revascularization, a stent retriever was added. Results: Direct thromboaspiration was the first treatment option in all patients. 16.7% of cases required the additional use of a stent retriever. A TICI score ≥ 2b reperfusion at the end of the procedure was obtained in 76.2% and a Rankin Score of 2 or less at 90 days in 45.7%. Two hemorrhagic complications were observed. Conclusions: Direct thromboaspiration appears a safe technique in acute isolated distal arterial occlusions. In a cohort of patients with absolute contraindication for intravenous fibrinolytic therapy, a significant percentage achieved good revascularization. [ABSTRACT FROM AUTHOR]

Background and purpose: Hydration status at the time of stroke has been acknowledged as an important determinant in early stroke recovery. However, the diagnosis of dehydration, or more accurately, a volume-contracted state, at the time of stroke is challenging since there are currently no consensus diagnostic criteria. In this systematic review, we gather the available evidence about diagnosis and treatment of dehydration after stroke.Methods: Studies of hospitalized ischemic stroke patients that reported rates of dehydration from January 1997 to March 2017 were screened for inclusion via a systematic search of PubMed, CINAHL, Cochrane, and Scopus using keywords hydration, dehydration, hemodilution, viscosity, volume status, and thirst.Results: Twenty-five studies of 8699 acute stroke patients were included. Nineteen studies reported on the diagnostic approach to dehydration. Findings are synthesized into four main categories of available research including studies that specify: (1) biological mechanisms using animal models to investigate the relationship between dehydration and stroke; (2) measures of dehydration in the acute human stroke population; (3) rehydration therapies after stroke; and (4) outcomes after stroke in dehydrated patients.Conclusions: We found considerable variation in terminology specific to hydration status, diagnostic approach to dehydration, and few prospective studies of treatment strategies with varying results. This review supports the need for consensus development of operational diagnostic criteria, standardization of language, and the opportunity for prospective study of rehydration strategies to impact outcome after stroke. [ABSTRACT FROM AUTHOR]

This document presents the consensus recommendations of the Hellenic Stroke Organization which can be of assistance to the treating stroke physicians. [ABSTRACT FROM AUTHOR]

Background: Recent studies suggested that preinterventional intravenous (i. v.) recombinant tissue plasminogen activator (rtPA) as bridging therapy facilitates successful and fast vessel recanalization in endovascular stroke treatment (EST); however, data on this effect and the associated clinical value are discrepant.Objective: This study examined if this discrepancy could be related to an effect-modifying variable, specifically to the exact occlusion site.Methods: Retrospective analysis of 239 patients with acute occlusion of the middle cerebral artery (MCA) treated with up to date endovascular techniques. Effects of i. v.-rtPA bridging on clinical outcomes and safety/efficacy of EST, defined as the respective rates of successful, first pass and thrombolysis in cerebral infarction (TICI) scale 3 recanalization, were evaluated and stratified according to distal versus proximal occlusion sites.Results: Overall, i. v.-rtPA bridging was associated with a significantly higher rate of successful recanalization (86.9 % vs. 75.7 %, p = 0.028). i. v.-rtPA bridging-related effects, however, were observable only in distal, but not in proximal MCA-occlusions. In distal occlusions, i. v.-rtPA clearly favored successful recanalization (adj. OR 4.6, 95 %-CI 1.5-13.6, p = 0.006) and first-pass successes (adj. OR 2.8, 95 %-CI 1.0-7.6, p = 0.042), but tended to be associated with lower rates of complete (TICI-3) reperfusion (adj. OR 0.4, 95 %-CI 0.2-1.1, p = 0.068). The net effect was a small clinical benefit, reflected in higher rates of strong neurological improvement (adj. OR: 2.8, 95 %-CI: 1.1-6.9, p = 0.03).Conclusion: i. v.-rtPA-bridging-related effects are occlusion site-dependent, paralleling similar effects of systemic i. v.-rtPA when applied without subsequent endovascular therapy. In distal occlusions, i. v.-rtPA facilitates thrombectomy, but may also promote distal embolization, with a small clinical benefit as overall net effect. Randomized trials assessing i.v-rtPA bridging need to be stratified according to occlusions sites. [ABSTRACT FROM AUTHOR]

Phosphatidylinositol 3-kinases (PI3Ks) have recently been implicated in apoptosis and ischemic cell death. We tested the efficacy of early intervention with a peptide PI3K activator in focal cerebral ischemia. After determining the most effective dose (24 μg/kg) and time window (2 h after MCAO) of treatment, a total of 48 rats were subjected to middle cerebral artery occlusion (MCAO). Diffusion weighted MRI (DWI) was performed 1 h after MCAO and rats with lesion sizes within a predetermined range were randomized to either PI3K activator or vehicle treatment arms. Fluid attenuated inversion recovery (FLAIR) MRI, neurological function, western blots, and immunohistochemistry were blindly assessed. Initial DWI lesion volumes were nearly identical between two groups prior to treatment. However, FLAIR showed significantly smaller infarct volumes in the PI3K activator group compared with vehicle (146 ± 81 mm and 211 ± 96 mm, p = 0.045) at 48 h. The PI3K activator group also had better neurological function for up to 2 weeks. In addition, PI3K activator decreased the number of TUNEL-positive cells in the peri-infarct region compared with the control group. Western blot and immunohistochemistry showed increased expression of phosphorylated Akt (Ser473) and GSK-3β (Ser9) and decreased expression of cleaved caspase-9 and caspase-3. Our results suggest a neuroprotective role of early activation of PI3K in ischemic stroke. The use of DWI in the randomization of experimental groups may reduce bias. [ABSTRACT FROM AUTHOR]

Given the importance of neuronal plasticity in recovery from a stroke and the huge variability of recovery abilities in patients, we investigated neuronal activity in the acute phase to enhance information about the prognosis of recovery in the stabilized phase. We investigated the microstates in 47 patients who suffered a first-ever mono-lesional ischemic stroke in the middle cerebral artery territory and in 20 healthy control volunteers. Electroencephalographic (EEG) activity at rest with eyes closed was acquired between 2 and 10 days (T0) after ischemic attack. Objective criteria allowed for the selection of an optimal number of microstates. Clinical condition was quantified by the National Institute of Health Stroke Scale (NIHSS) both in acute (T0) and stabilized (T1, 5.4 ± 1.7 months) phases and Effective Recovery (ER) was calculated as (NIHSS(T1)-NIHSS(T0))/NIHSS(T0). The microstates A, B, C and D emerged as the most stable. In patients with a left lesion inducing a language impairment, microstate C topography differed from controls. Microstate D topography was different in patients with a right lesion inducing neglect symptoms. In patients, the C vs D microstate duration differed after both a left and a right lesion with respect to controls (C lower than D in left and D lower than C in right lesion). A preserved microstate B in acute phase correlated with a better effective recovery. A regression model indicated that the microstate B duration explained the 11% of ER variance. This first ever study of EEG microstates in acute stroke opens an interesting path to identify neuronal impairments with prognostic relevance, to develop enriched compensatory treatments to drive a better individual recovery. [ABSTRACT FROM AUTHOR]

Purpose of Review: This study aims to describe the current state of telestroke clinical applications and policies, in addition to key technical and operational aspects of the telemedicine practice. Recent Findings: Delivery of telestroke services for neurovascular care expanded from the intravenous alteplase decision and administration in acute emergency department settings to a continuum of services in mobile and inpatient stroke units, intensive care units, virtual stroke clinics, rehabilitation, and clinical research. Telestroke cost-effectiveness is well established from multiple perspectives. Stroke centers, certification agencies, and national registries have made essential recommendations regarding telestroke quality measures monitoring and reporting. Summary: Telestroke continues to bring neurovascular expertise to resource-restricted areas with advanced virtual communication techniques, optimizing stroke care. Future research should aim at broadening telestroke technology applications, while improving quality and reducing the delivery-associated cost and resources. Comprehensive multidisciplinary virtual telestroke centers that cover all aspects of stroke management might become available in the future. [ABSTRACT FROM AUTHOR]

Most studies on sensory extinction have focused on selected patients with subacute and chronic right hemisphere lesions. In studies conducted on acute stroke patients, risk factors and time course were not evaluated. Our aim was to determine the prevalence, risk factors, and time course of sensory extinction in the acute stroke setting. Consecutive patients with acute stroke were tested for tactile, visual, auditory, and auditory-tactile cross-modal extinction, as well as for peripersonal visuospatial neglect (PVN). Tests were repeated at 2, 7, 15, 30, and 90 days after initial examination. A multivariable logistic regression analysis was performed to test the association between sensory extinction and demographic and clinical risk factors. Seventy-three patients (38.4% women) were recruited: 64 with ischemic stroke and nine with haemorrhagic stroke. Mean age was 62.3 years (95% CI 58.8-65.7), mean NIHSS score was 1.6 (95% CI 1.2-2.1), and mean time to first examination was 4.1 days (95% CI 3.5-4.8). The overall prevalence of all subtypes of sensory extinction was 13.7% (95% CI 6.8-23.8). Tactile extinction was the most frequent subtype with a prevalence of 8.2% (95% CI 3.1-17.0). No extinction was found beyond 15 days after the first examination. After adjustment for age, sex, lesion side, type of stroke, time to first examination and stroke severity, a lesion volume ≥2 mL (adjusted OR = 38.88, p = 0.04), and presence of PVN (adjusted OR = 24.27, p = 0.04) were independent predictors of sensory extinction. The insula, the putamen, and the pallidum were the brain regions most frequently involved in patients with sensory extinction. Extinction is a rare and transient phenomenon in patients with minor stroke. The presence of PVN and lesion volume ≥2 mL are independent predictors of sensory extinction in acute stroke. [ABSTRACT FROM AUTHOR]

To determine the clinical implications of hemorrhagic transformation (HT) after thrombolysis, 241 eligible patients receiving alteplase for acute ischemic stroke were studied. HT was classified, according to the European Cooperative Acute Stroke Study criteria, as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH). Symptomatic intracranial hemorrhage (SICH) was defined according to the National Institute of Neurological Disorders and Stroke study. A novel classification, clinically significant intracranial hemorrhage (CSICH) was defined as HTs associated with an unfavorable clinical outcome (modified Rankin Scale 5-6) at 3 months. For all subtypes of HT, we found that patients receiving alteplase were more often in the standard-dose group (0.90 ± 0.02 mg/kg) than in the lower dose group (0.72 ± 0.07 mg/kg). PH and SICH were related to an unfavorable clinical outcome, while HI was not. There was a positive trend between age and CSICH in patients receiving the standard dose (P = 0.0101), and between alteplase dose and CSICH in patients ≥70 years old (P = 0.0228). All PHs (including asymptomatic PHs) and symptomatic HIs have been found to be associated with unfavorable outcome, and for this reason defined as CSICH. Independent predictors of CSICH were age ≥70 years and the standard dose of alteplase. Further studies of thrombolysis for ischemic stroke with different doses of alteplase are warranted. [ABSTRACT FROM AUTHOR]

Anticoagulation is important in stroke prevention in patients with atrial fibrillation. Until recently, heparins and vitamin K antagonists were the only available therapy for stroke reduction in atrial fibrillation (AF) patients. Non-vitamin K antagonist oral anticoagulants (NOACs) including direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) are now available and offer new options for stroke prevention. This article reviews the available data on the use of NOACs for primary and secondary stroke prevention in AF patients and describes specific patient populations to guide clinician in making the informed decision regarding appropriate use of those agents. It also addresses the use of NOACs early after acute stroke and use of thrombolysis while on NOAC. [ABSTRACT FROM AUTHOR]

Anticoagulant therapy is recommended for the secondary prevention of stroke in patients with atrial fibrillation (AF). T he identification of patients at high risk for early recurrence, which are potential candidates to prompt anticoagulation, is crucial to justify the risk of bleeding associated with early anticoagulant treatment. The aim of this study was to evaluate in patients with acute ischemic stroke and AF the association between findings at trans-thoracic echocardiography (TTE) and 90 days recurrence. In consecutive patients with acute ischemic stroke and AF, TTE was performed within 7 days from hospital admission. Study outcomes were recurrent ischemic cerebrovascular events (stroke or TIA) and systemic embolism. 854 patients (mean age 76.3 ± 9.5 years) underwent a TTE evaluation; 63 patients (7.4 %) had at least a study outcome event. Left atrial thrombosis was present in 11 patients (1.3 %) among whom 1 had recurrent ischemic event. Left atrial enlargement was present in 548 patients (64.2 %) among whom 51 (9.3 %) had recurrent ischemic events. The recurrence rate in the 197 patients with severe left atrial enlargement was 11.7 %. On multivariate analysis, the presence of atrial enlargement (OR 2.13; 95 % CI 1.06-4.29, p = 0.033) and CHADS-VASc score (OR 1.22; 95 % CI 1.04-1.45, p = 0.018, for each point increase) were correlated with ischemic recurrences. In patients with AF-associated acute stroke, left atrial enlargement is an independent marker of recurrent stroke and systemic embolism. The risk of recurrence is accounted for by severe atrial enlargement. TTE-detected left atrial thrombosis is relatively uncommon. [ABSTRACT FROM AUTHOR]

Objective: The hyperintense acute reperfusion marker (HARM) on fluid-attenuated inversion recovery (FLAIR) images is associated with blood-brain barrier (BBB) permeability changes. The aim of this study was to examine the influence of contrast agent dosage on HARM incidence in acute ischaemic stroke patients.Methods: We prospectively included 529 acute ischaemic stroke patients (204 females, median age 71 years). Patients underwent a first stroke-MRI within 24 hours from symptom onset and had a follow-up on day 2. The contrast agent Gadobutrol was administered to the patients for perfusion imaging or MR angiography. The total dosage was calculated as ml/kg body weight and ranged between 0.04 and 0.31 mmol/kg on the first examination. The incidence of HARM was evaluated on day 2 FLAIR images.Results: HARM was detected in 97 patients (18.3%). HARM incidence increased significantly with increasing dosages of Gadobutrol. Also, HARM positive patients were significantly older. HARM was not an independent predictor of worse clinical outcome, and we did not find an association with increase risk of haemorrhagic transformation.Conclusions: A higher dosage of Gadobutrol in acute stroke patients on initial MRI is associated with increased HARM incidence on follow-up. MRI studies on BBB should therefore standardize contrast agent dosages.Key Points: • Hyperintense acute reperfusion marker on MRI indicates blood-brain barrier disruption. • This observational study on stroke patients characterizes HARM. • Incidence depends on contrast agent dosage on the previous day. • HARM is also associated with older age and poor kidney function. • Interpretation of HARM must take dosage into consideration. [ABSTRACT FROM AUTHOR]

Embolectomy with stentriever devices is the newest treatment for acute stroke. Since 1995, treatment of acute stroke has been limited to a 4.5-h window with the use of intravenous tissue plasminogen activator (tPA). Five articles have been published in 2015 with the results supporting the paired treatment of tPA and embolectomy. This has also expanded the treatment window to greater than 4.5 h and produced evidence which will guide selection of patients that will benefit most from this therapy. This article will compare and contrast this most recent evidence. [ABSTRACT FROM AUTHOR]

Imaging is an increasingly key component of advances in stroke care. Its role in the success of multiple recently reported trials that have now driven new standards of practice highlights its expanding importance in acute stroke management. With significant gains already realized, routine practice only stands to benefit further from additional advances in imaging in the future. The degree to which imaging will impact stroke care, however, is uncertain and complex: multiple aspects of stroke research and its translation into updated practice contribute to it. In this article, a few of these critical issues and questions related to imaging and its potential, both present and future, to drive stroke care forward are addressed. [ABSTRACT FROM AUTHOR]

Clinical evidence has established that sleep apnea is a risk factor for stroke. Patients with stroke have a high prevalence of sleep apnea that may have preceded or developed as a result of the stroke. Well-established concurrent stroke risk factors for stroke like hypertension and atrial fibrillation respond favorably to the successful treatment of sleep apnea. The gold standard diagnosis of sleep apnea is obtained in the sleep laboratory, but unattended polysomnography is gaining acceptance. Positive airway pressure (PAP) (continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) applications are the gold-standard treatment of sleep apnea. Suggestive evidence indicates that stroke occurrence or recurrence may be reduced with treatment of sleep apnea. [ABSTRACT FROM AUTHOR]

There has been a tremendous evolution in the stroke systems of care in the USA. Public awareness, prehospital care, and in-hospital protocols have never been so effectively connected. However, given the critical role of time to effective reperfusion in the setting of acute ischemic stroke, it is vital and timely to implement strategies to further streamline emergency stroke care. This article reviews the most current standards and guidelines related to the flow of stroke care in the prehospital and emergency settings. [ABSTRACT FROM AUTHOR]

Background: An intra-arterial (IA) mechanical thrombectomy has increased the recanalization rates for acute occlusion of proximal intracranial arteries. However, the current failure rate of endovascular recanalization remains at approximately 10 %, resulting in the need for surgical rescue treatment. The authors applied a minimally invasive and rapid surgical embolectomy (MIRSE) as a final rescue treatment after the failure of endovascular recanalization, and investigated the incidence, technical feasibility, and treatment results. Methods: For two years, from 2012 to 2013, a total of 131 patients with acute occlusion of proximal intracranial arteries underwent an IA mechanical thrombectomy using a Penumbra System and a Solitaire stent, yet ten (7.6 %) patients still experienced final recanalization failure. Four (40 %) of these ten patients subsequently underwent a MIRSE consisting of a superciliary keyhole approach, arteriotomy to remove the embolus, and arteriotomy repair techniques using aneurysm clips as the final repair material, or a temporary compartmentalizing clip. Results: Four patients aged 39 to 78 years with an embolic occlusion in the middle cerebral artery ( n = 1) and internal carotid artery ( n = 3) were treated using a MIRSE. Complete recanalization was achieved in all four patients, and the time from skin incision to reperfusion was 40-50 minutes. The modified Rankin Scale (mRS) scores at 3 months after surgery were 1 ( n = 2), 2 ( n = 1), and 3 ( n = 1), respectively. Conclusions: A MIRSE can be an effective rescue treatment after the failure of endovascular recanalization therapies for acute occlusion of proximal intracranial arteries if the patient is within the therapeutic time window. [ABSTRACT FROM AUTHOR]

Telemedicine is in increasing use in clinical neuroscience such as acute stroke care, especially by applying remote audiovisual communication for patient evaluation. However, telephone consultation was also used linking stroke centres to smaller hospitals. We compared costs of telestroke services using audiovisual and telephone communication in different organizational models. Within a small network in Northern Bavaria video-based teleconsultation (VTC) and telephone advice (TA) was provided for evaluation of acute stroke patients on a weekly rotation. The costs of the admissions process with or without one of both methods of telemedicine were calculated and compared from the perspective of the spoke hospital. Different levels of service and network size were modelled and costs of transfers as well as loss of revenues were calculated. Yearly total labour costs were 415,000 € for an on-site service VTC-service compared to 61,000 € in an on-call service. Additional costs for one teleconsultation were 109.55 € in VTC and 49.82 € in TA (VTC/TA ratio 2.2). The ratio decreased to 0.8 when accounting for costs of transfer and loss of reimbursement for all patients transferred as transfer of patients to the stroke centre was more frequent after TA (9.1 vs. 14.9 %full-time on-site ser). Costs of one QALY gained by using VTC instead of TA ranged from 115.00 € to 515.86 € depending on the different models. In the first view TA looks like the less expensive method as it is easy to access and works without additional costs. When accounting for all disadvantages TA becomes slightly more expensive. In telestroke care VTC should be recommended as the method of choice also from an economic perspective. [ABSTRACT FROM AUTHOR]

Disorders associated with prominent headaches, such as migraine with aura and cerebral arterial and venous diseases, increase the risk of ischemic and hemorrhagic stroke. Central nervous system vasculitis, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, and cerebral venous thrombosis are all disorders associated with severe or persistent headache in which the risk for ischemic and hemorrhagic stroke is increased. Hemorrhagic strokes, more frequently than ischemic strokes, present with distinct headaches, usually accompanied by focal neurological symptoms. Pregnancy, and especially the postpartum period, is a time of overlap between new-onset headache and stroke risk. [ABSTRACT FROM AUTHOR]

Post-stroke cognitive impairment (PSCI) includes all forms of cognitive decline that develop after stroke, even if not severe enough to fit the criteria of dementia. Our aims were to investigate the predictive value of a brief bedside examination (Montreal Cognitive Assessment, MoCA) in the acute phase of stroke on the diagnosis of mid-term PSCI, taking into account other clinical, cognitive, functional, and neuroimaging predictors. Consecutive patients admitted to a stroke unit were evaluated with MoCA between 5 and 9 days after stroke. At baseline, clinical, functional, and neuroimaging data were collected. Patients were reassessed between 6 and 9 months after stroke by means of an extensive neuropsychological and functional evaluation. Out of 137 enrolled stroke patients, 80 (58.4 %) were followed up (mean age 68.2 ± 14.6 years, males 66 %, mean NIHSS score 3.6 ± 4.8). PSCI was diagnosed in 47 patients (59 %; 35 mild cognitive impairment, 12 dementia). Controlling for age, education, functional and cognitive pre-morbid status, stroke severity, and pre-existing lacunar infarcts, MoCA baseline score [OR (95 % CI) = 1.4(1.1-1.8)] for each point] and leukoaraiosis severity [OR (95 % CI) = 0.4(0.2-0.9)] for each point of the van Swieten scale] were independently associated with PSCI. Using a ROC analysis, a cut-off of 21 predicted the diagnosis of PSCI with 91.4 % sensitivity, 75.8 % specificity, 80 % positive predictive value, and 89.3 % negative predictive value. In a sample of mild stroke patients, MoCA seems to be a good predictor of mid-term PSCI, making it a possible candidate for a brief cognitive screening in the acute stroke setting. [ABSTRACT FROM AUTHOR]

Background: Acute cervical carotid artery occlusion presents with a severe neurological deficit and is associated with unfavorable outcomes. In this study, the authors report their experience with patients having had acute ischemic stroke due to cervical carotid occlusion, who underwent endovascular intervention. Method: Sixteen acute cervical carotid occlusion patients (15 males and 1 female; mean age 67.7 years) were treated by endovascularly between January 2009 and November 2012. Clinical, procedural, and angiographic data were retrospectively evaluated. Successful intracranial recanalization was based on thrombolysis in cerebral infarction score of 2B-3. A favorable outcome was defined as a modified Rankin Scale score of 0-2 at 90 days. Findings: The average score of National Institutes of Health Stroke Scale before treatment was 15.9. Ten of 16 patients (63 %) were associated with intracranial tandem occlusion. Ten (63 %) cases were caused by atherosclerotic, 4 (25 %) by atrial fibrillation (AF), and 2 (13 %) by dissection. Thirteen of 16 (81 %) achieved successful cervical recanalization and 7 of 16 (44 %) patients obtained sufficient cervical and intracranial perfusion. As a result, 5 of 16 (31 %) patients demonstrated favorable outcomes. Five of seven patients (71 %) with successful cervical and intracranial recanalization presented favorable outcomes. In contrast, none of the patients without cervical or intracranial recanalization presented favorable outcomes. Three of 6 (50 %) patients initially without intracranial occlusion showed favorable outcomes, but only 2 of 10 (20 %) patients associated with intracranial occlusion had favorable outcomes. On the aspect of etiology, in atherosclerotic cases, 4 of 10 (40 %) showed favorable outcomes. However, all four AF cases deteriorated into poor outcomes. Conclusions: This study demonstrated the feasibility of endovascular intervention for acute cervical carotid artery occlusion. Although treatment for tandem occlusion and AF cases is an issue that should be resolved, intervention must be encouraged. Successful cervical and intracranial revascularization will be essential for favorable outcomes. [ABSTRACT FROM AUTHOR]

Stroke is the 4th leading cause of death in the US and a leading cause of disability among adults. Stroke is broadly classified into ischemic and hemorrhagic subtypes. Although the pathogenesis may differ between ischemic and hemorrhagic stroke subtypes, a unifying feature is that hypertension is a major risk factor for most ischemic and hemorrhagic strokes. Prevention of first and recurrent stroke is substantially dependent on blood pressure control. There is controversy about blood pressure management in acute stroke. In this review we discuss controversies about and guidelines for management of blood pressure in acute stroke. We subdivide our discussion to address important questions about acute blood pressure management in ischemic stroke, intraparenchymal hemorrhage, and subarachnoid hemorrhage. In addition, we address BP control recommendations when tissue plasminogen activator administration is being contemplated for treatment of acute ischemic stroke. [ABSTRACT FROM AUTHOR]

The evaluation of cognitive status is not routine in the acute stroke setting. We aimed to investigate feasibility, applicability, and performances of the Montreal cognitive assessment (MoCA) in acute stroke patients. Consecutive stroke patients (ischemic or hemorrhagic) admitted to one stroke unit were evaluated 5-9 days after stroke with MoCA (score range: 0-30; higher scores indicate better cognitive performance). Pre-morbid functional and cognitive status was assessed by a structured interview to caregivers. Neuroimaging data regarding index stroke and pre-existing lesions were collected. From December 2009 to December 2010, out of 207 patients with stroke, 137 (66 %) were enrolled [mean age 69.2 ± 14.8 years; males 62 %; mean National Institute of Health and Stroke Scale (NIHSS) score 5.9 ± 7.9]. The most common reason for non-enrolment was unfitting the time window inclusion criteria. MoCA was entirely applicable to 113/137 (82.5 %) patients and the mean score was 17.8 ± 7.1. Multivariate analyses showed that non-applicability was associated with higher NIHSS scores [OR (95 % CI) = 1.4 (1.2-1.7) for each point], left sided lesions [OR (95 % CI) = 18.8 (2.3-155.2)], and worse pre-morbid functional status [OR (95 % CI) = 0.7 (0.6-0.9) for each point of the instrumental activity of daily living scale]. Factors influencing MoCA performance were low education ( β = 0.264, p < 0.01), higher NIHSS scores ( β = −0.277, p < 0.01) and worse pre-morbid functional status ( β = 0.504, p < 0.001). MoCA administration is feasible in acute patients with mild-to-moderate stroke, with lesion location, stroke severity, and pre-morbid functional status as major determinants of its applicability and performance. MoCA seems to reveal some degree of cognitive deficit even in patients with mild stroke. [ABSTRACT FROM AUTHOR]

Acute stroke affects about 800,000 patients annually in the US and is the leading cause of disability. It is a complex condition with multiple causes and requires comprehensive but rapid evaluation by stroke specialists working in institutions with well-organized stroke systems of care. Acute stroke treatment is focused on early revascularization with intravenous tPA for those with strokes under 3 hours duration or intra-arterial therapy for most others and those who cannot receive tPA. The latter is evolving rapidly with the advent of stent-retriever embolectomy devices that are poised to revolutionize stroke treatment. Recanalization is associated with neurological recovery in 33-50 % of patients. This also means that many patients may have devastating and life-threatening brain injury, which highlights the need for comprehensive care for the prevention and treatment of medical complications, management of cerebral edema and intracerebral hemorrhage. [ABSTRACT FROM AUTHOR]

Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7-30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0-11.5 %, and 3.4-31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care. [ABSTRACT FROM AUTHOR]

Delirium is a common complication in acute stroke yet there is uncertainty regarding how best to screen for and diagnose delirium after stroke. We sought to establish how delirium after stroke is identified, its incidence rates and factors predicting its development. We conducted a systematic review of studies investigating delirium in acute stroke. We searched The Cochrane Collaboration, MEDLINE, EMBASE, CINHAL, PsychINFO, Web of Science, British Nursing Index, PEDro and OT Seeker in October 2010. A total of 3,127 citations were screened, full text of 60 titles and abstracts were read, of which 20 studies published between 1984 and 2010 were included in this review. The methods most commonly used to identify delirium were generic assessment tools such as the Delirium Rating Scale ( n = 5) or the Confusion Assessment Method ( n = 2) or both ( n = 2). The incidence of delirium in acute stroke ranged from 2.3-66%, with our meta-analysis random effects approach placing the rate at 26% (95% CI 19-33%). Of the 11 studies reporting risk factors for delirium, increased age, aphasia, neglect or dysphagia, visual disturbance and elevated cortisol levels were associated with the development of delirium in at least one study. The outcomes associated with the condition are increased morbidity and mortality. Delirium is found in around 26% of stroke patients. Difference in diagnostic and screening procedures could explain the wide variation in frequency of delirium. There are a number of factors that may predict the development of the condition. [ABSTRACT FROM AUTHOR]

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The purpose of this study was to test if magnetic resonance (MR) perfusion-weighted imaging (PWI) can reliably characterize the ischemic penumbra. Sixteen patients with nonlacunar ischemic stroke who were scanned within 24 h after onset of symptoms were selected for the study. In previous studies, the level of regional cerebral blood flow (rCBF) in the normal white matter of the contralateral hemisphere was defined as 22 ml/100 g/min. We used this level as a standard of reference. We hypothesized that rCBF below this level would be amenable to infarct. The lesion-to-white matter ratios of rCBF were measured in the regions of ischemic core (“Core”), infarcted penumbra (“Growth”), salvaged penumbra (“Reversed”), and contralateral normal cortex (“Normal”). The rCBF of “Growth” and “Reversed” areas showed substantial overlap, which hampered the delineation of areas that would become infarcted. The semiquantitative rCBF derived from MR PWI may not accurately characterize the ischemic penumbra. [ABSTRACT FROM AUTHOR]

Telemedicine is increasingly being used in acute stroke care. Some of the first studies and network projects are already applying remote audiovisual communication for patient evaluation. Formerly the telephone was the method of choice to contact experts for case discussion. We compared remote video-examination and telephone consultation in acute stroke care. Two district hospitals were linked to stroke centers in Northern Bavaria. Patients with symptoms suggestive of an acute stroke were included. Remote video examination (RVE) was provided by live audiovisual communication and access to brain images; telephone consultation (TC) was done via standard telephone using a structured interview. There was a weekly rotation of the two methods. Demographic data and other data concerning process and quality of care as well as outcome 10 days after stroke were recorded and compared between the two groups. Within the study period 151 consultations were made in acute stroke patients (mean age 66.8 years). 77 patients were seen by RVE and 74 by TC. Total examination times were 49.8 min for RVE and 27.2 min for TC (p < 0.01). Patients were more frequently transferred to the stroke center after TC consultation (9.1 % vs. 14.9 %, p < 0.05) and had a higher mortality 10 days after stroke (6.8 % vs. 1.3 %, p < 0.05). Diagnosis made by TC had to be corrected more frequently (17.6 % vs. 7.1 %; p < 0.05). Creating a network improves stroke care by establishing cooperation between hospitals. Telephone consultation could be a simple method of telemedicine to support cooperation as it is easy and widely available. However, outcome parameters like mortality indicate that remote video examination is superior to TC. Therefore, full-scale audiovisual communication is recommended for remote consultation in acute stroke care. [ABSTRACT FROM AUTHOR]

We evaluated the efficacy and safety of thrombus extraction using a microsnare in patients with acute ischemic stroke (AIS). This was a prospective, observational, cohort study in which consecutive patients with AIS (<6 hours of ischemia for anterior circulation and <24 hours for posterior circulation) who had been previously excluded from intravenous tissue plasminogen activator (tPA) thrombolysis were included and followed-up for 3 months. Mechanical embolectomy with a microsnare of 2–4 mm was undertaken as the first treatment. Low-dose intraarterial thrombolysis or angioplasty was used if needed. TIMI grade and modified Rankin stroke scale (mRSS) score were used to evaluate vessel recanalization and clinical efficacy, respectively. Nine patients (mean age 55 years, range 17–69 years) were included. Their basal mean NIHSS score was 16 (range 12–24). In seven out of the nine patients (77.8%) the clot was removed, giving a TIMI grade of 3 in four patients and TIMI grade 2 in three patients. Occlusion sites were: middle cerebral artery (four), basilar artery (two) and anterior cerebral artery plus middle cerebral artery (one). The mean time for recanalization from the start of the procedure was 50 min (range 50–75 min). At 3 months, the mRSS score was 0 in two patients and 3–4 in three patients (two patients died). According to our results, the microsnare is a safe procedure for mechanical thrombectomy with a good recanalization rate. Further studies are required to determine the role of the microsnare in the treatment of AIS. [ABSTRACT FROM AUTHOR]

Acute hemorrhagic stroke in Krushinsky-Molodkina rats was used to assess the ability of erythrocytes to change their shape in a shear flow. Membrane rigidity and internal viscosity of erythrocytes were measured by laser diffractometry (i.e., obtaining a diffraction pattern from a thin layer of an erythrocyte suspension in a shear flow followed by computer processing of the image). The results testify to reduced deformability of erythrocytes under hemorrhagic stroke. [ABSTRACT FROM AUTHOR]

In an open pilot study 55 patients suffering from acute stroke were treated with Flunarizine, a calcium overload blocker, in addition to standard therapy including diet, physiotherapy, adequate management of accompanying disorders, and hemodilution. The initial high-dose i.v. treatment (2 x 25 mg Flunarizine/day) and the subsequent oral regimen were well-tolerated. The main side effect was slight transient weariness. No adverse effects regarding blood pressure, heart rate, enzymes, blood analysis, renal function and, especially, no extrapyramidal motor symptoms or depression were detected. Flunarizine may be regarded as a relatively safe drug in acute stroke. The probable beneficial effect on the patient's recovery will be evaluated in a multicenter double-blind study. [ABSTRACT FROM AUTHOR]

Purpose Of Review: Cerebral hyperperfusion syndrome (CHS) is a rare but significant complication after carotid revascularization and is increasingly recognized after acute stroke treatments. In this review, we discuss the epidemiology and pathophysiology of CHS, clinical presentation including ipsilateral headache, seizures, and focal neurological deficits, and radiographic presentation. We propose preventive therapies with emphasis on acute stroke post-thrombectomy hyperperfusion.Recent Findings: CHS was first described after carotid revascularization but is now also reported in patients with acute ischemic stroke. Proposed criteria involve a combination of new clinical symptoms, radiographic evidence of hyperperfusion, and/or presence of intracerebral hemorrhage occurring within 30 days after the carotid or intracranial vessel manipulation. Strongest risk factors include reduced cerebral vasoreactivity, contralateral stenosis of ≥ 70%, post-procedure hypertension, and recent ipsilateral stroke. Pathophysiology is incompletely understood but is likely due to increase in cerebral blood flow and impaired cerebral autoregulation, particularly in the areas of disrupted blood-brain barrier, as well as baroreceptor dysfunction during carotid surgery. Strict blood pressure control pre-, during, and post-procedure is recommended, depending on the recanalization status of the vessel. However, there is no randomized data regarding the goal blood pressure to prevent cerebral hyperperfusion syndrome. With technical advances, carotid or intracranial vessel manipulation is increasingly common. CHS is a likely under-recognized and serious complication of carotid revascularization and intracranial thrombectomy. Awareness of and surveillance for CHS is important to reduce morbidity and mortality. Future research should focus on validation of proposed diagnostic criteria and determining optimal post-procedure hemodynamic management to prevent CHS. [ABSTRACT FROM AUTHOR]

It is well known that stroke is associated with high morbidity and mortality. Previous studies and metaanalysis provide evidence favouring care of stroke patients in Stroke Units (SU). We published data on SU coverage for seven Italian regions during 2000-2001. The aim of this study is to conduct a new recent survey of SUs in the entire national territory and to evaluate changes in number of SUs and in organisation of in-hospital care in the seven Italian regions evaluated in our previous survey. Hospital services were identified through the diagnosis-related groups (DRG 14) from national hospital discharge registers. We selected services recording at least 50 acute stroke discharges per year. The characteristics of hospital services were obtained from a structured questionnaire submitted by phone by trained researchers to the doctors in charge of services. A SU was defined as a ward that admits acute stroke patients cared for in dedicated beds and by dedicated staff. Out of 676 hospital services evaluated during 2003-2004, 68 were SUs. The national coverage for SU services was 10%, ranging from 0% to 50% in different regions. In 2003-2004 SUs admitted 10% of the total national acute stroke cases. SUs have a more facilitated access to diagnostic evaluations and also seem to be better organised than general wards. Between 2000 and 2004 the number of SUs increased from 7% to 11% in the seven regions evaluated in our first survey. Notwithstanding we found an increase of 30% in the number of SUs, at least in the regions previously evaluated, there is still a shortage of SU beds and high regional heterogeneity. [ABSTRACT FROM AUTHOR]

With multislice CT scanners, CT angiography is increasingly becoming a diagnostic tool for supraaortal (extra- and intracranial) vessel pathology. There are three different fields in which CTA might replace invasive DSA and even compete with MRI techniques. In intracranial aneurysms CTA has a high diagnostic accuracy with a very small number of false negative results. The cutoff aneurysm size is approximately 3 to 4 mm, and nearly 99% of ruptured aneurysms can be recognized by CTA. In ICA stenosis CTA is obviously more accurate than MRA, because it does not have the inherent error of stenosis overestimation and has the additional advantage of visualisation of calcification. Specifically, the latter is a major advantage if one has to decide between stenting and surgical repair of the stenosis. In acute stroke, the combination of tissue and vessel imaging with MR techniques is obviously better than CT technology. However, MR is not always available everywhere. In these cases, the combination of a brain CT and CTA of the supra-aortal vessels might be a good alternative, specifically if thrombolytic therapy is a therapeutic option. In summary, CTA clearly can replace DSA for many diagnostic purposes and will even replace MRA in patients with ICA stenosis. [ABSTRACT FROM AUTHOR]