Search

Background Sonothrombolysis is safe and may increase the likelihood of early recanalization in acute ischemic stroke patients. Aims In preparation of a phase III clinical trial, we contrast the likelihood of achieving a sustained recanalization and functional independence in a post hoc subgroup analysis of patients randomized to transcranial Doppler monitoring plus intravenous tissue plasminogen activator (sonothrombolysis) compared with intravenous tissue plasminogen activator alone in the CLOTBUST trial. Methods We analyzed the data from all randomized acute ischemic stroke patients with pretreatment National Institutes of Health Stroke Scale scores ≥ 10 points and proximal intracranial occlusions in the CLOTBUST trial. We compared sustained complete recanalization rate (Thrombolysis in Brain Ischemia flow grades 4–5) and functional independence (modified Rankin Scale 0–1) at 90 days. Safety was evaluated by the rate of symptomatic intracranial hemorrhage within 72 h of stroke onset. Results Of 126 patients, a total of 85 acute ischemic stroke patients met our inclusion criteria: mean age 71 ± 11years, 56% men, median National Institutes of Health Stroke Scale 17 (interquartile range 14–20). Of these patients, 41 (48%) and 44 (52%) were randomized to intravenous tissue plasminogen activator alone and sonothrombolysis, respectively. More patients achieved sustained complete recanalization in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (38·6% vs. 17·1%; P = 0·032). Functional independence at 90 days was more frequently achieved in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (37·2% vs. 15·8%; P = 0·045). Symptomatic intracranial hemorrhage rate was similar in both groups (4·9% vs. 4·6%; P = 1·00). Conclusions Our results point to a signal of efficacy and provide information to guide the subsequent phase III randomized trial of sonothrombolysis in patients with severe ischemic strokes.

BackgroundTelemedicine may facilitate the selection of stroke patients who require emergency transfer to a comprehensive stroke center to receive additional therapies other than intravenous tissue plasminogen activator.Aims and/or hypothesisWe sought to analyze frequency, patient characteristics, and specific therapies among emergently transferred patients within the telemedical Stroke East Saxony Network.MethodsWe reviewed consecutive patients who were transferred emergently from remote spoke sites to hub sites. Certified stroke neurologists performed teleconsultations 24/7, with access to high-speed videoconferencing and transfer of brain images. Emergent transfers were initiated when considered necessary by the stroke neurologist.ResultsIn 2009 and 2010, we conducted 1413 teleconsultations and subsequently recommended transfer in 339 (24%) patients [mean age 64 ± 14 years, 54% males, median National Institutes of Health Stroke Scale score 5 (interquartile range, IQR 12). The mean teleconsultation-to-arrival time was 1·7 ± 0·8 h (median 1·6 h). Sixty-eight (20%) transferred patients had a nonstroke diagnosis. The remaining 271 (80%) patients had stroke diagnoses [ischemic stroke, 114 (34%); transient ischemic attack, 8 (2%); and intracranial haemorrhage, 149 (44%)]. Forty (35%) ischemic stroke patients received tissue plasminogen activator at spoke sites (‘drip and ship’). Of the 240 stroke patients emergently transferred to the main hub site, 119 (49·6%) received at least one specific stroke therapy.ConclusionA remarkable number of stroke patients can be transferred within a telemedical network to enable the delivery of specific stroke therapies that require advanced multispecialty expertise. Whether associated logistic efforts and costs have an impact on patients' clinical outcomes needs to be evaluated.

Introduction With a view to develop an operator-independent monitoring system for sonothrombolysis, we aimed to evaluate the per cent agreement of power motion transcranial Doppler vessel tracks compared with computed tomography angiography in identification of the anterior and posterior circulation vessels in patients with acute ischaemic stroke. Methods Consecutive acute ischaemic stroke patients who underwent emergent brain computed tomography angiography and bedside power motion transcranial Doppler were studied. Depth ranges for detecting anterior and posterior circulation vessels were derived from power motion transcranial Doppler flow tracks and computed tomography angiography images of the circle of Willis. We calculated percent agreement of power motion transcranial Doppler with computed tomography angiography for the anterior and posterior circulation vessel localization using computed tomography angiography as reference. Results Samples were obtained from 34 acute ischaemic stroke patients (mean age 61 ± 16 years, 62% men, median National Institutes of Health Stroke Scale (NIHSS) score 5, interquartile range 2–8). A total of 229 Power motion Doppler computed tomography angiography vessel pairs were analysed. Power motion transcranial Doppler tracks for M1 and proximal M2 middle cerebral artery (MCA) were located at 24–68 mm (M1 MCA: 36–68 mm; M2 MCA: 24–53 mm); anterior cerebral artery (ACA): 50–78 mm; P1 posterior cerebral artery (PCA): 50–74 mm; left vertebral artery: 30–74 mm; right vertebral artery: 30–78 mm; basilar artery: 76–106 mm. The per cent agreement of power motion Doppler-transcranial Doppler for identifying proximal intracranial arteries compared to computed tomography angiography was: M1 and M2 MCA: 100% (95% confidence interval: 96–100%); M1 MCA: 98% (95% confidence interval: 86–100%); M2 MCA: 94% (95% confidence interval: 79–99%); A1 ACA: 82% (95% confidence interval: 68–91%); P1 PCA: 70% (95% confidence interval: 53–83%); left vertebral artery: 96% (95% confidence interval: 80–100%); right vertebral artery: 96% (95% confidence interval: 79–100%); basilar artery: 100% (95% confidence interval: 89–100%). Conclusions Power motion transcranial Doppler intercepts proximal vessels with good-to-excellent agreement with computed tomography angiography. Depth ranges (as opposed to average depths) can be used to target intracranial arterial segments for sonothrombolysis.

The pathogenic link between sleep-disordered breathing and early neurological deterioration in acute ischaemic stroke patients is now a subject of clinical investigations. Vasomotor reactivity and intracranial blood flow steal in response to changing vasodilatory stimuli like carbon dioxide play a pivotal role in clinical deterioration with reversed Robin Hood syndrome. A mechanical ventilatory correction in selected acute stroke patients might have a beneficial effect on sleep-disordered breathing and brain perfusion. This is a novel therapeutic target and the missing link in the pathogenesis of early neurological deterioration and stroke recurrence.