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Introducción: El tiempo sigue siendo una variable determinante para los tratamientos de reper-fusión del ictus isquémico agudo. A pesar de las recomendaciones de las guías clínicas, soloalrededor de la tercera parte de los pacientes con ictus isquémico agudo son fibrinolizadosen = 60 min. El objetivo de este trabajo es describir nuestra experiencia implementando unprotocolo específico de atención del ictus isquémico agudo y evaluar su impacto en nuestrostiempos puerta-aguja. Métodos: A finales del 2015, se implantaron gradualmente unas medidas dise ~nadas para acortarlos tiempos de actuación y optimizar la atención del ictus isquémico agudo incluyendo unaguardia específica de Neurovascular. Se compararon los tiempos de actuación antes (2013-2015)y después (2017-2019) de la introducción de este protocolo. Resultados: Se incluyó a 182 pacientes antes y 249 después de la intervención. Cuando todas lasmedidas fueron introducidas, la mediana global de tiempo puerta-aguja fue de 45 min (previa74 min, 39% menos, p < 0, 001) con un 73, 5% de pacientes tratados en = 60 min (47% más quepreintervención, p < 0, 001). El tiempo global al tratamiento (inicio síntoma-aguja) se redujo en20 min de mediana (p < 0, 001). Conclusiones: Las medidas asociadas en nuestro protocolo han conseguido una disminución deltiempo puerta-aguja de forma significativa y sostenida, aunque todavía nos queda margen demejora, la dinámica establecida de control de resultados y mejora continua hará posible seguiravanzando en este sentido. Introduction: Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60 minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital. Methods: Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol. Results: The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45 minutes (vs 74 minutes before, a 39% reduction; P

Purpose: The early identification of oropharyngeal dysphagia (OD) in patients after an acute stroke using non-invasive and easily administered instruments can minimize its consequences and reduce comorbidity and mortality. The Volume-Viscosity Swallow Test (V-VST) is a screening test that makes it possible. The goal of this study is to contribute to the validation of the V-VST European Portuguese (V-VST: EP) version and study the prevalence of safety and efficacy signs in acute stroke patients. Method: The V-VST: EP, its instructions manual and algorithm, was presented to a panel of experts, to assess its content validity. It was applied to 33 acute stroke patients, with signs of OD, to analyze its psychometric properties. Finally, the prevalence of impaired signs of safety and efficacy was analyzed. Results: The V-VST: EP and its instruction manual (content) demonstrate very good agreement values. Most of the results for inter and intra-evaluator reliability presented Cohen’s kappa values higher than 0.60 or 0.80 (75.0%). The concurrent validity (against the 3 OZ wst) presented a sensitivity of 100% and a specificity of 57.1%. For evaluator 1, the results presented are for the nectar, liquid and pudding consistencies, the prevalence values for the 5 ml, 10 ml and 20ml volume capacity was: impaired lip closure (36%, 39%, 18%), piecemeal deglutition (50%, 50%, 50%), oral residue (7%, 0%, 9%), pharyngeal residue (25%, 17%, 9%) and safe swallowing (89%, 33%, 94%), respectively. Propósito: La identificación temprana de la disfagia orofaríngea (DO) en pacientes después de un accidente cerebrovascular, utilizando instrumentos no invasivos y de fácil administración, puede minimizar sus consecuencias y reducirla comorbilidad y la mortalidad. El examen VolumeViscosity Swallow Test (V-VST) es una prueba de detección que lo hace posible. El objetivo de este estudio es contribuir para la validación del V-VST Versión en portugués europeo (V-VST: EP) y estudio de prevalencia de signos de seguridad y eficacia en pacientes con ictus agudo. Método: Se presentó el V-VST: EP, su manual de instrucciones y algoritmo, a un panel de expertos, para evaluar su validez de contenido. Se aplicó a 33 pacientes con ictus agudo, con signos de DO, para analizar sus propiedades psicométricas. Finalmentese analizó la prevalencia de senales ˜ de deterioro de seguridad y eficacia. Resultados: El V-VST: EP y su manual de instrucciones (contenido) demuestran valores demuy buenaconcordancia. La mayoría de los resultados de confiabilidad inter e intra evaluador presentaron valoreskappa de Cohen superiores a 0,60 o 0,80 (75,0%). La validez concurrente (contra el peso de 3 OZ) presentada una sensibilidad del 100% y una especificidad del 57,1%. Para el evaluador 1, los resultados presentados son para las consistencias de néctar, líquido y budín, los valores de prevalencia para los 5 ml, 10 ml y 20 ml capacidad de volumen fue: deterioro del cierre de los labios (36%, 39%, 18%), deglución fragmentaria (50%, 50%, 50%), residuo oral (7%, 0%, 9%), residuo faríngeo (25%, 17%, 9%) y deglución segura (89%, 33%, 94%), respectivamente. published

Resumen Introduccion El uso de activador tisular del plasminogeno (rt-PA) a dosis bajas fue propuesto inicialmente en paises asiaticos en atencion a particularidades raciales relacionadas con la funcionalidad del fibrinogeno y factores de coagulacion que contribuyen al riesgo de hemorragias intracerebrales, asi como a la intencion de ahorrar costos. Ante la controversia sobre el uso de rt-PA por debajo de la dosis estandar, realizamos una revision de la literatura sobre los estudios que motivaron su uso y aquellos dirigidos a comparar diferentes dosis de rt-PA. Desarrollo Se revisaron 198 resumenes relacionados con los terminos de busqueda. Se revisaron 52 publicaciones de texto completo de los ultimos 30 anos. Se incluyeron 13 ensayos clinicos aleatorizados dirigidos a determinar la eficacia y seguridad del uso de rt-PA a diferentes dosis en el ictus agudo, 14 estudios de cohorte observacionales, 5 metaanalisis y 3 revisiones sistematicas. Conclusiones No se cuenta con evidencia suficiente para catalogar la dosis baja de alteplase como superior o al menos no inferior que el tratamiento estandar en el manejo del ictus agudo en poblacion occidental. Se requieren mas ensayos clinicos para determinar, si el uso de dosis bajas es beneficioso en pacientes con contraindicaciones relativas de terapia trombolitica u otras circunstancias particulares que eleven el riesgo de hemorragias intracerebrales.

This article focuses on the inpatient evaluation and management of ischemic stroke and transient ischemic attack (TIA). We describe foundational principles including quality metrics, TIA, and stroke as emergencies, TIA/minor stroke management, and standard assessments before discussing tailored evaluation and management strategies by stroke type.

Introduction Patients hospitalized for acute ischemic stroke have an increased risk of venous thromboembolism (VTE) that may persist beyond the currently recommended period of 6 to 14 days of thromboprophylaxis. This systematic review evaluated the efficacy and safety of extended venous thromboprophylaxis in patients hospitalized for acute ischemic stroke. Materials and methods MEDLINE, EMBASE and Clinicaltrials.gov were searched up to December 2020 for randomized controlled trials comparing extended versus standard venous thromboprophylaxis in patients hospitalized for acute ischemic stroke. The efficacy outcome was a composite of asymptomatic or symptomatic deep vein thrombosis, symptomatic pulmonary embolism, and VTE-related death. The safety outcome was major bleeding. Summary risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Results Four randomized controlled trials enrolling 33718 patients were included. Of 4330 (12.8%) patients hospitalized for acute ischemic stroke, 2152 (49.7%) received extended thromboprophylaxis for four to five weeks with betrixaban (n = 405, 18.8%), enoxaparin (n = 198, 9.2%), or rivaroxaban (n = 1549, 72.0%), and 2178 (50.3%) received standard venous thromboprophylaxis with enoxaparin. VTE risk was lower in acute ischemic stroke patients receiving extended thromboprophylaxis (RR 0.67; 95% CI, 0.43 to 1.04; 13 fewer per 1000), whereas the increase in major bleeding seemed trivial when compared with standard prophylaxis (RR 1.10; 95% CI, 0.31 to 3.95; 1 more per 1000). Conclusion In patients hospitalized for acute ischemic stroke, the net clinical benefit may favor extended venous thromboprophylaxis for four to five weeks over standard thromboprophylaxis.

BACKGROUND: Hospital arrival via ambulance influences treatment of acute stroke. We aimed to determine the factors associated with use of ambulance and access to evidence-based care among patients with stroke. METHODS: Patients with first-ever strokes from the Australian Stroke Clinical Registry (2010-2013) were linked with administrative data (emergency, hospital admissions). Multilevel, multivariable regression models were used to determine patient, clinical and system factors associated with arrival by ambulance. RESULTS: Among the 6,262 patients with first-ever stroke, 4,737 (76%) arrived by ambulance (52% male; 80% ischaemic). Patients who were older, frailer, with comorbidities or were unable to walk on admission (stroke severity) were more likely to arrive by ambulance to hospital. Compared to those using other means of transport, those who used ambulances arrived to hospital sooner after stroke onset (minutes, 124 vs 397) and were more likely to receive reperfusion therapy (adjusted odds ratio, 1.57, 95% CI: 1.09, 2.27). CONCLUSION: Patients with stroke who use ambulances arrived faster and were more likely to receive reperfusion therapy compared to those using personal transport. Further public education about using ambulance services at all times, instead of personal transport when stroke is suspected is needed to optimise access to time critical care.

Made available in DSpace on 2022-04-29T08:29:39Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-07-01 Introduction: Stroke patients often exhibit an altered perception of verticality, but there are no studies evaluating verticality perception in the first 72 h after stroke and its relationship with trunk control. Therefore, this study aimed to analyze visual and haptic verticality in the acute phase of stroke. Methods: This was a cross-sectional study conducted with two groups: (a) 13 individuals with stroke and (b) 12 healthy participants. We assessed verticality via the subjective visual vertical (SVV) and the subjective haptic vertical (SHV); and we measured trunk control with the Trunk Impairment Scale (TIS). We performed t-tests to compare the SVV and SHV between groups. Pearson correlation was performed between verticality tests with National Institutes of Health Stroke Scale (NIHSS) and the TIS. Results: Participants with recent stroke presented higher true and absolute SVV deviation values than did the control group. There was significant negative correlation between absolute (r = −0.57; p = 0.02) and true SVV (r = −0.54; p = 0.01) with TIS scores There was also significant positive correlation between absolute (r = 0.63; p = 0.009) and true SVV (r = 0.61; p = 0.003) with NIHSS. A significant negative correlation between NIHSS and TIS scores also was found (r = −0.80; p = 0.005). Conclusion: Individuals with acute stroke presented larger variability in their perceptions of visual verticality than did healthy controls, and verticality perceptions were positively correlated with trunk impairment. Master's Program in Physical Therapy Universidade Federal do Triângulo Mineiro (UFTM) Department of Neurology Botucatu Medical School (UNESP) Department of Applied Physical Therapy Universidade Federal do Triângulo Mineiro (UFTM) Department of Neurology Botucatu Medical School (UNESP)

Sudden focal neurological symptoms or ‘brain attacks’ in children are a common scenario for acute paediatric care givers. A small proportion will have had a vascular stroke. Suspected stroke in adults, signalled by FAST (Face, Arms, Speech, Time) test positivity, is an accepted medical emergency. Children are rarely dealt with urgently unless there is coma. Barriers to stroke recognition and response in children are multifactorial. Childhood stroke is rare and may be ‘FAST negative’. Overall, there is low awareness, low clinical suspicion and many logistic obstacles to timely detection and aspired treatment delivery. Yet stroke continues to affect hundreds of children in the UK each year, causing life-changing disability and, in some, death. This article highlights current key recommendations for the diagnosis and management of acute stroke set out in the 2017 Royal College of Paediatrics and Child Health (RCPCH) Stroke in childhood guideline. Evidence and rationale are discussed, and important practice points offered. There is focus on arterial ischaemic stroke in light of the proposed hyperacute management pathway, which includes thrombolysis. Ongoing challenges on the ground and how these may be overcome are considered.

INTRODUCTION: Imaging in stroke, allows its classification into ischaemic stroke (IS) or intracranial haemorrhagic stroke (ICH), ensuring time-sensitive treatment to be administered. Imaging can also allow detection of cerebral microbleeds (CMBs), which may further determine pharmacological intervention in acute stroke. True gradient echo (T2∗GRE) or susceptibility weighted imaging (SWI) have high sensitivity for the detection of CMBs. These two sequences are included in the national guidelines; however, the implementation of these guidelines can vary depending on local interpretation and scanner capabilities. \ud \ud AIM: To explore the use and application of blood sensitive MRI sequences in a specialist UK stroke unit for the detection of CMBs, to improve local practice. \ud \ud METHODS: A retrospective data analysis of the native database, spanning a 6-month period, was used. The data of 281 acute stroke patients with an MRI were reviewed and analysed. The MRI sequences applied, and the final diagnosis were noted for each case. \ud \ud RESULTS: Of the 281 acute stroke patients with MRI, 259 (92.1%) had an IS, 16 (5.68%) an ICH and 6 (2.14%) had both. Overall, 13 (4.63%) had a CMB diagnosis. All of these 13 patients had a true T2∗GRE sequence. CMBs were not detected in the absence of a T2∗GRE sequence. \ud \ud CONCLUSION: T2∗GRE imaging is essential for detecting CMBs. When omitted, CMB incidence can be considerably lower than that suggested in the literature. Missing CMB diagnoses in stroke patients may result in suboptimal treatment pathways, compromising the patients' standard of care. \ud \ud IMPLICATIONS FOR PRACTICE: When SWI is not available, it is imperative to always include a true T2∗GRE sequence to detect microbleeds in suspected acute stroke cases.

Dosing of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke treatment is often based on estimated body weight (BW) worldwide in routine clinical practice due to infeasible of accurate BW measurement. The aim of our study is to explore the impact of estimated BW when dosing rt-PA in acute ischemic stroke treatment on clinical outcome. Between January 2013 to May 2018, 126 acute ischemic stroke patients received intravenous rt-PA treatment based on estimated BW dosage were recruited. All patients had actual BW measured in ward after treatment. Based on the dosage of rt-PA given, patients were categorized into three groups, standard dose (0.8-1.0 mg/kg), overdose (1.0 mg/kg), and underdose (0.8 mg/kg). Among all 126 patients, 101 (80.2%) patients were treated with standard dose, 12 (9.5%) patients with overdose, and 13 (10.3%) patients with underdose of rt-PA respectively. There was no significant difference between demographic characteristics, pre-morbid risk factors, National Institutes of Health Stroke Scale (NIHSS) score at 24 h, NIHSS score at discharge, modified Rankin scale (mRS) within 0 to 2 in discharge or in 3 months after the event within the three groups. There was also no significant difference in hemorrhagic transformation and symptomatic intracranial hemorrhage (SICH). In conclusion, calculation of the dose of rt-PA based upon the estimated BW to treat acute ischemic stroke patients had no negative impact on the clinical outcome in our study.

BACKGROUND: In an effort to improve stroke quality of care and patient outcomes, quality of care metrics are monitored to assess utilization of evidence-based stroke care processes as part of the Paul Coverdell National Acute Stroke Program (PCNASP). We aimed to assess temporal trends in defect-free care (DFC) received by stroke patients in the PCNASP between 2008 and 2018. METHODS: Quality of care data for 10 performance measures were available for 849,793 patients aged ≥18 years who were admitted to a participating hospital with a clinical diagnosis of stroke between 2008 and 2018. A patient who receives care according to all performance measures for which they are eligible, receives “defect-free care” (DFC) (eg, appropriate medications, assessments, and education). Generalized estimating equations were used to examine the factors associated with receipt of DFC. RESULTS: DFC among ischemic stroke patients increased from 38.0% in 2008 to 80.8% in 2018 (P < .0001), with the largest improvement seen in receipt of stroke education (relative percent change, RPC = 64%). Similarly, DFC for hemorrhagic stroke and transient ischemic attack patients increased from 46.7% to 82.6% (RPC = 76.9%) and 39.9% to 85.0% (RPC = 113.0%) (P < .001), respectively. Among ischemic stroke patients, the adjusted odds for receiving DFC were lower for women, patients aged 18 to 54 years, Medicaid or Medicare participants, and patients with atrial fibrillation (P < .05). CONCLUSIONS: From 2008 to 2018, receipt of DFC by ischemic stroke patients significantly increased in the PCNASP; however certain subgroups were less likely to receive this level of care. Targeted quality improvement initiatives could result in even further improvements among all stroke patients and help reduce disparities in care

Introduction Our objective was to determine whether acute ischemic stroke (AIS) patients' language preference is associated with differences in time from symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DTI), and door-to-needle (DTN) time. Methods We identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003–05/2014 for whom language preference was available. Data were abstracted from the institution's Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DTI, and 4) DTN time. Results Of 3190 AIS patients, 300 (9.4%) were non-English preferring (NEP). Comparing NEP to English preferring (EP) patients in unadjusted or adjusted analyses, time from symptom discovery to arrival and rate of EMS utilization were not significantly different (overall median time 157 min, IQR 55–420; EMS utilization: 65% vs. 61.3% p = 0.21). There was also no significant differences in DTI or in likelihood of guideline-recommended DTI ≤ 25 min (overall median 59 min, IQR 29–127; DTI ≤ 25 min 24.3% vs. 21.3% p = 0.29) or DTN time or in likelihood of guideline-recommended DTN ≤ 60 min (overall median 53 min, IQR 36–73; DTN ≤ 60 min 62.5% vs. 58.2% p = 0.60). Conclusion Consistent with prior reports examining disparities in care, a systems-based approach to acute stroke prevents differences in hospital-based metrics. Reassuringly, NEP and EP patients also had similar speed of symptom recognition and EMS utilization.

Background It is not known whether aspiration-specific catheters are necessary for successful mechanical thrombectomy, but if not, off-label use of more versatile catheters could offer significant cost savings over specialized aspiration catheters. The Syphontrak (Depuy Synthes, Raynham, MA, USA) support catheter is designed for introduction of devices into distal neurovasculature but is not specifically indicated for use in mechanical thrombectomy. We sought to compare our experience using this catheter to historical controls to show the non-inferiority of aspiration achieved. Methods Data were collected retrospectively on patients who underwent mechanical thrombectomy using the Syphontrak catheter for aspiration at our institution. Patient demographics, procedure characteristics, and outcome information was recorded. Results were compared to five landmark studies on mechanical thrombectomy: MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA. Results There were 63 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke. Despite significantly older patients and greater time from symptom onset to groin puncture, Thrombolysis in Cerebral Infarction grade 2B or 3 reperfusion was achieved in significantly more patients than in MR CLEAN, ESCAPE, and REVASCAT. Development of symptomatic intracranial hemorrhage occurred in 6.4% of patients, which was not significantly different from MR CLEAN, ESCAPE, REVASCAT, and EXTEND-IA. Mortality was 19.1%, which was not significantly different from any of the trials. Conclusions These data support the off-label use of distal intracranial support catheters for this mechanical thrombectomy, which may result in significant cost savings over aspiration-specific catheters, especially in low-volume centers.

Acute ischemic stroke is a source of long-term disability in the United States, of which a large portion of cases are a result of large vessel occlusion (LVO). LVO strokes have high rates of morbidity and mortality due to difficulty of treatments in achieving recanalization. Recently, however, results of randomized clinical trials have shown that treatment options are expanding in both availability and efficacy. As these methods of intervention become more optimal, so must the preceding methods of assessment. Transcranial Doppler (TCD) ultrasound is a non-invasive method of evaluating cerebral hemodynamics, and has a long history in stroke assessment. Despite the importance of information provided by a TCD exam, its utilization in the acute stroke workflow has remained low because of its dependence on expert analysis. Here, we review the evolution of morphological analysis of TCD waveforms for the indication, localization, and monitoring of acute LVO.

This study aimed to investigate the correlation between blood glucose variability and the risk of death in patients with severe acute stroke. One hundred and fifty-eight patients diagnosed with severe acute stroke were divided into survival group and death group and were retrospectively analyzed. The baseline National Institutes of Health Stroke Scale (NIHSS) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score, mean blood glucose, blood glucose standard deviation, mean amplitude of glycemic excursion, and mean variation coefficient of blood glucose were obtained and compared. Single-factor binary logistic regression analysis was used to determine the predictors of death in patients with severe acute stroke. The baseline NIHSS score (P

Background and aims Acute ischemic stroke patients with large vessel occlusion (LVO) have severe symptoms and poor prognosis. Early recognition of these patients in prehospital setting contributes to rapid triage to comprehensive stroke centers with endovascular therapy conditions. We aimed to develop a simple and efficient scale to identify LVO and compare with other published scales. Methods Medical records of acute ischemic stroke patients within 24 h of stroke onset at Beijing Tiantan hospital were retrospectively collected. The Prehospital Acute Stroke Triage (PAST) scale was designed based on the National Institutes of Health Stroke Scale (NIHSS) items with higher predictive values for LVO. Receiver operating characteristics curves were used to determine and compare the discriminative ability of each scale. Results A total of 1313 patients diagnosed with acute ischemic stroke were included in this study. Half of the patients were used to design and the other were used to validate the PAST scale. The PAST scale showed a comparable predictive ability to NIHSS to detect LVO (c-statistics, 0.8607 vs 0.8715, p = 0.1889). A FAST scale ≥2 showed sensitivity of 0.85209, specificity of 0.76301 and accuracy of 0.80518. The PAST scale also showed good performance in subgroup analysis based on the time of onset, infarct location and the type of vascular examination. Conclusions PAST scale is relatively simple and has comparable ability to more complex NIHSS for recognizing large vessel occlusion.

Background Acute stroke resolution via endovascular thrombectomy requires transcarotid access when transfemoral access is not possible. Although postoperative complications such as cervical hematoma and airway compression have been reported, an appropriate postprocedural management is largely unknown yet. We aim to provide new insights and learning points from our experience using the Jaw Elevation Device (JED) as a tool to facilitate recovery post surgery. Case Description A 79-year-old female underwent endovascular thrombectomy via transcervical, transcarotid access for a left internal carotid artery occlusion. No intraprocedural complications were reported. After successful thrombectomy, manual compression was applied in the carotid artery, and to achieve neck immobilization a JED was used for 4 hours after the procedure. No complications occurred. Conclusions JED appears to be a reasonable option to facilitate patient recovery due to its capacity to maintain the airway, provide mild compression for hemostasis, and prevent cervical hematoma through a comfortable neck immobilization.

Background Carotid endarterectomy (CEA) represents a standard procedure in case of symptomatic carotid stenosis of 50–99% within 2 weeks from onset of stroke or transient ischemic attack (TIA) symptoms. The optimal time to perform CEA after intravenous thrombolysis (IVT) is still unclear. The aim of this study was to analyze the safety of CEA performed within 2 weeks from IVT. Materials and methods A consecutive series of 70 patients affected by symptomatic carotid stenosis have been treated as per the international guidelines during 3 years. Eleven (15.7%) patients have been treated with IVT before CEA for ischemic stroke; remaining 59 (84.3%) patients received only CEA. CEA was performed in median 8 days (range: 2–13) after IVT. We examined the grade of disability before and after surgery as well as at 3 months follow-up, using the modified Ranking Scale (mRS). Results Among the patients who underwent CEA + IVT, CEA was performed in median 8 days (range: 2–13) after IVT. One patient received CEA within 48 hours from IVT, 3 patients within 72 hours, and 7 patients within 2 weeks. The complications within 90 days from surgery, in CEA + IVT group, were 3 cases of intracerebral hemorrhage (ICH) without symptoms. In patients who received only CEA, the complications were 1 case of stroke and 2 cases of ICH. The mortality registered was 0% in both groups. Among CEA + IVT group at 90 days after surgery, 9 patients had a mRS grade of 0–2, 2 patients had mRS of 3–5. Conclusions In our series, IVT before CEA did not seem to increase the rate of complications. However, the study has several limitations, and further studies must be performed before solid evidence is available for recommendations regarding the timing of CEA after IVT.

Background Acute telestroke is the use of telemedicine to improve acute stroke care. It has demonstrated to be a safe and effective medical practice. Since 2011, acute telestroke has been promoted by the Ministry of Health in France, and in 2018 many regions were in the process or completion of implementing telestroke. The objective of this study was to describe acute telestroke implementation in France. Methods A systematic review was conducted using PubMed and ScienceDirect databases. Articles and abstracts in English and French, published between January 1st, 2000 to April 30th, 2018 were used. Studies conducted in France and that had presented an outcome evaluation of a regional acute telestroke activity were included. No meta-analysis was conducted. Results A total of 24 studies (14 in French, 10 in English) were included, with 13 published articles (7 indexed on PubMed) and 11 abstracts. Among the 13 published articles, there were seven observational retrospective studies, one quasi-experimental before-after study, one experimental randomised controlled trial , and four medico-economic studies. All telestroke network models of care were drip-and-ship with hub and spoke organisation. The case-control studies did not show a difference with or without telemedicine. The territorial thrombolysis rate was measured in two regions, with an increase in Franche-Comte from 0.2% (2004) to 9.9% (2015), and a relative increase of 76% in Nord-Pas-de-Calais between 2009-2010 and 2012. Conclusion Implementation of acute telestroke in France had a positive clinical and public health impact but the evaluation remained limited and needs to be supported.

Acute ischemic stroke is a major cause of death and disability in the United States. Historically, acute stroke patients were treated with intravenous (IV) thrombolysis. Patients with large vessel occlusions (LVOs) should be offered mechanical thrombectomy, with or without IV thrombolysis, in an extended window up to 24 hours of last known well. Both treatment options are the standard of care for a patient with an LVO. It is critical that the intensive care unit nurse understand new treatment indications for LVO strokes, and the priorities of nursing care with medical and endovascular intervention.

Acute stroke assessment is classically supported by clinical localization whereby presenting disabilities are associated with key arterial territories in the brain. Clinical localization skills are rarely taught to nonneurologists; yet, these skills are essential to the provision of evidence-based nursing care of stroke, enabling rapid patient identification, diagnosis, and ultimately, the delivery of acute treatment. This article explores the process of clinical localization in relation to the physiology affected by stroke vascular insufficiency. Elements of the neurologic examination are described as they relate to discreet areas in the brain and the National Institutes of Health Stroke Scale.

This article reviews the current state of imaging for acute ischemic stroke. Protocolized imaging acquisition using computed tomography in conjunction with coordinated stroke care allows for rapid diagnosis and prompt revascularization. Following the initial evidence to support endovascular therapy for large-vessel occlusion, published between 2014 and 2015, there are now guidelines supporting treatment up to 24 hours after time of onset of symptoms. Neuroimaging remains a central component in diagnosing acute stroke and potentially excluding patients from stroke treatment, as outlined in this article.

Objectives Lack of a rapid biochemical test for acute stroke is a limitation in the diagnosis and management of acute stroke. The aim of this study is to evaluate the efficacy of BDNF and VILIP-1 as diagnostic markers in acute ischemic stroke and as predictors of mortality. Methods The study included 75 patients with acute ischemic stroke older than 18 years. During the same period, 28 normal controls were recruited from the hospital ED. Blood samples were collected from all patients at admission to determine the levels of VILIP-1 and BDNF. Results The mean VILIP-1 levels in the study and control groups were 0.547 ± 0.081 and 0.515 ± 0.035 ng/mL, respectively, and the difference was not significant (p = 0.071). The mean BDNF levels in the study and control groups were 3.89 ± 2.05 ng/mL and 14.9 ± 4.7 ng/mL, respectively, and the level was significantly (p Conclusion The BDNF level showed a significant ability to discriminate stroke and control patients but did not predict mortality. The VILIP-1 level showed insignificant ability to discriminate stroke patients and again did not predict mortality.

Acute ischaemic stroke can be treated by intravenous thrombolysis whereby tissue plasminogen activator (tPA) is infused to dissolve clots that block blood supply to the brain. In this study, we aim to examine the influence of clot location and size on lysis pattern and recanalisation by using a recently developed computational modelling framework for thrombolysis under physiological flow conditions. An image-based patient-specific model is reconstructed which consists of the internal carotid bifurcation with the A1 segment of anterior cerebral arteries and M1 segment of middle cerebral arteries, and the M1 bifurcation containing the M2 segments. By varying the clot size and location, 7 scenarios are simulated mimicking thrombolysis of M1 and M2 occlusions. Our results show that initial breakthrough always occurs along the inner curvature of the occluded cerebral artery, due to prolonged tPA residence time in the recirculation zone. For a given occlusion site, lysis completion time appears to increase almost quadratically with the initial clot volume; whereas for a given clot volume, the simulated M2 occlusions take up to 30% longer for complete lysis compared to the corresponding M1 occlusions.

The association between prestroke sarcopenia and functional outcomes in patients who have had a stroke has not, to our knowledge, been evaluated to date. We aimed to investigate the prevalence of prestroke sarcopenia, and determine whether prestroke sarcopenia is associated with functional outcomes in elderly patients who have suffered an acute stroke.We assessed prestroke sarcopenia in elderly patients with acute stroke using the SARC-F questionnaire. Patients were divided into two groups according to their SARC-F score: non-sarcopenia (SARC-F score4) and prestroke sarcopenia (SARC-F score ≥4). The study endpoint was the modified Rankin Scale score at 3 mo after the stroke (0-3, good outcome; 4-6, poor outcome). The Mann-Whitney U-test, Pearson χOf the 152 patients (81 men; median age [interquartile range]: 76 [11] y) enrolled, the prevalence rate of prestroke sarcopenia was 18% (27 patients). These 27 patients showed poor functional outcome at 3 mo after the stroke (50% versus 12%, prestroke sarcopenia versus nonsarcopenia; P0.001). After adjusting for variables, prestroke sarcopenia was an independent predictor of poor functional outcome at 3 mo after stroke (odds ratios: 7.39, 95% confidence interval: 1.47-37.21, P = 0.02).Prestroke sarcopenia is an independent predictor of functional outcome at 3 mo after a stroke. Our findings highlight the importance of detecting prestroke sarcopenia in elderly patients with acute stroke.

Coated-platelets are a subset of highly procoagulant platelets observed after dual agonist stimulation with collagen and thrombin. Coated-platelet levels are increased in acute stroke compared to controls, and higher levels are associated with stroke recurrence. We examined whether coated-platelet levels measured at the time of the stroke correlate with cognitive scores at 3 months following the brain infarction.Coated-platelets were assayed in consecutive patients with nonlacunar stroke. Cognitive screening was performed using the Mini-Mental State Examination (MMSE) at 3 months after discharge. Linear regression, with adjustment for individual covariates, was used to model the association between coated-platelet levels and MMSE scores.One hundred and twenty-eight patients with a mean MMSE score of 26 points (range 14-30, standard deviation [SD] 3.1) and mean coated-platelet levels of 40.9% (range 5.2-76.2, SD 13.3), completed cognitive screening. An inverse linear association was found between coated-platelet levels and MMSE score, with higher levels seen in patients with lower MMSE scores (r = -.34, RThese findings support a link between increased platelet procoagulant potential at the time of the stroke and development of cognitive impairment following cerebral infarction.

Background Advances in acute and long-term poststroke care have resulted in improved survival and functional outcomes for patients who have suffered large vessel ischemic strokes. For years, tissue plasminogen activator was the mainstay of treatment for acute stroke. Its use was previously limited to patients without known comorbid intracranial vascular pathology because of concern for bleeding risk. More recently, however, the use of tissue plasminogen activator in select patients with vascular anomalies has increased and is now largely thought to be safe. With the safety and efficacy of mechanical thrombectomy now proven for large vessel occlusions (LVOs), similar investigation is needed to assess procedural safety in patients with concomitant arteriovenous (AV) malformations or fistulae. Methods We reviewed patients treated for LVOs at our institution and those of our collaborators and identified 6 patients who were treated for LVO with either known or incidentally identified concomitant AV malformations or dural AV fistulae. Results We present a case series of 6 patients with nonaneurysmal intracranial vascular lesions who underwent mechanical thrombectomy for LVO without complications related to these lesions. Conclusions Although limited by small size, our series adds to the literature evidence that mechanical thrombectomy for LVO can safely be performed with concomitant dural AV fistulae and AV malformations.

The Neutrophil-to-Lymphocyte Ratio (NLR) is suggested as a readily available and inexpensive biomarker to predict prognosis of acute stroke. Experience with intravenous (IV) tissue plasminogen activator (tPA) treatment is limited.Total 142 (80 female, age: 69 ± 13 yearr) consecutive acute stroke patients treated with IV tPA were evaluated. Admission and 24th hour lymphocyte, neutrophil, and monocyte counts were measured and the NLR was calculated.Average NLR elevated (by 3.47 ± 6.75) significantly from admission to 24th hour (P.001). Total 52% of patients exerted good response to IV tPA (NIHSS ≤1 or decrease in NIHSS ≥4 at end of 24 hour), while 27% showed dramatic response (decrease in NIHSS ≥8 at end of 24 hour). The patients with "thrombolysis resistance" had significantly higher 24 hour Neutrophil-to-Lymphocyte Ratio (24h NLR) (P= .001). At the end of 3rd month, 46.5% of patients had favorable (modified Rankin's score, mRS 0-2) and 32.4% had excellent (mRS 0-1) outcome. Patients without favorable/excellent outcome had significantly higher 24h NLRs. Regression analysis indicated that post-tPA, but not admission NLR, was an independent negative predictor of excellent (β =-.216, P= .006) and favorable (β = -.179, P= .034) outcome after adjustment for age, hypertension, and admission NIHSS. Nine patients who developed symptomatic intracerebral hemorrhage had elevated pre-tPA (7.6 ± 7.39 versus 3.33 ± 3.07, P.001) and 24h NLR (26.2 ± 18.6 versus 5.78 ± 4.47, P.001). Of note, receiver operating characteristics analysis failed to detect any reliable NLR threshold for absence of tPA effectiveness/dramatic response, 3rd month good/excellent outcome or any type tPA-induced hemorrhage.As a marker of stroke-associated acute stress response, the NLR, which increases during the first 24 hours, is an epiphenomenon of poor prognosis. However, pretreatment NLR values have no importance in predicting IV tPA response.

Background The aim of this study is to evaluate in the relationships between alcohol intake and ischemic stroke severity in Japanese stroke patients. Methods Of a total of 101,165 registered cases of stroke in Japan, patient data of total strokes (n = 60,836), cardiogenic strokes (n = 11,894), and noncardiogenic strokes (n = 29,129) were extracted. The National Institutes of Health Stroke Scale (NIHSS) score at admission and the modified Rankin Scale (mRS) score at discharge were used. Significant alcohol consumption in regard to stroke severity at admission and discharge was identified by multivariate adjusted logistic regression analysis. Results Among all subject and males, nondrinkers had significantly poorer NIHSS scores of cardiogenic strokes as did those consuming greater than or equal to 60 g/day, whereas there was a significant difference in past heavy drinkers with noncardiogenic strokes. Among females, nondrinkers had a significance of cardiogenic stroke and non-cardiogenic strokes. Among all subjects and males, 20-39 g/day and 40-59 g/day were significantly associated with protective effects on mRS severity of cardiogenic strokes, whereas 40-59 g/day also had significant protective effects for noncardiogenic strokes. Among females, greater than or equal to 60 g/day had a significant protective effect for cardiogenic strokes. Conclusions For males, alcohol intake of less than 60 g/day played a protective role in functional prognosis at discharge and showed a J-shape relationship. For females, although there was a limitation that the number of female drinkers was small, negative effects were shown at admission with less consumption than males.

Objective To determine differences between continuous videofluoroscopic swallow studies (VFSS) with a pulse rate and frame rate of 30 and the same swallows reduced to 15 frames per second (fps) on measures of swallowing function in patients after acute ischemic stroke. Design Blinded comparison. Setting Acute hospital. Participants Patients after ischemic stroke (N=20). Interventions Not applicable. Main Outcome Measures Single and sequential sips of thin liquids, single sips of nectar liquids, pudding, and cookie boluses were rated on measures of timing of swallowing events, Modified Barium Swallowing Impairment Profile component scores, and Penetration-Aspiration Scale scores. The ratings for videos at 15 fps and 30 fps were compared by Wilcoxon signed rank tests. Results Pharyngeal transit time was longer and bolus entry into the hypopharynx was later for 30 fps than for 15 fps. Components of Oral Residue and Pharyngoesophageal Segment Opening ratings were more severe for 15 fps than 30 fps, whereas Bolus Transport and Initiation of Pharyngeal Swallow were rated as more severe for 30 fps than for 15 fps. There was no difference between 30 fps and 15 fps on the remaining measures, including Penetration-Aspiration Scale scores. Conclusion Continuous VFSS recorded at 30 fps and their down-sampled 15 fps duplicates yielded contrasting results on certain durational and functional measures of swallowing, though not on others. VFSS should be administered continuously or at 30 pulses per second for valid assessment of swallowing while using other methods to reduce radiation exposure.

Early information on vascular status in acute stroke is essential. We analyzed whether duplex ultrasound (DUS) using a fast-track protocol provides this information without relevant delay. One hundred forty-six patients were prospectively enrolled. DUS was performed by sonographers with two levels of experience. The carotid and vertebral arteries, as well as all basal cerebral arteries, were bilaterally analyzed. Criteria for vessel analysis were (i) normal or stenosis50%, (ii) stenosis ≥50% and (iii) occlusion. The mean duration of the ultrasound investigation was 6:07 ± 2:06 min with a significant difference between more and less experienced investigators (p0.0001). Insonation times decreased during the study in both groups. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound findings in comparison with computed tomography angiography were 73%, 99%, 84% and 98%, respectively. Our data suggest that "fast track" DUS is feasible and reliable. The time required for DUS assessment depends on the sonographer´s experience.

This hermeneutic phenomenological study was undertaken in response to the recent re-organization of stroke unit provision in the United Kingdom. Through the analysis of four acute stroke unit practitioners' subjective accounts, the acute stroke unit emerged as a dynamic, meaningful space, where they experienced authenticity and belonging. The findings showed how these practitioners navigated their way through the space, thriving, and/or surviving its' associated vulnerabilities. They offer a different gaze on which to attend to the complexity and challenge that is interwoven with health professionals’ flourishing, the spatiality of healthcare practice, and perhaps other demanding places of work.

Introduction Despite the increasing incidence of acute ischemic stroke in the United States, many health care facilities remain unprepared to manage patients with acute stroke, including the administration of intravenous alteplase (recombinant tissue plasminogen activator [rTPA]). This has led to an opportunity for telemedicine systems to facilitate these evaluations and acute medical stroke treatment decisions. However, even telemedicine systems can fail to provide timely evaluation and management of the patient with acute stroke. The purpose of this retrospective study was to compare stroke outcome metrics pre- and postimplementation of a hybrid, local nurse-led "stroke-responder" telemedicine system. Methods A retrospective chart review was performed on 21 patients at a regional community hospital between the years of 2014 and 2016. Data were collected pre- and postimplementation of a local stroke-responder system. Outcomes obtained included door-to-alert time, door-to-computerized tomography (CT) time, door-to-rtPA order time, and door-to-rtPA bolus dose administration time. Outcomes were compared among years. Results Between 2014 and 2016, 21 charts were reviewed. Decreased mean times were observed for all metrics. The mean time for door-to-alert decreased from 21.19 to 5.84 minutes (P = 0.021), door-to-CT from 29.9 to 12.2 minutes (P = 0.022), door-to-rtPA order 88.4 to 53 minutes (P = 0.021), and door-to-rtPA administration from 106.94 to 64.65 minutes (P = 0.001). Conclusion In an acute stroke telemedicine system, implementation of a local nurse-led "stroke responder" system resulted in significantly decreased acute stroke metrics for a community hospital within a regional hospital system.

Goal We performed a systematic review and meta-analysis aiming to clarify the relationship between acid-suppressive medication (ASM) and the risk of pneumonia in acute stroke. Methods The included studies examined patients with an acute ischemic and/or hemorrhagic stroke, assessed the relationship of one or both groups of ASM, histamine-2 receptor antagonist (H2RA) and proton-pump inhibitor (PPI), as a variable of interest, and used the occurrence of hospital-acquired pneumonia (HAP) as an outcome measure. The search was conducted in MEDLINE, Cochrane, Embase, and Google Scholar. Random-effects meta-analyses were used to obtain pooled estimates of the effect. Results 5 retrospective cohort-studies fulfilled study criteria. The results revealed a higher risk of pneumonia for both, patients receiving PPI (adjusted relative risk [RR] 2.37, 95% confidence interval [CI] 1.36–4.17, I2 0%) and H2RAs (adjusted RR 1.73, 95% CI 0.74–4.25, I2 68.3%), although the latter did not reach statistical significance. A comparison of the overall acid versus non-acid groups using unadjusted values yielded likewise an increased risk for pneumonia for patients receiving ASM (unadjusted RR 4.65, 95% CI 1.64–13.16, I2 93.3%). Conclusion Results of this meta-analysis show an increased risk for HAP in acute stroke patients who receive ASM, particularly those exposed to PPIs. Larger, well-controlled studies in acute stroke populations are needed to establish a clearer association between ASM and HAP. These results, however, urge caution when prescribing ASM – especially to stroke patients considered to be at high risk for pneumonia.

pH-weighted amide proton transfer (APT) MRI is sensitive to tissue pH change during acute ischemia, complementing conventional perfusion and diffusion stroke imaging. However, the currently used pH-weighted magnetization transfer (MT) ratio asymmetry (MTR(asym)) analysis is of limited pH specificity. To overcome this, MT and relaxation normalized APT (MRAPT) analysis has been developed that to homogenizes the background signal, thus providing highly pH conspicuous measurement. Our study aimed to calibrate MRAPT MRI toward absolute tissue pH mapping and determine regional pH changes during acute stroke. Using middle cerebral artery occlusion (MCAO) rats, we performed lactate MR spectroscopy and multi-parametric MRI. MRAPT MRI was calibrated against a region of interest (ROI)-based pH spectroscopy measurement (R(2)=0.70, P

The two most common approaches to thrombectomy of emergent large vessel occlusion (direct aspiration and primary stent retriever thrombectomy) have been extensively studied; however, the detailed benefit and risk comparison is largely unknown.To conduct a systematic review and meta-analysis to compare radiographic and clinical outcomes between the use of primary stent retrievers and direct aspiration in management of acute ischemic stroke.PubMed database was searched for studies between September 1, 2012 and December 31, 2017 with acute ischemic stroke patients.We identified 64 studies with 6875 patients in the primary stent retriever group and 25 studies with 2252 patients in the aspiration group. Primary aspiration alone, without the need of rescue stent retriever devices within the aspiration cohort, was performed in 65% of 2252 patients. There was no difference in the distribution of emergent large vessel occlusion based on occlusion site, age, baseline National Institutes of Health Stroke Scale, or the use of intravenous tPA (P = .19, .051, .23, and .093, respectively). Successful recanalization rates, defined as thrombolysis in cerebral Infarction 2b/3, were significantly higher in the aspiration group than the primary stent retriever group (89% versus 80%, P.0001). No significant difference in good clinical outcome, defined as modified Rankin scale 0-2 (aspiration 52% versus stent 48%, P = .13), symptomatic intracerebral hemorrhage (aspiration 5.6% versus stent 7.2%, P = .07), and mortality at 3 months (aspiration 15% versus stent 19%, P = .10).Both aspiration-first (including the subsequent use of stent retriever) and primary stent retriever thrombectomy approaches are equally effective in achieving good clinical outcomes. Our study suggests that direct aspiration with or without subsequent use of stent retriever is a safe and effective alternative to primary stent retriever in acute ischemic stroke.

Highlights •Ischemic stroke is now treatable with catheter intervention. Revascularization must be accomplished rapidly for optimal results, but there are not enough comprehensive stroke centers or neurointerventionists to achieve this. •Cardiologists have excellent catheter skills and extensive experience with emergency intervention, and catheterization labs are widespread, suggesting a possible solution for needed immediate intervention worldwide. •Stroke intervention must be rapidly expanded geographically and with a dramatic increase in the number of willing and trained interventionists to meet the enormous public health need.

Multiphase computed tomography angiography (CTA) provides information on the status of major cranial arteries and extent of brain collateralization. The purpose of the study was to determine whether implementation of multiphase CTA in routine clinical practice was feasible, safe and useful. Patients with acute ischemic stroke (NIHSS ≥ 6) were included. Multiphase CTA was performed. Duration of performing multiphase CTA, inter-rater correlation and incidence of contrast-induced nephropathy (CIN) were studied. Infarct volume, incidence of hemorrhagic transformation, the rates of favorable outcome and death were compared between those with poor and intermediate-good collateralization. Multiphase CTA was performed in 108 patients. Mean duration on each multiphase CTA study was 4.8 min. Inter-rater reliability was intermediate-good (weighted kappa 0.7569, p 0.001). CIN occurred in 3 patients (2.8%). There were no major intracranial/extracranial artery occlusion in 31 patients (29%) and there were severe stenosis or occlusions in 77 patients (71%). In the subgroup of patients with major artery severe stenosis or occlusion, 36 patients (36/77, 47%) had poor collateralization. Despite non-significant difference in acute treatment, the patients with poor collateralization had larger infarct (123 vs 35 cc, p 0.001) and poorer outcomes (mean modified Rankin scale 3.86 vs 2.73, p = 0.011), while the differences in symptomatic hemorrhagic transformation (2.6 vs 7%, p = 0.385) and death rate (14 vs 12%, p = 0.825) were non-significant, as compared to those with intermediate-good collateralization. Multiphase CTA was feasible and safe. Besides the status of major arteries, multiphase CTA provided information on collateralization, which was associated with the size of infarct and clinical outcomes.

International audience; Objective: Minimizing out-of-hospital time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome, or acute stroke. Our objective was to compare out-of-hospital times by helicopter versus ground services when the estimated time of arrival on the scene was over 20 minutes. Methods: We proposed a retrospective observational monocentric study following 2 cohorts. The helicopter group and the ground group included patients with severe trauma, acute coronary syndrome, or acute stroke transported by helicopter or ground services. Results: Two hundred thirty-nine patients were included; 118 were in the ground group, and 121 were in the helicopter group. Distances for the helicopter group were higher (62.1 ± 22.5 km vs. 27.6 ± 10.4 km, P < .001). When distances were over 35 km, the helicopter group was faster. We identified distance, need for surgery, and intensive care hospitalization as 3 predicting factors for choosing helicopters over ground modes of transport. Conclusion: In cases of severe trauma, acute coronary syndrome, or acute stroke, emergency medical helicopter transport can be chosen over ground transport when patients are in a severe state and when the distance is further than 35 km from the hospital.

The superiority of endovascular treatment (EVT) in acute stroke due to large vessel occlusion has been proven in recent randomized trials. Yet, there are no randomized trials which have tested the additive effect of standard treatment with intravenous thrombolysis (IVT) as pretreatment to EVT over EVT treatment alone. So far, the EVT treatment groups of RCTs most often had pretreatment with IVT. The current guidelines on acute stroke treatment rely on meta-analyses and systematic analyses from RCTs and observational studies on pretreatment with IVT + EVT. Clinicians also apply their clinical experience and local “in-house” protocols. We performed literature search on randomized controlled trials, systematic and meta-analyses and observational studies on recanalization therapies including intravenous thrombolysis and endovascular treatment or thrombectomy in acute stroke. Here we present a review and an opinion on the current choice of treatment modalities.

Research Objectives This study aims to examine the safety and feasibility of implementing an additional hour of time-on-task upper limb training using video game technology (VGT) or conventional Occupational Therapy (COT) in the early phase post-stroke. Design This is a randomized controlled, single-site trial. After a rollup period, sixty participants will be randomized to either a therapy group (VGT or COT) versus standard of care. Patients receive an additional hour of time-on-task upper limb training 5 days a week for the duration of their hospital stay. Setting Hospital acute stroke unit or acute rehabilitation unit. Participants Patients are eligible if they had stroke within the previous four weeks and have upper extremity weakness. Interventions VGT therapy includes the MindPod Dolphin, immersive gaming software that promotes motor recovery and bimanual arm trainer. COT includes Graded Repetitive Arm Supplementary Program. Main Outcome Measures Primary outcomes are safety and feasibility of adding an additional hour of VGT or COT into acute stroke units as measured by successful completion of the extra session. Secondary outcomes include time on task and session duration. Results In the rollup period, 14 patients were enrolled. They had an average age of 57 years. Initially, patients spent an average of 15 minutes time-on-task during 23 minute session; after protocol iteration they achieved 43 minutes during 80 minutes sessions. There have been no safety issues and motor endpoints and perceived exertion are measured. Study is ongoing. Conclusions This study is examining the safety and feasibility of integrating VGT for an additional hour of upper limb training in the early phase of post-stroke care. Author(s) Disclosures Authors have no disclosures.