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BackgroundWith the proposed pathophysiologic mechanism of neurologic injury by SARS COV-2 the frequency of stroke and henceforth the related hospital admissions were expected to rise. In this paper we investigate this presumption by comparing the frequency of admissions of stroke cases in Bangladesh before and during the pandemic.MethodsWe conducted a retrospective analysis of stroke admissions in a 100-bed stroke unit at the National Institute of Neurosciences and Hospital (NINS&H) which is considerably a large stroke unit. We considered all the admitted cases from the 1st January to the 30th June, 2020. We used Poisson regressions to determine whether statistically significant changes in admission counts can be found before and after 25 March since when there is a surge in COVID-19 infections.ResultsA total of 1394 stroke patients got admitted during the study period. Half of the patients were older than 60 years, whereas only 2.6% were 30 years old or younger with a male-female ratio of 1.06:1. From January to March, 2020 the mean rate of admission was 302.3 cases per month which dropped to 162.3 cases per month from April to June with an overall reduction of 46.3% in acute stroke admission per month. In those two periods, reductions in average admission per month for ischemic stroke (IST), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and venous stroke (VS) were 45.5%, 37.2%, 71.4% and 39.0%, respectively. Based on weekly data, results of Poisson regressions confirm that the average number of admissions per week dropped significantly during the last three months of the sample period. Further, in the first three months, a total of 22 cases of hyperacute stroke management were done whereas in the last three months there was an 86.4% reduction in the number of hyperacute stroke patients getting reperfusion treatment. Only 38 patients (2.7%) were later found to be RT- PCR for SARS Cov-2 positive based on nasal swab testing.ConclusionOur study revealed more than fifty percent reduction in acute stroke admission during the COVID-19 pandemic. It is still elusive whether the reduction is related to the fear of getting infected by COVID-19 from hospitalization or the overall restriction on public movement and stay-home measures.

Abstract: The coronavirus disease 2019 (COVID-19) pandemic has broad implications on stroke patient triage. Emergency medical services providers have to ensure timely transfer of patients while minimizing the risk of infectious exposure for themselves, their co-workers, and other patients. This statement paper provides a conceptual framework for acute stroke patient triage and transfer during the COVID-19 pandemic and similar healthcare emergencies in the future.

Since the initial reports surfaced of a novel Coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe infecting millions and leaving hundreds of thousands dead. As hospitals cope with the influx of COVID-19 patients, new challenges have arisen as healthcare systems care for COVID-19 patients while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that COVID-19 patients are at increased risk of thromboembolic complications including strokes. In this paper, we detail our experience caring for acute stroke patients, and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era., Highlights: • COVID-19 continues its relentless march through the United States and the globe, presenting unique challenges for healthcare providers as they treat other emergent conditions while minimizing the risk of COVID-19 exposure and infection. • Acute stroke is especially challenging during the COVID-19 due to time constraints required for effective mechanical thrombectomy to improve neurologic outcomes and survival in patients whose COVID infection status is unknown. • The institutional protocol for mechanical thrombectomy described in this article may help inform models at other centers as they prepare for their respective COVID peaks

Background: There is increasing evidence for music-based interventions in neurorehabilitation, improving mood and functional outcomes. In response, there is growing interest from healthcare providers in setting up Neurologic Music Therapy (NMT) services. This paper presents some preliminary data on the feasibility and acceptability of NMT in the acute stroke, multidisciplinary team setting, about which little is known.\ud Objectives: To assess the feasibility and acceptability of a two-day per-week NMT service over 24 months.\ud Methods: Data were collected on the number of referrals received, sessions attended, sessions declined and reasons why. Staff completed questionnaires, and collected them from patients and their relatives, rating interventions: 1. Not helpful, 2. Quite helpful, 3. Helpful, 4. Very helpful. Patients completed the Visual Analogue Mood Scale (VAMS) pre-/post- a single session.\ud Results: Of 201 patients referred, 177 received treatment and 675 sessions were delivered. Twenty-four patients were discharged before sessions were scheduled and twenty-eight sessions were declined, predominantly due to fatigue. Mean scores (SD) from questionnaire data were: patients (n = 99) 3.34 (0.825), relatives (n = 13) 3.83 (0.372), staff (n = 27) 3.85 (0.388). Mean, post-session VAMS data (n = 52) showed a non-significant reduction in ‘Sad’ (7.5, p = 0.007, CI = 2.1, 12.9) and an increase in ‘Happy’ (+ 6.2, p = 0.013, CI = -11.0, -1.4). \ud Conclusions: Data suggest the service was feasible and helpful, particularly for patient mood, possibly improving engagement in rehabilitation. Research to determine generalisability in different stroke environments and treatment effects within them is warranted.

Background and Purpose: In September 2017, a new Hyperacute Stroke Unit (HASU) was opened in a metropolitan hospital with over 400 acute stroke admissions per year, offering endovascular clot retrieval (ECR) and IV thrombolysis; 185 ECR procedures completed in 2018. The HASU opening coincided with publication of the 2017 Australian Clinical Guidelines for Stroke Management. The Guidelines state stroke severity be assessed using a validated tool, such as the National Institute of Health Stroke Scale (NIHSS). A Quality Improvement workshop, March 2018, identified attendance of correct and reliable assessment for stroke severity as a service gap. Goal = Improve NIHSS completion on all stroke patients on presentation to hospital and 24hours post endovascular clot retrieval. This was to be achieved within 90 days of project implementation with the focus on nursing education; a new skill addition to the ward environment. Methods: Education workshops (August-September 18) were implemented with the goal of building knowledge, skills and confidence along with gaining NIHSS certification. All clinical and registered nurses were provided designated time to attend workshops. Workshops were also provided to Medical officers (January 2019) allocated to the Stroke team. Cognitive aids to assist with reducing variability in application of the NIHSS were created. These included NIHSS navigation aids to the electronic medical record, NIHSS app upload to mobile phones, paper based NIHSS assessment to assist the bedside nurses and ward round note templates with auto text for NIHSS completion. Data from three months pre and post implementation was collected and compared using the Australian Stroke Clinical Registry (AuSCR). All patients admitted with stroke were included in this analysis (Jan 18-April 19). Results: NIHSS completion on patient presentation increased by 12% (n=325). NIHSS completion at 24hrs for patients post ECR increased by 22% (n=163). 31 registered nurses trained; 8 medical officers trained. Conclusions: Targeted, multimodal strategies improved completion of NIHSS on presentation and particularly, 24hrs post ECR. Further implementation in the emergency department is required to gain improvements in NIHSS completion on presentation.

Introduction: Women have historically been underrepresented in RCTs of cardiovascular disease. We undertook a review of acute stroke RCTs to determine whether women were equitably represented and whether any sex disparity varied across geographic region. Methods: We searched for papers describing primary results of acute stroke RCTs published 2013-2018 in 9 major journals and abstracted the proportion of trial participants that were women (PPW). We then searched for incidence studies from the geographic regions in which trial enrollment took place and estimated the proportion of incident strokes occurring in women (PSW) in each region (i.e., North America, Europe, Asia Pacific, Multiple Regions). We quantified the representation of women using the enrollment disparity difference (EDD) calculated as the absolute difference between the two proportions (i.e., PSW - PPW). An EDD greater than 0 indicated a disparity in favor of men. We pooled EDDs from individual RCTs using random effects meta-analysis to estimate overall and region-specific disparities. Results: Among 60 trials the PPW ranged from 33.8% to 56.9% (median 44.7%). The overall pooled EDD was 0.07 (95% CI=0.06-0.08, Q p2 =85.8%) (Figure), indicating that 7% more men were included in the trials, relative to the underlying incidence. A statistically significant EDD existed in all regions; the magnitude was largest for RCTs with enrollment from Asia Pacific (EDD=0.11, 95% CI=0.10-0.13) and Multiple Regions (EDD=0.10, 95% CI=0.08-0.12) and smallest among North American and European trials (EDD 0.04 and 0.06, respectively). All region-specific summary estimates showed significant between study heterogeneity apart from Asia (Q p=0.102, I 2 =38.4%). Conclusions: Women were underrepresented globally in contemporary acute stroke RCTs; the magnitude of the disparity differed between regions. Future research should focus on trial eligibility criteria that may contribute to this disparity.

Increased use of Diffusion-weighted imaging (DWI) in acute stroke has led to observations of early diffusion normalization in lesions thatinitially show diffusion slowing. The “renormalization” of DWI may be spontaneous or the result of thrombolytic therapy, thus, acuteslowing of diffusion is not necessarily an indicator of irreversible tissue damage. The perfusion-diffusion mismatch concept is attractiveas it assumes that DWI lesion size reflects the infarct core whilst the mismatch area reflects the penumbra. However, this concept maybe an oversimplification. This paper shows a case with Diffusion Lesion Reversal after successful neuroendovascular treatment andexcellent clinical outcome, and discuss the imaging characteristics associated with this phenomenon.

Many facets of an image acquisition workflow leave a digital footprint, making workflow analysis amenable to an informatics-based solution. This paper describes a detailed framework for analyzing workflow and uses acute stroke response timeliness in CT as a practical demonstration. We review methods for accessing the digital footprints resulting from common technologist/device interactions. This overview lays a foundation for obtaining data for workflow analysis. We demonstrate the method by analyzing CT imaging efficiency in the setting of acute stroke. We successfully used digital footprints of CT technologists to analyze their workflow. We presented an overview of other digital footprints including but not limited to contrast administration, patient positioning, billing, reformat creation, and scheduling. A framework for analyzing image acquisition workflow was presented. This framework is transferable to any modality, as the key steps of image acquisition, image reconstruction, image post processing, and image transfer to PACS are common to any imaging modality in diagnostic radiology.

Background and purpose The presence of dysphagia and aspiration in stroke patients is associated with increased mortality and morbidity. Early recognition and management of these two conditions via reliable, minimally invasive bedside procedures before complications arise remains challenging in everyday clinical practice. This study reviews the available bedside screening tools for detecting swallowing status and aspiration risk in acute stroke by qualitatively observing reference population study design, clinical flexibility, reliability and applicability to acute-care settings. Methods The primary search was conducted using the PubMed, Embase, and Cochrane Library databases. The search was limited to papers on humans written in English and published from 1991 to 2016. Eligibility criteria included the consecutive enrollment of acute-stroke inpatients and the development of a protocol for screening aspiration risk during oral feeding in this population. Results Of the 652 sources identified, 75 articles were reviewed in full however, only 12 fulfilled the selection criteria. Notable deficiencies in most of the bedside screening protocols included poor methodological designs and inadequate predictive values for aspiration risk which render clinicians to be more conservative in making dietary recommendations. Conclusions The literature is dense with screening methods for assessing the presence of dysphagia but with low predictive value for aspiration risk after acute stroke. A standard, practical, and cost-effective screening tool that can be applied at the bedside and interpreted by a wide range of hospital personnel remains to be developed. This need is highlighted in settings where neither trained personnel in evaluating dysphagia nor clinical instrumentation procedures are available.

Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients’ length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.

We read the interesting paper by Elgendy et al. ([1][1]) in a recent issue of the Journal . Although their study sounds eloquent and scientific, some critical questions should be considered. First, the study was carried out from January 2007 to September 2015 to investigate the incidence and

Background and Purpose— Delirium is associated with increased mortality, length of stay, and poor functional outcome following critical illness. The epidemiology of delirium in stroke is poorly described. We sought to collate evidence around occurrence (incidence or prevalence) of delirium in acute stroke. Methods— We searched multiple cross-disciplinary electronic databases using a prespecified search strategy, complemented by hand searching. Eligible studies described delirium in acute (first 6 weeks) stroke. We compared delirium occurrence using random-effects models to describe summary estimates. We assessed risk of bias using the Newcastle-Ottawa tool, incorporating this in sensitivity analyses. We performed subgroup analyses for delirium diagnostic method (confusion assessment method scoring, clinical diagnosis, other), duration and timing of delirium assessment (>1 or Results— Of 8822 titles, we included 32 papers (6718 participants) in the quantitative analysis. Summary estimate for occurrence of delirium was 25% (95% CI, 20%–30%; moderate quality evidence). Limiting to studies at low risk of bias (22 studies, 4422 participants), the occurrence rate was 23% (95% CI, 17%–28%). Subgroup summary estimates suggest that delirium occurrence may vary with assessment method: confusion assessment method, 21% (95% CI, 16%–27%); clinical diagnosis, 27% (95% CI, 19%–38%); other, 32% (95% CI, 22%–43%) but not with duration and timing of assessment. Meta-regression suggested decline in occurrence of delirium comparing historical to more recent studies (slope, 0.03 [SE, 0.004]; P Conclusions— Delirium is common, affecting 1 in 4 acute stroke patients. Reported rates of delirium may be dependent on assessment method. Our estimate of delirium occurrence could be used for audit, to plan intervention studies, and inform clinical practice. Clinical Trial Registration— URL: http://www.crd.york.ac.uk/PROSPERO/ . Unique identifier: CRD42015029251.

Stroke is a “brain attack” that often causes paralysis, resulted from either bleeding in the brain (hemorrhagic) or the blockage of blood flow to the brain (ischemic). It posed a big challenge to Malaysian healthcare services with at least 32 deaths per day, while survivors were burdened with multiple problems. Conventionally, the diagnosis is performed manually by neuroradiologists during a highly subjective and time consuming tasks. Therefore, this paper intends to diagnose and classify stroke by investigating diffusion- weighted imaging (DWI) of brain stroke images using Bagged Tree classification. Stroke is classified into three main types which are acute stroke, chronic stroke and hemorrhage stroke. The performance of the proposed method is then verified using accuracy and Area Under the Curve (AUC). Based on the results, the overall accuracy for the classification is 96.7%. The AUC of each type of stroke for acute stroke, chronic stroke and hemorrhage stroke is 97%, 100% and 99%, respectively. This outcome could serve as an insight to improve the healthcare of the community by providing better solutions using such intelligent system.

Rationale: Glyceryl trinitrate, a nitric oxide donor, is a candidate treatment for acute stroke; it lowers blood pressure, does not alter cerebral blood flow or platelet function and is neuroprotective in experimental stroke. The ongoing rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial aims to assess the safety and efficacy of paramedic-delivered glyceryl trinitrate in patients with ultra-acute stroke. Aims and design: The rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial is a multicentre UK-based prospective randomised sham-controlled outcome-blinded parallel-group trial in patients with presumed stroke who present to the ambulance service following a 999 emergency call. The primary outcome is the modified Rankin scale measured by central telephone follow-up at 90 days. Results This paper describes the statistical analysis plan for the rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial and was developed prior to unblinding to treatment allocation. The statistical analysis plan includes details of methods for analyses and unpopulated tables and figures to be included in the primary and other secondary publications. Discussion Statistical analysis plan details what analyses will be done prior to unblinding to treatment allocation to avoid bias in the findings. Rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial will determine whether glyceryl trinitrate administered ultra-acutely can improve outcome after stroke. The rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial is registered as ISRCTN26986053.

Introduction: At our institution, the pediatric stroke alert activations started in April 2011 to allow for rapid evaluation and imaging of children presenting within 48 hours with acute stroke symptoms. In a previously published paper, stroke alerts initiated in the pediatric emergency department confirmed strokes in 25% of children. The purpose of this study was to characterize pediatric stroke alerts in hospitalized children. Methods: Demographic and clinical information was obtained from a quality improvement database and medical records for patients (28 days -20 years) at a single institution. Stroke alerts were activated after hospital admission from April 2011 through December 2016. A stroke alert activation means that a neurology resident sees the patient within 15 minutes and MRI is acutely made available. All values were assessed with descriptive statistics. Results: There were 56 in-hospital stroke alerts (mean age 7.5 y, SD 6.1y, 52% male) over 5.75 years. Stroke was the final diagnosis for 25 (45%) children, 72% ischemic, 28% hemorrhage (Figure 1). Other diagnoses included other neurological urgencies including seizure (21%), posterior reversible encephalopathy syndrome (9%), transient ischemic attack (5%) and acute demyelinating encephalomyelitis (4%). Of 25 actual strokes, 68% were stroke alerts initiated by the pediatric ICU or pediatric cardiac ICU. Rapid imaging was completed in 91% of stroke alerts; MRI brain was the 1 st image in 55%. Nine of 25 children with stroke died (36%); 4 secondary to the stroke and the remainder were critically ill prior to stroke diagnosis. Conclusions: Pediatric in-hospital stroke alerts were confirmed stroke in 45% of children, while 38% were other neurological conditions requiring urgent neurologic evaluation. The high frequency of stroke and other serious illnesses in already hospitalized children demonstrates the importance of rapid evaluation via a pediatric stroke alert protocol when stroke is suspected.

Acute stroke care has undergone momentous changes in recent years with the introduction of intravenous thrombolysis, mechanical thrombectomy and integrated stroke services. While these are welcome developments, they also carry unique medico-legal challenges. In 2015, a patient from Greater Manchester was awarded over £1 million in compensation after ambulance paramedics failed to admit her to a specialist unit. This paper explores the medico-legal implications of this first but over looked thrombolysis-related claim in the United Kingdom. It is submitted that the highly time-dependent and multidisciplinary nature of acute stroke care may expose a host of healthcare personnel, both medical and non-medical, to risks of legal pursuit for failing to provide appropriate care, and that available scientific evidence will likely support such claims. The situation calls for an urgent and concerted effort at implementing improvement measures at national levels. A reminder of the legal consequences of substandard acute stroke care is timely and necessary.

Stroke represents a global challenge and is a leading cause of permanent disability worldwide. Despite much effort, translation of research findings to clinical benefit has not yet been successful. Failure of neuroprotection trials is considered, in part, due to the low quality of preclinical studies, low level of reproducibility across different laboratories and that stroke co-morbidities have not been fully considered in experimental models. More rigorous testing of new drug candidates in different experimental models of stroke and initiation of preclinical cross-laboratory studies have been suggested as ways to improve translation. However, to our knowledge, no drugs currently in clinical stroke trials have been investigated in preclinical cross-laboratory studies. The cytokine interleukin 1 (IL-1) is a key mediator of neuronal injury and the naturally occurring IL-1 receptor antagonist (IL-1Ra) has been reported as beneficial in experimental studies of stroke. In the present paper, we report on a preclinical cross-laboratory stroke trial designed to investigate the efficacy of IL-1Ra in different research laboratories across Europe. Our results strongly support the therapeutic potential of IL-1Ra in experimental stroke and provide further evidence that IL-1Ra should be evaluated in more extensive clinical stroke trials.

Objective In the weeks immediately following a stroke, impairments across multiple cognitive domains are pervasive yet there is little literature that explores cognitive recovery during this period. This paper evaluates the use of Mahalanobis distance as a means of statistically evaluating cognitive change at the individual level. Method A small battery of standardized neuropsychological tests was administered on five or six occasions across a 2-week period to the participants recovering from a stroke and a non-stroke control group. Mahalanobis distance was used to evaluate the change profile of those who were recovering from a stroke relative to the non-stroke control. Results The outcomes of three patients show that Mahalanobis distance could statistically differentiate recovery, no change, and deterioration from normal repetition effects. Discussion In the acute phase of stroke using Mahalanobis distance it is possible to distinguish between recovery, normal learning, and gerneralized learning deficits thereby identifying likely candidates for further cognitive assessment and rehabilitation.

Background: This study aims to investigate the effectiveness of mechanical thrombectomy compared with thrombolytic therapy in patients with acute stroke. Methods: This study is a systematic review on clinical studies, as the Cochrane library, PubMed, Google Scholar, Web of Science, and Embase databases were searched. The time span selected to retrieve articles is 1990 to 2017. The quality of the articles found was evaluated by the CONSORT checklist. Fixed effects and random effects models were employed for meta-analysis. Results were subject to sensitivity analysis in specified curtained interval, CMA (Comprehensive Meta-Analysis software): 2 software was used to carry out the meta-analysis task, and alpha was set to 5%. Results: The eight papers found met the inclusion criteria. Patients in mechanical thrombectomy group had a significantly higher improvement rate compared to the thrombolytic therapy group [OR 1.71 (1.182.48), P = 0.005]. There were no significant differences between mechanical thrombectomy and thrombolytic therapy groups regarding intracerebral hemorrhage ([OR 1.03 (0.71 - 1.49), P = 0.88]). Mechanical thrombectomy was more effective in reducing mortality rate of patients, however, this difference was not significant ([OR 0.84 (0.67 - 1.05), P = 0.12]). The effectiveness of mechanical thrombectomy is superior to thrombolytic therapy based on the improvement rate, 90-day mortality and symptoms of intracerebral hemorrhage OR: 2.23 (1.77 - 2.81), P < 0.00001; OR 0.79 (0.60 - 1.05), P = 0.10, and OR 1.02 (0.61 - 1.70), P = 0.95, respectively. Conclusions: Through some good criteria for selecting appropriate patients, mechanical thrombectomy can be superior to thrombolytic therapy in patients with acute stroke.

RESUMEN El tratamiento con activador recombinante del plasminógeno tisular (sigla en inglés rt-PA), aplicado por vía intravenosa (VIV) es el procedimiento de primera línea en casos de ataque cerebrovascular agudo (ACVA) en una ventana de 4,5 horas. En Colombia hay una experiencia publicada del uso exitoso de este medicamento. En el número actual se publica una nueva experiencia del uso de rt-PA en el caribe colombiano, de gran utilidad para reseñar los artículos publicados en Colombia acerca del tema. ABSTRACT Treatment with intravenous recombinant tissue plasminogen activator (rt-PA) for acute stroke (AS) is the first line procedure for patients in 4,5 hours window. In Colombia there is a published experience about the successful use of this medication. In the currently issue a new experience from Colombian Caribbean is presented, which it is taken in advantage for briefly reviewing the published papers about the theme in our country.

Background: Patients who experience acute stroke often have complex discharge planning needs that impact transitions of care. The hectic acute care hospital environment is not always conducive to addressing these needs in a standardized fashion. Purpose: To improve communication among team members and identify potential post-acute needs early in the hospital stay. Ultimately we hoped to have a positive impact the readmission rate and the patient experience. Methods: We designed a structure for daily rounds, identifying who would attend, setting clear expectations, and having a consistent schedule. We piloted a paper based check list that would serve as a guide to the dialogue during daily rounds to ensure that the team addressed key issues in a step wise, standardized fashion. This process also included the patients and families and their goals of care. Results: Readmissions were reduced from 15.4% to 10.9%. HCAHPS scores improved, specifically "Discharge Information" from 70% to 94% and "Communication with Nurses" from 46% to 83%. Conclusions: For a patient population with complex discharge needs, transitions of care can be improved by implementing a daily rounding checklist. This could positively impact the readmission rate and the patient experience.

Previous reports revealed that middle cerebral artery occlusion (MCAO) models in rats were very diverse in nature, and experimental stroke of a more homogenous nature had not been previously documented. This paper aims to present our novel observations of experimental stroke in rats with similar MRI characteristics after MCAO. Immediately after MCAO, 19 rats were placed into a 4.7 T MRI scanner, and diffusion weighted imaging (DWI) of axial and coronal planes was repeated every 10 minutes up to post-occlusion 115 minutes. Apparent diffusion coefficient (ADC) values of the ischemic lesions were calculated and compared to those of the unaffected contra-lateral hemispheres. Successful MCAO was defined when the whole left MCA territory showed ADC abnormality on DWI. Percentage of hemispheric lesion volume (% HLV), relative ADC value (rADC), and relative DWI signal intensity (rDWI) were serially evaluated for quantitative analysis of ADC-derived lesion characteristics. Successful MCA territorial infarction was induced in nine rats (9/19, 47.4%). In quantitative analysis of ADC-derived lesion characteristics, lesion volumes of seven rats (group 1) were very similar, but larger than those of the other two rats (group 2): % HLV of initial MRI = 45.4 ± 2.5 / 19.1 ± 6.6. rADCs and rDWIs of group 1 showed similar patterns of temporal change, which was different from those of group 2. Using prospective diffusion MRI after MCAO in rats, we identified territorial hyperacute ischemic lesions with similar MRI characteristics. This observation would contribute to the establishment of more homogenous rodent models for ischemic stroke translational research.

The Department of Veterans Affairs (VA) manages the largest healthcare system under a single management structure in the United States. Providing access to high quality healthcare to the VA’s nearly 9 million enrollees is a mission priority for the Veterans Health Administration (VHA), the arm of the VA that oversees all medical facilities and operations. Geographic Information Systems (GIS) tools enable analysts to construct data-driven recommendations to policy makers for providing the best and most timely healthcare to those individuals who have honorably served their country. This paper illustrates how GIS is being used by the VHA and provides the example of acute stroke care access for Veterans in one Veterans Integrated Service Network (VISN) within the VHA.

Background: Intravenous thrombolysis is one of few evidence-based treatments for acute stroke. Treatment uptake is low outside major stroke care centres. There is a need for greater understanding of barriers encountered by clinicians when seeking to increase thrombolysis rates. Aim: The aim of this study is to describe physicians’ and nurses’ perceptions regarding thrombolysis for acute stroke at hospitals in the earlier stages of thrombolysis implementation. Methods: A cross-sectional paper survey completed by physicians’ and nurses’ was distributed to 1127 staff at stroke care units, emergency departments or equivalent stroke care facilities at 19 Australian hospitals, as part of a cluster randomised controlled trial for thrombolysis implementation and systems improvement. Results: Of 1127 potential participants, 503 (148 physicians and 355 nurses) completed surveys (45% response rate). Over 90% agreed that thrombolysis improved the odds of independent survival. However, 42% to 58% agreed that there were limitations in the evidence base. A small proportion of staff indicated deficits in technical competencies. Interactive or competency-based training was reported by less than two-thirds of the sample. Challenges such as quick bed availability were identified. Emergency department physicians were less positive towards the treatment compared with nurses (p Conclusion: Australian hospitals seeking to address barriers to stroke thrombolysis implementation may benefit from the availability of interactive and competency-based training, staff performance feedback, support to make beds available quickly and bypass arrangements to quickly deliver acute stroke patients to appropriate facilities.

The paper considers the main therapeutic and preventive areas of management of patients with stroke, which are relied on evidence-based medicine data. To treat stroke patients is a multistep and multidisciplinary problem that starts with the emergence of the first neurological symptoms and extends over the entire life. Each period, including factors, such as the pattern of prehospital first medical aid; the rate of patient delivery to hospital; further actions of medical staff; measures for the prevention of recurrent cerebral ischemic events, cardiac complications, and cognitive disorders, is of importance in itself and serves a common aim. All efforts must aim eventually to reduce death rates in acute stroke, patient functional dependence, and recurrent brain damage rates, to prevent and timely treat cognitive impairments, to strictly adhere to the principles of secondary treatment of cardiovascular events in order to increase life expectancy and quality.

Stroke is the third most common cause of death and the sixth most common cause of disability worldwide. Treating acute ischemic stroke with thrombolytic therapy within 4.5 hours from symptom onset is effective in improving patient outcomes. The time from stroke onset to arrival to hospital has been identified as the single most important issue in determining patients' eligibility for stroke thrombolysis. There is a need for simultaneous systemic evaluation of multi-factorial interventions in pre-hospital acute care systems, aimed at increasing patients' eligibility for stroke thrombolysis. In this paper an OR solution is proposed in the form of a simulation model that provides clear measure of the relative benefit of alternative potential interventions, demonstrating how OR modeling can be used for providing decision support in pre-hospital stroke care operations and contributing to health OR literature.

The manner in which information is presented can profoundly affect the interpretation of that information and, consequently, any action taken. As an illustrative example, let us assume that swimming pools across the country have to report the time it takes to rescue a child who is drowning. As a parent, would you be satisfied if the median time to rescue a drowning child was 30 seconds? Knowing that a lifeguard could reach your child in only half a minute may be comforting. However, this comfort likely would not last if you were then informed that the 90th percentile is 6 minutes, a time which is likely life-threatening. We argue here that acute ischemic stroke treatment faces a similar reporting issue and that we should be doing more to acknowledge and improve the 90th percentile for stroke patients. We recommend that investigators report interval times with the 90th percentile, in addition to median and interquartile range, in their primary results on paper and at presentation. In the long run, this change would allow us to focus on ensuring that the majority of patients are treated within an acceptable time frame, rather than only 50% of patients. Additionally, efforts tailored to improving the 90th percentile would result in improved systems of care and stroke outcomes. Based on data from recent endovascular trials, it is absolutely clear that when it comes to stroke treatment, time is brain.1–5 The longer the time from onset to reperfusion, the lower the likelihood of good outcome.6 The effect of time delay is even more pronounced when one considers onset to randomization times in endovascular trials.1–5 This is not because of physiological factors; rather, it is the result of these trials overtly selecting patients based on favorable imaging. In all of …

We thank the authors Ehrlich et al for their study, which is a valuable effort to look at the safety of computed tomographic angiography (CTA) in acute stroke patients in terms of renal function.1 Multiple previous papers have also found the use of contrast to be safe in triage of acute stroke patients, some even concluding that contrast could be injected even before waiting for serum creatinine levels.2 However, we would like to raise a few concerns about this study. Of the 289 patients included in the …

Background: Recent nursing initiatives encourage early mobilization of neurocritical care patients, but whether this intervention can be safely generalized to acute stroke is debatable. We performed a systematic review of findings from recent studies to provide direction for patient management and future research. Methods: An exhaustive literature search was performed in Medline, SCOPUS and the Cochrane Central Register of Controlled Trials to identify published clinical trial research using a very early mobility intervention (within 24 hours) in acute ischemic stroke patients. The primary efficacy outcome supporting the search was neurologic disability reduction or improved functional outcomes, and the primary safety outcome was neurologic deterioration. Studies were critically reviewed for inclusion by 3 separate investigators, findings were synthesized, and an overall recommendation for very early mobilization use in acute stroke was assigned according to GRADE criteria. Results: We initially identified 12 papers focused on early mobilization in acute stroke; of these, 6 observational studies were excluded, 1 study was excluded due to an ambiguous population, and 3 studies were excluded due to first initial mobilization out of bed occurring greater than 24 hours after admission. Two prospective randomized outcome blinded evaluation (PROBE) studies were retained, consisting of a total 2160 patients; ischemic stroke subtype was not disclosed in either study, limiting an understanding of the impact of very early mobilization on small versus large artery occlusion. Slower mobilization occurring beyond the first 24 hours was associated with higher rates of favorable outcome (mRS 0-2) at 90 days, whereas very early mobilization within the first 24 hours was associated with a number needed to harm of 25. Conclusions: In acute stroke, evidence supports a rested approach to care within the first 24 hours of hospitalization (GRADE: Strong recommendation, high quality of evidence). Similar to acute myocardial infarction, vascular insufficiency experienced in stroke likely warrants a more guarded approach to mobility. Additional studies exploring timing beyond 24 hours and dose of mobility interventions are warranted in discreet populations.