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Our case highlights an atypical presentation of Coxiella burnetii endocarditis with acute ischaemic stroke in a male patient in his 60s. The patient had undergone a congenital bicuspid aortic valve replacement with a bioprosthetic valve and an ascending aortic root graft with a pacemaker. He experienced intermittent fevers, chills and malaise over 15 months leading up to his presentation. During our diagnostic process, we used the newly developed Karius test, which detects microbial cell-free DNA in the patient's serum. The patient was treated with doxycycline and hydroxychloroquine for 24 months along with surgical removal and replacement of his aortic valve and graft. Our case underscores the utility of the Karius test and the essential role of neurology in the multidisciplinary team., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In China, disparities in the quality of stroke care still exist and implementing quality improvement is still a challenge., Aim: The aim of the study was to determine whether the intervention by Shanghai Stroke Service System (4S) has helped improve adherence to stroke care guidelines and patient outcome., Methods: The 4S is a regional stroke network with real-time data extraction among its 61 stroke centers in Shanghai. A total of 11 key performance indicators (KPIs) were evaluated. The primary outcomes were a composite measure and an all-or-none measure of adherence to 11 KPIs. The secondary outcomes were length of hospital stay and in-hospital mortality., Results: The study enrolled 92,395 patients (mean age 69.0 ± 12.5 years, 65.2% men) with acute ischemic stroke hospitalized within 7 days of onset in Shanghai from January 2015 to December 2020. More patients received guideline recommended care between 2018 and 2020 than those between 2015 and 2017 (composite measure 87.1% vs 83.6%; absolute difference 2.9%, 95% confidence interval (CI) = [2.7%, 3.2%], p < 0.001; all-or-none measure 49.2% vs 44.8% patients; absolute difference 3.5%, 95% CI = [2.7%, 4.2%], p < 0.001). Further analysis of individual KPIs showed an absolute increase in six KPIs ranging from 3.4% to 8.9% (p < 0.001 for all comparisons). Compared with 2015-2017, hospital length of stay was shorter (10.95 vs 11.90 days; absolute difference -1.08, 95% CI = [-1.18, -0.99], p < 0.001), and in-hospital mortality was significantly reduced (risk ratio (RR) = 0.88, 95% CI = [0.79, 0.98], p = 0.01) in 2018-2020., Conclusion: The 4S intervention was associated with increased adherence to the stroke care guidelines, which further translated to improved clinical outcomes., Trial Registration: ClinicalTrials.gov identifier: NCT02735226.

Background: In June 2015, the Chinese Stroke Association (CSA) initiated the Chinese Stroke Center Alliance (CSCA) to establish the national hospital-based stroke care quality assessment and improvement platform. This article outlines its objectives, operational structure, patient population, quality improvement (QI) intervention tools, data elements, data collection methodology and current patient and hospital data., Methods: The CSCA is a national, hospital-based, multicentre, voluntary, multifaceted intervention and continuous QI initiative. This multifaceted intervention includes stroke centre development, written care protocols, workshops and a monitoring/feedback system of evidence-based performance measures. The data coordinating centre of the CSCA resides at the China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital., Results: As of July 2017, 1576 hospitals in China have contributed detailed clinical information to serve as a benchmark for the stroke care quality of 433 264 patients with acute stroke/transient ischaemic attacks (TIA), including 352 572 (81.38%) acute ischaemic stroke, 30 362 (7.01%) TIA, 42 080 (9.71%) spontaneous intracranial haemorrhage, 5505 (1.27%) subarachnoid haemorrhage and 2745 (0.63%) not specified stroke., Conclusion: The CSCA programme is designed to establish a continuous national stroke registry and help healthcare providers develop stroke centres and treat patients in a consistent manner in accordance with accepted national guidelines and, ultimately, improve patient outcomes. It supports the CSA mission to reduce stroke burden in China., Competing Interests: Competing interests: None declared.

Aims The purpose of this study was to discuss the relationship between blood pressure and prognosis of patients with symptomatic intracranial arterial stenosis. Methods Data on 2426 patients with symptomatic intracranial large artery stenosis and occlusion who participated in the Chinese Intracranial Atherosclerosis ( CICAS) study were analyzed. According to the JNC 7 criteria, blood pressure of all patients was classified into one of the four subgroups: normal, prehypertension, hypertension stage I, and hypertension stage II. Poor outcomes were defined as death and functional dependency ( mRS 3-5) at discharge or at 1 year. Results For patients with intracranial stenosis of 70% to 99%, the rate of poor outcome at discharge was 19.3%, 23.5%, 26.8%, and 39.8% ( P = 0.001) for each blood pressure subgroup. For patients with intracranial large artery occlusion, the rates were 17.6%, 22.1%, 29.5%, and 49.8%, respectively ( P < 0.0001). The rate of poor outcome at 12-month follow-up was 12.6%, 15.3%, 28.5%, and 27.9% ( P = 0.0038) in patients with stenosis of 70% to 99% for each blood pressure subgroup and 11.6%, 21.5%, 23.9%, 35.1% ( P < 0.0001) in patients with occlusion. Conclusions For patients with severe intracranial arterial stenosis or occlusion, higher hypertension stages are associated with an increased risk of poor outcome at discharge and 12-month follow-up. [ABSTRACT FROM AUTHOR]

Background Collateral circulation is becoming more significant in the individual management strategy of ischemic stroke, there are more data updated recently. Aim To make the further acknowledgment of the evaluation and how to improving collateral flow, for better treatment selection. Method A panel of experts on stroke providing related statement based on review the results from most up-to-date clinical research. Results DSA is the gold standard in evaluating all levels of collaterals. CTA can be used for evaluating leptomeningeal collaterals, MRA for CoW, TCD or TCCS can be used as screening tool for primary evaluation. The treatment modalities include direct interventions, such as Extracranial-Intracranial bypass, and indirect interventions, as External counterpulsation and pressor therapy. The consideration of methodology to augment and improve can be considered on an individual basis. Discussion In this consensus, we interpret the definition, neuroimaging evaluation, intervention and potential strategy on collaterals in the future. Conclusion Assessment of collateral circulation is crucial for selecting therapeutic options, predicting infarction volume and making prognosis after ischemic stroke. Data is still needed to provide therapeutic evidence for many new developed technologies. Until more evidence is available, the clinical significance of applying the new technologies is unclear and perhaps limited. [ABSTRACT FROM AUTHOR]

Background: Intracranial atherosclerotic stenosis (ICAS) is an important cause of ischemic stroke worldwide. The role of high-density lipoprotein cholesterol (HDL-C) or low-density lipoprotein cholesterol (LDL-C) in the development of ICAS remains to be elucidated. In the current study, we investigated the relationship of HDL-C level and the risk of developing ICAS in Chinese patients with acute ischemic stroke. Methods: From October 2007 to June 2009, a total of 1,984 consecutive ischemic stroke patients were evaluated for the presence of symptomatic ICAS by magnetic resonance angiography (MRA). Patients were classified into two groups: intracranial steno-occlusion (ICAS group, n = 888) and non-intracranial stenosis (NICAS group, n = 1096). Serum lipid profiles were analyzed and compared between the ICAS and NICAS group. Results: Significantly more patients in ICAS group had low HDL-C level (51.6%) than in the NICAS group (42.9%, P<0.001). The observed association remained significant after adjustment for conventional risk factors [(adjusted OR 1.36; 95%CI (1.13–1.63)]. Such predictive value of low level HDL-C persisted even when LDL-C was at very low level(<1.8 mmol/L). Patients in the lowest serum HDL-C quartile (<0.96 mmol/L) had the highest risk of developing ICAS [adjusted OR 1.52; 95%CI (1.17–1.98)] compared to patients in the highest serum HDL-C quartile (≥1.32 mmol/L) after adjustments for the covariates. Conclusions: Low HDL-C level is strongly associated with the development of ICAS. There was an inverse relationship between the level of HDL-C and the risk of developing ICAS. [ABSTRACT FROM AUTHOR]