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BACKGROUND AND PURPOSE: The experience gained during the first COVID-19 wave could have mitigated the negative impact on stroke care in the following waves. Our aims were to analyze the characteristics and outcomes of patients with stroke admitted during the second COVID-19 wave and to evaluate the differences in the stroke care provision compared with the first wave. METHODS: This retrospective multicenter cohort study included consecutive stroke patients admitted to any of the seven hospitals with stroke units (SUs) and endovascular treatment facilities in the Madrid Health Region. The characteristics of the stroke patients with or without a COVID-19 diagnosis were compared and the organizational changes in stroke care between the first wave (25 February to 25 April 2020) and second wave (21 July to 21 November 2020) were analyzed. RESULTS: A total of 550 and 1191 stroke patients were admitted during the first and second COVID-19 waves, respectively, with an average daily admission rate of nine patients in both waves. During the second wave, there was a decrease in stroke severity (median National Institutes of Health Stroke Scale 5 vs. 6; p = 0.000), in-hospital strokes (3% vs. 8.1%) and in-hospital mortality (9.9% vs. 15.9%). Furthermore, fewer patients experienced concurrent COVID-19 (6.8% vs. 19.1%), and they presented milder COVID-19 and less severe strokes. Fewer hospitals reported a reduction in the number of SU beds or deployment of SU personnel to COVID-19 dedicated wards during the second wave. CONCLUSIONS: During the second COVID-19 wave, fewer stroke patients were diagnosed with COVID-19, and they had less stroke severity and milder COVID-19.

Background and purposeSpain has been heavily affected by COVID-19. Reallocation of resources for managing the outbreak might have caused a disruption in stroke care. This study analyses the impact on stroke care of reorganising the healthcare system in response to the first COVID-19 outbreak peak in Spain and the strategies adopted by Spanish stroke units to deal with this impact.Materials and methodsWe obtained data from a structured survey sent to the responsible of stroke units across the country. We recorded the number of strokes, stroke code activations, intravenous thrombolysis treatments and mechanical thrombectomies during February and March 2019 and 2020. We also collected information on the impact on workflow metrics and on the availability of specialised neurological care and rehabilitation treatments, the characteristics of stroke care for patients with SARS-CoV-2 infection and the impact on human resources. We compared the activity data between 2019 and 2020 and the information on activity and impact on stroke care between regions classified according to the disease incidence rate.ResultsFifty-seven (75%) of all stroke units in Spain responded to the survey. There was an overall reduction in admissions for all stroke types during the outbreak’s peak and in the number of stroke code activations and intravenous thrombolysis treatments, results that were independent of the COVID-19 incidence rate. Participants reported a delay in workflow metrics and a reduction of admissions to stroke units, outpatient clinics and rehabilitation therapies. Specific pathways and protocols for managing stroke patients with SARS-CoV-2 infection have been established.ConclusionThe COVID-19 outbreak has jeopardised all phases of stroke care. As a consequence, some patients with stroke did not receive adequate treatment.

Background and Purpose: The coronavirus disease 2019 (COVID-19) outbreak has added challenges to providing quality acute stroke care due to the reallocation of stroke resources to COVID-19. Case series suggest that patients with COVID-19 have more severe strokes; however, no large series have compared stroke outcomes with contemporary non–COVID-19 patients. Purpose was to analyze the impact of COVID-19 pandemic in stroke care and to evaluate stroke outcomes according to the diagnosis of COVID-19. Methods: Retrospective multicenter cohort study including consecutive acute stroke patients admitted to 7 stroke centers from February 25 to April 25, 2020 (first 2 months of the COVID-19 outbreak in Madrid). The quality of stroke care was measured by the number of admissions, recanalization treatments, and time metrics. The primary outcome was death or dependence at discharge. Results: A total of 550 acute stroke patients were admitted. A significant reduction in the number of admissions and secondary interhospital transfers was found. COVID-19 was confirmed in 105 (19.1%) patients, and a further 19 patients were managed as suspected COVID-19 (3.5%). No differences were found in the rates of reperfusion therapies in ischemic strokes (45.5% non–COVID-19, 35.7% confirmed COVID-19, and 40% suspected COVID-19; P =0.265). However, the COVID-19 group had longer median door-to-puncture time (110 versus 80 minutes), which was associated with the performance of chest computed tomography. Multivariate analysis confirmed poorer outcomes for confirmed or suspected COVID-19 (adjusted odds ratios, 2.05 [95% CI, 1.12–3.76] and 3.56 [95% CI, 1.15–11.05], respectively). Conclusions: This study confirms that patients with COVID-19 have more severe strokes and poorer outcomes despite similar acute management. A well-established stroke care network helps to diminish the impact of such an outbreak in stroke care, reducing secondary transfers and allowing maintenance of reperfusion therapies, with a minor impact on door-to-puncture times, which were longer in patients who underwent chest computed tomography.

Background: The use of the cardiovascular polypill, a fixed-dose combination treatment, is conceived to improve adherence. However, randomized controlled trials (RCTs) may overestimate it. Studies focusing on cerebrovascular disease and real-life efficacy compared with conventional treatment are lacking. Methods: This is a retrospective, hospital-based cohort study of acute ischaemic stroke patients who were prescribed a polypill (aspirin 100 mg, atorvastatin 20/40 mg, ramipril 2.5/5/10 mg) versus conventional treatment (aspirin 100 mg and other blood pressure/lipid-lowering agents) in secondary prevention (2017–2018). Clinical records were reviewed 90 days after discharge for stroke recurrence, vascular risk factor control, and safety. Adherence was assessed using the adapted Morisky-Green scale. Results: A total of 104 patients were included (61% male; mean age 69.7 ± 13.9 years); 54 were treated with the polypill and 50 with conventional treatment. No baseline differences in clinical or demographic variables were detected. No recurrences were registered in the polypill group, compared to 1 recurrence in the conventional treatment group. A significant reduction of systolic blood pressure (SBP) was achieved in the polypill group (12.1 mm Hg) compared to the conventional treatment group (6.8 mm Hg) (p = 0.002). No significant differences were detected regarding the goal of LDL cholesterol ≤70 mg/dL (41 vs. 44%). The adverse events were mild and their frequency was similar in the two groups (9 vs. 2%, ns). Adherence was similarly good in the two groups (93 vs. 88%, ns). Polypill group adherence was similar to that reported in a previous meta-analysis of RCTs (93 vs. 84%, ns). Conclusion: In our experience, the cardiovascular polypill achieved a higher reduction in SBP levels and was well tolerated. Adherence was similar to that found in the previous literature, which is remarkable given the real-life setting of our study.

Introduction. Patients treated with vitamin K antagonists (VKA) are at increased risk of intracranial haemorrhage (ICH). The purpose of our study was to determine the quality of previous anticoagulation control in patients with VKA-associated ICH. Materials and Methods. We prospectively assessed every consecutive patient admitted to our stroke unit with VKA-associated ICH between 2013 and 2016. Demographic, clinical, and radiological variables, as well as consecutive international normalized ratios (INR) during 7 previous months, were extracted. Time in therapeutic range (TTR), time over range (TOR), time below range (TBR), and percentage of INR within range (PINRR) were calculated. Results and Discussion. The study population comprised 53 patients. Mean age was 79 years; 42% were women. Forty-eight patients had atrial fibrillation (AF) and 5 mechanical prosthetic valves. Therapeutic or infratherapeutic INR on arrival was detected in 64.4% of patients (95% CI 2.7 to 3.2). TTR was 67.8% (95% CI: 60.2 to 75.6 %) and PINRR was 75% (95% CI: 49.9-100). TOR was 17.2% (95% CI: 10.4 to 23.9% ) and TBR was 17% (95% CI: 10.6 to 23.9%). Conclusion. VKA-associated ICH happens usually in the context of good chronic anticoagulation control. Newer risk assessment methods are required.

We investigated whether pre-treatment with statins is associated with surrogate markers of amyloid and hypertensive angiopathies in patients who need to start long-term oral anticoagulation therapy. A prospective multicenter study of patients naive for oral anticoagulants, who had an acute cardioembolic stroke. MRI was performed at admission to evaluate microbleeds, leukoaraiosis and superficial siderosis. We collected data on the specific statin compound, the dose and the statin intensity. We performed bivariate analyses and a logistic regression to investigate variables associated with microbleeds. We studied 470 patients (age 77.5 +/- 6.4 years, 43.7% were men), and 193 (41.1%) of them received prior treatment with a statin. Microbleeds were detected in 140 (29.8%), leukoaraiosis in 388 (82.5%) and superficial siderosis in 20 (4.3%) patients. The presence of microbleeds, leukoaraiosis or superficial siderosis was not related to pretreatment with statins. Microbleeds were more frequent in patients with prior intracerebral hemorrhage (OR 9.7, 95% CI 1.06-90.9) and in those pre-treated antiplatelets (OR 1.66, 95% CI 1.09-2.53). Prior treatment with statins was not associated with markers of bleeding-prone cerebral angiopathies in patients with cardioembolic stroke. Therefore, previous statin treatment should not influence the decision to initiate or withhold oral anticoagulation if these neuroimaging markers are detected., This study was funded by the Spanish Ministery of Health - Instituto Carlos III, Redes Tematicas de Investigacion Cooperativa (INVICTUS PLUS RD16/0019/0010) and Fondo de Investigaciones Sanitarias FI12/00296. The study also received funding from FEDER (Fondo Europeo de Desarrollo Regional). The study was done with the aid of the Stroke Project, Cerebrovascular Diseases Group of the Spanish Neurological Society.

Introduction: Statin therapy might be associated with an increased risk of hemorrhagic stroke, which has been attributed to low LDL-cholesterol levels and antithrombotic effects. Hypothesis: Previous statin therapy is associated with surrogate markers of amyloid and hypertensive angiopathies in patients with cardioembolic stroke who need to start long-term oral anticoagulation (OA). Methods: A prospective multicenter study of patients included in the HERO study (Intracerebral Hemorrhage due to Oral Anticoagulants: Prediction of the Risk by Magnetic Resonance). Patients were naïve for OA and had an acute cardioembolic ischemic stroke (TIA or infarct). A MR examination was performed during admission to evaluate: 1) Microbleeds (-MB-, number, distribution, burden); 2) Leukoaraiosis (-LK- presence and degree); 3) Superficial siderosis (-SS-, presence). We collected data on the specific statin, the dose and the statin intensity (low, medium or high according to accepted classifications). We also recorded demographic data and traditional vascular risk factors. Results: We studied 470 patients (age 77.5±6.4 years, 43.7% were men). A total of 193 (41.1%) patients received prior treatment with any statin, of whom 43.5% received simvastatin and 41.3% atorvastatin. Statin intensity was low in 14.5%, medium in 61.1%, high in 16.5% and unknown in 10.8%. LK was detected in 82.5% and was severe in 19.8%. SS was detected in 20 (4.3%) patients. MBs were detected in 140 (29.8%) patients and the distribution was lobar in 55%, deep in 30% and both in 15%. Of the MB group 74 (53%) had 1 MB, 66 (47%) had >1 MB, and 11.4% had >5 MBs. The presence of MB, LK or SS was not related to the pre-treatment with statin. The statin intensity was not related to the presence of SS, the presence/degree of LK, and the presence/distribution/burden of MBs. MBs were detected with increased frequency in hypertensive patients (p=0.09). LK presence and degree were increased in patients with MB (p=0.012) and SS (p=0.041). Conclusion: In conclusion, prior treatment with statins is not associated with surrogate markers of bleeding-prone cerebral angiopathies in patients with cardioembolic stroke. Therefore previous statin treatment should not influence the decision to start long-term oral anticoagulation.

Background and purposeThe benefits of mechanical thrombectomy (MT) in basilar artery occlusions (BAO) have not been explored in recent clinical trials. We compared outcomes and procedural complications of MT in BAO with anterior circulation occlusions.MethodsData from the Madrid Stroke Network multicenter prospective registry were analyzed, including baseline characteristics, procedure times, procedural complications, symptomatic intracranial hemorrhage (SICH), modified Rankin Scale (mRS), and mortality at 3 months.ResultsOf 479 patients treated with MT, 52 (11%) had BAO. The onset to reperfusion time lapse was longer in patients with BAO (median (IQR) 385 min (320–540) vs 315 min (240–415), pConclusionsMT is more laborious and shows more procedural complications in BAO than in anterior circulation strokes. The likelihood of futile recanalization is higher in BAO and is associated with greater age and longer procedure duration. A refinement of endovascular procedures for BAO might help optimize the results.

A stroke is a time-dependent medical emergency. Swiftness in its recognition and in the care received by the patients plays a key role in the prognosis.To analyse the medical intervention times, to evaluate possible areas where improvements can be made and to examine the allocation of resources in the centres.The study was based on a prospective register of patients with suspected stroke and stroke code activation treated in eight experienced Spanish stroke units. Onset-to-door, door-to-computed tomography (CT), door-to-needle, CT-to-needle and onset-to-needle times were collected. Information about the means of transport used to get to the hospital, the type of stroke and reperfusion therapies was also collected. With regard to the structural resources of the centres, data were gathered about the nurse-to-patient ratio, bed monitoring, availability of multimodal CT and magnetic resonance, and doing information or training courses.Altogether 197 patients were included, of whom 181 (151 infarctions and 30 brain haemorrhages) were valid. The medians (p25-p75) in minutes were: onset-to-door, 104 (70-188); door-to-CT, 27 (19-41); CT-to-needle, 30 (21-43); door-to-needle, 64 (49-83); and onset-to-needle, 156 (129-202). Reperfusion therapies were applied in 68 patients (45% of the cerebral infarctions), of which 81% were intravenous thrombolyses; 7%, endovascular treatments; and 12%, a combination of the two. The resources available in the centres were in accordance with those recommended by the clinical guidelines. There was a low percentage of patients who were studied by means of magnetic resonance.The percentage of patients treated with thrombolysis was very high and although the times of the in-hospital circuits were good, there is still room for further improvement.Atencion urgente al ictus en hospitales con unidad de ictus. Proyecto Quick.Introduccion. El ictus es una emergencia medica dependiente del tiempo. La rapidez en su reconocimiento y en la atencion que reciben los pacientes es clave en el pronostico. Objetivos. Analizar los tiempos de actuacion medica, evaluar posibles areas de mejora y estudiar la dotacion de recursos de los centros. Pacientes y metodos. Registro prospectivo de pacientes atendidos en ocho unidades de ictus experimentadas españolas con sospecha de ictus y activacion del codigo ictus. Se recogieron los tiempos inicio-puerta, puerta-tomografia computarizada (TC), puerta-aguja, TC-aguja e inicio-aguja. Tambien se recogieron el metodo de trasporte al hospital, el tipo de ictus y las terapias de reperfusion. En cuanto a la dotacion estructural de los centros, se recogieron la ratio de enfermeria, la monitorizacion de camas, la disponibilidad de TC multimodal y resonancia magnetica, y la realizacion de cursos de informacion o formacion. Resultados. Se incluyeron 197 pacientes, de los cuales fueron validos 181 (151 infartos y 30 hemorragias cerebrales). Las medianas (p25-p75) en minutos fueron: inicio-puerta, 104 (70-188); puerta-TC, 27 (19-41); TC-aguja, 30 (21-43); puerta-aguja, 64 (49-83); e inicio-aguja, 156 (129-202). Se aplicaron terapias de reperfusion en 68 pacientes (el 45% de los infartos cerebrales), de los cuales el 81% fueron trombolisis intravenosas; el 7%, tratamientos endovasculares; y el 12%, una combinacion de ambos. Los recursos de los centros estuvieron de acuerdo con lo recomendado por las guias clinicas. Hubo un bajo porcentaje de pacientes estudiados con resonancia magnetica. Conclusion. El porcentaje de pacientes tratados con trombolisis fue muy elevado y los tiempos de los circuitos intrahospitalarios, aunque buenos, tienen margen de mejora.

Atrial fibrillation is the most frequent arrhythmia seen in clinical practice and is one of the most important risk factors for suffering a stroke. Strokes associated to atrial fibrillation are more severe, present higher mortality and disability rates, and there is a greater risk of recurrence. Consequently, both primary and secondary prevention of stroke associated to atrial fibrillation by means of suitable antithrombotic treatment is clearly essential in order to lower this risk. Chronic oral anticoagulants are the cornerstone of antithrombotic treatment in patients with non-valvular atrial fibrillation, especially in those who have already had a stroke. Vitamin K antagonists have traditionally been used for this purpose. Yet, these drugs have several important disadvantages (narrow therapeutic window, unpredictable response, numerous interactions with drugs and foods, as well as starting and finishing their action slowly), which limit their use in clinical practice. The new oral anticoagulants not only overcome these disadvantages but also have proved to be at least as effective as warfarin in the prevention of strokes and systemic embolism in patients with non-valvular atrial fibrillation. Additionally, they have been shown to have a better safety profile, especially with an important drop in the risk of intracranial haemorrhage, regardless of the antecedents of stroke or transient ischaemic attack, which makes them first-choice drugs in the treatment of these patients.Manejo actual del tratamiento antitrombotico en pacientes con fibrilacion auricular no valvular y antecedentes de ictus o ataque isquemico transitorio.La fibrilacion auricular es la arritmia mas frecuente en la practica clinica y es uno de los factores de riesgo mas importantes para padecer un ictus. Los ictus asociados a la fibrilacion auricular son mas graves, presentan una mayor mortalidad y discapacidad, y el riesgo de recurrencias es mayor. En consecuencia, la prevencion, tanto primaria como secundaria, del ictus asociado a la fibrilacion auricular mediante el adecuado tratamiento antitrombotico es claramente esencial y crucial para disminuir este riesgo. La anticoagulacion oral cronica supone la piedra angular del tratamiento antitrombotico en el paciente con fibrilacion auricular no valvular, especialmente en el paciente que ya ha tenido un ictus. Para este fin, tradicionalmente se han empleado los antagonistas de la vitamina K. Sin embargo, estos farmacos poseen importantes desventajas (estrecha ventana terapeutica, respuesta impredecible, numerosas interacciones con farmacos y alimentos, asi como un comienzo y final de accion lentos) que limitan su uso en la practica clinica. Los nuevos anticoagulantes orales no solo superan estas desventajas, sino que, ademas, han demostrado ser, al menos, tan eficaces como la warfarina en la prevencion de ictus y embolia sistemica en los pacientes con fibrilacion auricular no valvular, y poseer un mejor perfil de seguridad, en particular con una importante disminucion del riesgo de hemorragia intracraneal, independientemente de los antecedentes de ictus o ataque isquemico transitorio, lo que hace que sean farmacos de primera linea en el tratamiento de estos pacientes.

We report the case of a healthy 12-year-old girl with an acute ischemic stroke successfully treated with mechanical thrombectomy. The child was referred to our hospital 6 hours after sudden onset of severe headache and left hemiparesis. Cerebral angiography findings were consistent with right distal internal carotid artery occlusion in addition to ipsilateral middle cerebral artery occlusion. Subsequent mechanical thrombectomy with Solitaire AB device resulted in complete vessel recanalization. The patient experienced progressive neurologic improvement with good clinical recovery at the 3-month follow-up. To our knowledge, only 3 cases of primary mechanical thrombectomy in children have been previously reported in the literature. Safety and efficacy data for endovascular therapies in pediatric acute ischemic stroke are lacking. We propose mechanical thrombectomy as an option in children with significant neurologic deficits and proven arterial occlusion, especially when the therapeutic window for intravenous thrombolysis has been exceeded.

Objectives Neurological problems are reported to be common in air travellers. The authors aimed to study neurological problems which might be associated with air traffic in a systematic way. Methods The authors analysed a prospective registry of all the patients referred from Madrid-Barajas International Airport to the emergency department of their tertiary university hospital (Hospital Universitario Ramon y Cajal), for whom a neurological consultation was required, during a period of 21 months. Results 77 patients with a history of air travel presented with neurological problems and were included in the analysis. Fifty-nine (76.6%) were male, and the mean age was 45.9 (range 8–89, SD 17.5). Onset of symptoms was after landing in 44 subjects (58.7%), during the flight in 31 (41.3%), and unknown in two (5.1%). Thirty-nine (50.9%) had seizures, 18 (23.4%) had a stroke, and 20 (26%) other diagnosis. Sixty-one per cent of the patients with seizures had no previous history of epilepsy. Seizures on presentation were significantly associated with the use of drugs (p=0.0008), and most of the cases with known epilepsy admitted non-adherence to treatment. Three ‘body packers’ were admitted with seizures secondary to intra-abdominal cocaine pack rupture. Of eight ischaemic strokes, five had high-grade carotid stenosis, and one case had economy-class stroke syndrome. Six patients with stroke were eligible and treated with intravenous thrombolysis. Conclusion In our series of neurological problems among air travellers, drug-induced seizures and ischaemic strokes due to large-artery atherosclerosis were the commonest observed diagnoses.