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Aim: As part of a program of work to develop an educational strategy and implementation plan for the World Stroke Organization, we conducted a survey of World Stroke Organization members (health professionals, laypersons (Stroke Support Organizations)) to identify their potential educational needs., Methods: We developed a questionnaire to identify priority educational needs in consultation with the World Stroke Organization Education Committee. The World Stroke Organization invited all individual members and associated Stroke Support Organizations to complete the questionnaire via a web-based survey. Survey responses were supplemented by questionnaires emailed directly to key persons in Stroke Support Organizations and information from semi-structured telephone interviews, where necessary. The questionnaire asked respondents to prioritize topics in diagnosis, management of acute stroke, stroke care services, stroke rehabilitation, and stroke prevention. Free-text responses were assessed with word cloud., Results: The online survey was completed by 264 respondents from 60 countries; 19.1% were from low- and middle-income countries, 59% were stroke specialist physicians, 28% allied health professionals or nurses, 9% Stroke Support Organizations, 4% general physicians. Fifteen Stroke Support Organizations from 11 countries responded to the emailed survey. Seven Stroke Support Organizations' members were interviewed by telephone; one was interviewed in-person. We highlight the two highest priority topics in each of the five questionnaire domains., Conclusion: The 10 priority topics were all applicable in a low- or middle-income setting: setting up and delivering stroke diagnosis, treatment, rehabilitation and prevention services, and emphasized the most basic elements of care. The survey participants have identified a number of key topics that merit inclusion in stroke teaching materials and courses, especially those aimed at practitioners working in resource-limited settings.

Background: Education in stroke is relevant to stroke survivors, clinicians, care providers, and healthcare system administrators and is of special importance in resource-limited settings. The World Stroke Organization Education Committee undertook a program of work, culminating in a focused workshop, to establish the key educational priorities, and work toward maximizing the WSOs impact on the global burden of stroke., Methods: A facilitated workshop took place during the World Stroke Congress in Montreal, Canada in October 2018. The workshop was developed using opinions on priority topics for World Stroke Organization educational activities obtained from web-based surveys of World Stroke Organization Members, supplemented by interviews with international stroke support organizations. The workshop included over 50 international participants, selected to represent a balance of age, gender, geographical region, and different levels of health resources. Participants also included members of the World Stroke Organization Education Committee, the World Stroke Academy, stroke support organizations, and the International Journal of Stroke editorial board. The workshop focused on understanding more about educational needs (at all levels), with emphasis on resource-limited settings.  Three broad questions were posed: (1) What are the key educational needs: (a) in your region, (b) from your perspective (e.g. stroke support organization)? (2) Do the current educational activities offered by World Stroke Organization and WSA meet your needs? (3) What could World Stroke Organization/World Stroke Academy offer in your region that would meet your needs? The facilitated discussions were recorded, and the results transcribed and summarized by members of the World Stroke Organization Education Committee., Results: Five key needs were identified: 1. Collaborative interdisciplinary, training in both stroke care and how to advocate for stroke. 2. Educational materials provided in a wider range of formats that could be adapted to local circumstances and clinical practices. 3. Educational activities for healthcare providers and stroke support organizations organized regionally, with the World Stroke Organization providing organizational support, and a pool of experts, therapists, nurses, etc. to deliver locally relevant materials. 4. Clear and authoritative online resources, where it is easy to find key policy and protocol guidance. 5. A range of online interactive education and training resources to help build knowledge and competence in stroke care., Conclusion: The results of the workshop have been presented to the World Stroke Organization Board and will be used to help to guide the educational initiatives of the World Stroke Organization and World Stroke Academy going forward.

Background Specialist training provides skilled workforce for service delivery. Stroke medicine has evolved rapidly in the past years. No prior information exists on background or training of stroke doctors globally. Aims To describe the specialties that represent stroke doctors, their training requirements, and the scientific organizations ensuring continuous medical education. Methods The World Stroke Organization conducted an expert survey between June and November 2014 using e-mailed questionnaires. All Organization for Economic Co-operation and Development countries with >1 million population and other countries with >50 million population were included ( n = 49, total 5.6 billion inhabitants, 85% of global strokes). Two stroke experts from each selected country were surveyed, discrepancies resolved, and further information on identified stroke-specific curricula sought. Results We received responses from 48 (98%) countries. Of ischemic stroke patients, 64% were reportedly treated by neurologists, ranging from 5% in Ireland to 95% in the Netherlands. Per thousand annual strokes there were average six neurologists, ranging from 0.3 in Ethiopia to 33 in Israel. Of intracerebral hemorrhage patients, 29% were reportedly treated by neurosurgeons, ranging from 5% in Sweden to 79% in Japan, with three neurosurgeons per thousand strokes, ranging from 0.1 in Ethiopia to 24 in South Korea. Most countries had a stroke society (86%) while only 10 (21%) had a degree or subspecialty for stroke medicine. Conclusions Stroke doctor numbers, background specialties, and opportunities to specialize in stroke vary across the globe. Most countries have a scientific society to pursue advancement of stroke medicine, but few have stroke curricula.

Background and Purpose: The prevalence of silent brain infarcts varies from 8% to 28% in the general elderly population. Silent brain infarcts are associated with increased risk of subsequent stroke and cognitive dysfunction. By definition, silent strokes lack clinically overt stroke-like symptoms and fail to come to clinical attention; however, impaired recall of symptoms may be a potential confounder. Our aim is to report a series of patients with incidentally detected acute and subacute strokes and examine whether they were truly asymptomatic., Methods: Subjects included in this study were drawn from ongoing dementia research studies at the Memory Ageing and Cognition Center, in which all participants underwent a cranial MRI. Incidental hyperintense lesions on diffusion-weighted imaging with corresponding apparent diffusion coefficient defects indicative of acute/subacute silent stroke were identified. Clinical data for individuals with incidental hyperintense lesions on diffusion-weighted imaging were collated., Results: Six of 649 subjects had incidental hyperintense lesions on diffusion-weighted imaging; on retrospective questioning, 3 recalled symptoms temporally correlated with MRI lesions, which had been reported to but ignored by family members. Two subjects had focal neurological signs. A majority of the subjects with incidental hyperintense lesions on diffusion-weighted imaging had significant cognitive impairment., Conclusions: A significant number of strokes may be "silent" due to lack of awareness of stroke-like symptoms in the elderly and their families. Enhanced stroke prevention education strategies are needed for the elderly population and, in particular, for their families.

Background and Purpose: Hypothermia is neuroprotective in ischemic stroke models. The influence of baseline body temperature on outcomes after thrombolytic therapy is unclear. We examined outcomes after alteplase treatment across baseline body temperature for patients with ischemic stroke in data held within the Virtual International Stroke Trials Archive (VISTA; 1998 to 2007)., Methods: We collated data on age, baseline severity (National Institutes of Health Stroke Scale), and 90-day modified Rankin Scale score on patients presenting with acute ischemic stroke. We compared 90-day modified Rankin Scale score between thrombolyzed and nonthrombolyzed comparators across baseline body temperature. We report age and baseline National Institutes of Health Stroke Scale-adjusted Cochran-Mantel-Haenszel probability value and proportional OR with 95% CI for improved modified Rankin Scale distribution. We report temperature profiles over 72 hours after stroke by treatment group., Results: Rankin data were available for 5586 patients with acute ischemic stroke in VISTA (1980 received alteplase). Age and baseline severity were similar (age 68.0±13.0 years versus 69.9±12.3 years, National Institutes of Health Stroke Scale 14.2±5.2 versus 13.0±5.6). Alteplase was associated with improved outcome (OR, 1.49; 95% CI, 1.35 to 1.65, P<0.0001). Alteplase treatment effect was not associated with baseline temperature (P=0.14). Point estimates showed benefit of alteplase treatment across 35.5°C to 37.5°C but showed a negative trend >37.5°C. Alteplase did not influence temperature profiles over 72 hours after stroke., Conclusions: There is no evidence of influence of body temperature on alteplase treatment response. These results are reassuring that low temperatures across a physiological range do not compromise therapeutic effect of alteplase.

Background and Purpose: Transient ischemic attack and minor stroke are associated with high ischemic recurrence in the first week. We prospectively studied the correlation between baseline diffusion/perfusion deficits and development of new ischemic lesions., Methods: Patients with transient ischemic attack and those with minor stroke (n=50) underwent MRI at admission. Acute perfusion-weighted imaging deficit (Tmax+2-second delay) and diffusion-weighted imaging (DWI) lesion volumes were measured planimetrically. Follow-up scans were examined for new DWI/fluid-attenuated inversion recovery lesions at Days 7 and 30., Results: Twenty-eight patients (56%) had acute DWI lesions. New DWI lesions developed in 9 of 50 patients (18%) at 1 week and 11 of 50 (cumulative 22%) at 4 weeks. Patients with new infarcts were more likely to have baseline DWI lesions (χ²=8.264, P=0.003). Baseline DWI lesion volume was significantly larger in those who developed new lesions at Day 7 (median, 13.2 mL; interquartile range, 12 versus median 0.1 mL; interquartile range, 2 mL; P<0.001) and Day 30 (11.1 mL; interquartile range, 13 mL versus 0.1 mL; interquartile range, 13 mL; P<0.001). Thirty-eight patients had baseline perfusion-weighted imaging. Patients with recurrent lesions were more likely to have baseline perfusion deficits (χ²=19.5, P<0.0001). All new lesions developed within the baseline hypoperfused regions. Baseline DWI lesion volume predicted new lesion development at day 7 (OR, 1.17 per mL; CI, 1.05 to 1.30; P=0.005) and Day 30 (OR, 1.39 per mL; CI, 1.03 to 1.26; P=0.009) by regression analysis., Conclusions: Early recurrence of stroke is much more likely in patients with larger baseline DWI and perfusion-weighted imaging lesions. MRI lesion "recurrence" appears to be related to completion of the natural history of the original cerebrovascular syndrome rather than de novo events in most patients.

Background and Purpose: The Oxfordshire Community Stroke Project (OCSP) is a common clinical stroke classification tool. We evaluated the accuracy of OCSP classification with a prospective magnetic resonance imaging (MRI) study., Methods: Stroke/transient ischemic attack patients presenting within 48 hours of onset were included in the study (n=130). Following computed tomography scan, OCSP classification, total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), lacunar circulation infarcts (LACI), and posterior circulation infarcts (POCI) were performed by 3 independent examiners. All patients underwent diffusion-weighted MRI with planimetric volume measurement and classification into OCSP categories, organized by lesion location., Results: Patients were clinically classified as TACI (12 patients), PACI (62 patients), LACI (38 patients), and POCI (18 patients). In 101 patients with diffusion-weighted MRI lesions, correct classification rates were: TACI (83.3%), PACI (83%), LACI (39%), and POCI (86%). OCSP had the following sensitivity (SE), specificity (SP), and positive predictive value (PPV): TACI (SE, 100%; SP, 98%; PPV, 83%), PACI (SE, 73%; SP, 78%; PPV, 83%), LACI (SE, 47%; SP, 83%; PPV, 39%), and POCI (SE, 92%; SP, 98%; PPV, 86%). Sixty-one percent of patients in the LACI group had radiographic appearances consistent with PACI, and 15% of those classified as PACI had lacunar infarcts. No differences in stroke severity existed between patients classified correctly (median National Institutes of Health Stroke Scale [NIHSS]=4; interquartile range [IQR]=7) or incorrectly (median NIHSS=3; IQR=3). Patients classified correctly had larger infarct volume (median=6.75 mL; IQR=33.2) than did those who were incorrectly classified (1.86 mL; IQR=5; P=0.008)., Conclusions: OCSP classification does not permit accurate discrimination between lacunar and small-volume cortical infarcts. Differential patterns of investigation for stroke etiology should not be based solely on clinical criteria.

Background and Purpose: Diffusion-weighted MRI (DWI) demonstrates ischemic tissue with high sensitivity. Although low cerebral blood volume (CBV) is also used as a marker for infarction, the quantitative relationship between diffusion abnormalities and CBV is unknown. We tested the hypothesis that CBV would decrease proportionally to the apparent diffusion coefficient in patients with acute stroke and thus could be used as a surrogate parameter for diffusion restriction., Methods: Perfusion-weighted imaging and DWI was performed in 54 patients within 28 hours of symptom onset. Mean apparent diffusion coefficient, cerebral blood flow, and CBV were measured within DWI lesions and contralateral regions., Results: Within DWI lesions, CBV (3.3 ± 1.9 mL/100 g) was significantly decreased relative to contralateral regions (4.1 ± 2.1 mL/100 g, P < 0.001). Relative CBV was not decreased in patients with evidence of early reperfusion (1.2 ± 0.5) or mild stroke (National Institutes of Health Stroke Scale < 4, 1.1 ± 0.6). Linear regression indicated that relative CBV was predictive of relative apparent diffusion coefficient only in patients imaged within 9 hours of symptom onset (R = 0.50, P = 0.02). Ischemic tissue volumes generated using a CBV threshold of the 50th percentile of normal tissue were correlated with DWI lesion volumes (R = 0.73, P < 0.001). The mean difference between the CBV threshold of the 50th percentile of normal tissue and DWI lesion volumes was 6.3 mL (95% limits of agreement, 0.1 to 12.6 mL)., Conclusions: Decreases in relative CBV are predictive of diffusion abnormalities in ischemic stroke. The pattern of CBV changes varies with clinical severity and symptom duration. Ischemic tissue volumes comparable to DWI lesions can be generated using CBV thresholds, but the use of this method is limited in patients with minor stroke.

Hypertension is the most prevalent of the modifiable risk factors for stroke. The benefits of blood pressure (BP) lowering on primary and secondary prevention of stroke are undeniable. Despite this, BP control in hypertensive individuals and patients with prior cerebrovascular events is suboptimal. Noncompliance, inappropriate antihypertensive usage and under-utilization of medications contribute significantly to inadequate BP control. Recently, elegantly designed studies that assessed the preventive role of BP lowering in patients with cerebrovascular disease have helped clarify management issues in terms of BP targets and effective antihypertensive regimens. Current evidence suggests that BP targets for primary and secondary prevention are suboptimal and need reassessment. The effect of BP modulation in acute stroke is still not completely understood. Although the thresholds for BP treatment in acute stroke have been recommended, BP targets are as yet ill-defined. The available evidence supports early lowering of blood pressure following stroke. This review discusses the impact of blood pressure on stroke incidence and outcomes, outlines the recommendations for blood pressure lowering in stroke and delineates questions that still need to be addressed.

Neuroimaging is fundamental to stroke diagnosis and management. Non-contrast computed tomography (NCCT) has been the primary imaging modality utilized for this purpose for almost four decades. Although NCCT does permit identification of intracranial hemorrhage and parenchymal ischemic changes, insights into blood vessel patency and cerebral perfusion are limited. Advances in reperfusion strategies have made identification of potentially salvageable brain tissue a more practical concern. Advances in CT technology now permit identification of acute and chronic arterial lesions, as well as cerebral blood flow deficits. This review outlines principles of advanced CT image acquisition and its utility in acute stroke management.

Background and Purpose: Experimental studies have shown that hyperthermia is a determinant of poor outcome after ischemic stroke. Clinical studies evaluating the effect of temperature on poststroke outcome have, however, been limited by small sample sizes. We sought to evaluate the effect of temperature and timing of hyperthermia on outcome after ischemic stroke., Methods: Data of 5305 patients in acute stroke trials from the Virtual International Stroke Trials Archive (VISTA) data set were analyzed. Data for temperatures at baseline, eighth, 24th, 48th, and 72nd hours, and seventh day were assessed in relation to outcome (poor versus good) based on the modified Rankin Scale at 3 months. Hyperthermia was defined as temperature >37.2 degrees C and poor outcome as 90-day modified Rankin Scale >2. Hazard ratios with 95% CIs were reported for hyperthermia in relation to the outcome. Logistic regression models, in relation to hyperthermia, were fitted for a set of preselected covariates at different time points to identify predictors/determinants of hyperthermia., Results: The average age of patients was 68.0+/-11.9 years, 2380 (44.9%) were females, and 42.3% (2233) received thrombolysis using recombinant tissue plasminogen activator. After adjustment, hyperthermia was a statistically significant predictor of poor outcome. The hazard ratios (95% CI) for poor outcome in relation to hyperthermia at different time points were: baseline 1.2 (1.0 to 1.4), eighth hour 1.7 (1.2 to 2.2), 24th hour 1.5 (1.2 to 1.9), 48th hour 2.0 (1.5 to 2.6), 72nd hour 2.2 (1.7 to 2.9), and seventh day 2.7 (2.0 to 3.8). Gender, stroke severity (National Institutes of Health Stroke Scale score >16), white blood cell count, and antibiotic use were significantly associated with hyperthermia (P< or =0.01)., Conclusions: Hyperthermia, in acute ischemic stroke, is associated with a poor clinical outcome. The later the hyperthermia occurs within the first week, the worse the prognosis. Severity of stroke and inflammation are important determinants of hyperthermia after ischemic stroke. In patients with acute ischemic stroke, aggressive measures to prevent and treat hyperthermia could improve the clinical outcomes.

Worldwide, non-contrast computed tomography (NCCT) has been the imaging modality of choice in acute stroke, primarily due to its accessibility and short acquisition time. However, magnetic resonance imaging (MRI), specifically diffusion-weighted imaging (DWI), is much more sensitive to hyperacute ischemic changes. Multimodal MRI studies provide significantly more pathophysiological and prognostic information than NCCT. Finally, perfusion-weighted MRI permits visualization of the extent of the ischemic penumbra in individual patients. MRI-based penumbral imaging appears to be the most promising approach to expanding the thrombolysis population base to include patients with prolonged symptoms. This article describes advances in MRI techniques and their application to acute stroke management.

Stroke remains one of the leading causes of morbidity and mortality worldwide. Sexual differences in stroke have been recognized, though the mechanisms remain unclear. Women have a unique risk factor profile, especially so in the reproductively active age group. Exposure to oral contraceptives, hormone replacement therapy and a higher incidence of migraine and vasculitic disorders in women suggest that stroke would be common in women. Yet, the incidence of stroke remains higher in men across all ages, indicating a protective role of sex hormones. The differences in incidence and prevalence of stroke decreases as women age, confirming that hormones play a pivotal role in terms of normal physiology, disease and recovery. Recent evidence also points to sex based differences in response to therapy, in terms of acute management and prevention. Gender based differences in accessibility and provision of health care facilities add to the observed differences in terms of stroke outcome, though here women seem to fare worse than men. This review summarizes the observed sex differences in stroke, possible hormonal mechanisms that may explain the same and outlines recent patents and scope for future research in this field.

Background The impact of body mass index on acute ischemic stroke outcomes is unclear. Aims and/or hypothesis We sought to determine the effect of body mass index on short-term (90 days) acute ischemic stroke outcomes. Methods Data were extracted for patients with acute ischemic stroke and records of body mass index at baseline from the Virtual International Stroke Trials Archive database. Multivariate logistic regression and Cox proportional hazard analysis were used to analyze effect of body mass index on poor functional outcome (modified Rankin Scale >2) and mortality, respectively, within 90 days of stroke's onset. Results Of the 4811 patients (mean age 68·8 ± 12·2 years) included in the study, 2002 (41·6%) were overweight, and 1095 (22·8%) were obese. Overweight (body mass index 25-29·9 kg/m2) was associated with decreased mortality (hazard ratios 0·59; 95% confidence interval 0·51-0·68; P < 0·01) and decrease in poor functional outcome (odds ratio 0·74; 95% confidence interval 0·64-0·85; P < 0·01) following acute ischemic stroke. The association of body mass index with stroke outcomes was dependent on age, gender, and use of thrombolytic therapy. Conclusions Being overweight or obese is associated with a better functional outcome and reduced mortality in patients of acute ischemic stroke. However, the definition of an 'optimal' body mass index, in relation to stroke outcomes, may be affected by age, gender, and use of thrombolytic therapy. [ABSTRACT FROM AUTHOR]

The article discusses the case of a 70-year-old woman who exhibited progressive memory disturbance, urinary incontinence, dressing difficulty and gait ataxia for 12 weeks. The woman has not been in a cardiovascular stroke or any stroke-like event or seizure even in her childhood. The article discusses a case of rapid progressive dementia with myclonus and presents a differentiation with Creutzfeldt-Jakob disease.