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Purpose. Stroke has far reaching effects on both stroke survivors and their informal carers. Research has highlighted changes in autonomy of stroke survivors, but insufficient focus has been put on the associated reduced control and independence of their informal carers. This study investigates the experiences of informal carers of stroke survivors from discharge to 3 months later. Method. A purposive sample of 31 informal carers was interviewed in depth just prior to discharge, 1 month and 3 months post-discharge. Interviews lasted 30-90 min and were audio-taped and transcribed. Data analysis was ongoing starting during data collection and ending with themes that described and helped understand carers' experiences. Results. Carers described reductions in their autonomy and independence but also over time identified strategies to manage these changes and to increase control in their lives. These strategies included selection, optimisation, compensation, asking for and accepting help and negotiation. Some carers, especially older carers and those with prior caring experience, were less likely to describe changes in autonomy and control. Conclusions. Carers' reduced autonomy and independence should be recognised by practitioners and service providers. Helping carers to negotiate choice and control over the support offered could help increase their autonomy and independence. To offer improved support to these carers, greater attention should to given to the diversity of their situations and experiences.

Purpose. To examine the support required by family carers for stroke survivors. Methods. Forty-two family carers were recruited for surveys of needs, knowledge, satisfaction, and competence in caring before and 4-6 weeks after discharge from an Acute Stroke Unit (ASU). Results. Information deficits about dealing with psychological, emotional, and behavioural problems and local service information were priorities before and after discharge. Younger female carers (under 56 years) were least satisfied with communication with ASU staff. Face to face contact was valued. After discharge younger female carers, particularly of non-White ethnic groups, reported lower levels of competence in caring and higher burden. Knowledge of stroke risk factors was low in all groups. High satisfaction with treatment and therapy in the ASU, was not transferred to the community. Carers reported feeling alone and described uncoordinated services. Conclusions. Carers are able to anticipate and prioritise their needs, value communication with staff and involvement with discharge-planning, but particular difficulties were experienced by younger female carers and those from non-White ethnic groups. This requires particular attention when developing targeted interventions for family carers from a mixed ethnic community. In-depth and longitudinal studies are needed to detail psychosocial needs and guide practice particularly amongst non-White family carers.

Background and purpose: Posterior circulation stroke accounts for 20% of ischaemic strokes. Recent data suggest that the early stroke recurrence risk is high and comparable with carotid artery disease. Vertebral artery stenosis accounts for approximately 20% of posterior circulation stroke, and with endovascular treatment available accurate diagnostic imaging is important. We performed a systematic literature review to validate the accuracy of the non-invasive imaging techniques Duplex ultrasound (DUS), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) in detecting severe vertebral artery stenosis, with intra-arterial angiography (IAA) as the reference standard. Methods: We identified studies that used non-invasive imaging and IAA as the reference standard to determine vertebral artery stenosis and provided adequate data to calculate sensitivity and specificity. We analysed the quality of these studies, looked for evidence of heterogeneity and performed subgroup analysis for different degrees of stenosis. Results: 11 studies categorised stenosis into 50–99%. The sensitivity of CTA (single study) and pooled sensitivities of contrast enhanced MRA (CE-MRA) and colour duplex were 100% (95% CI 15.8 to 100), 93.9% (79.8 to 99.3) and 70.2% (54.2 to 83.3), respectively. The specificities for CTA, CE-MRA and colour duplex were 95.2% (83.8 to 99.4), 94.8% (91.1 to 97.3) and 97.7% (95.2 to 99.1). However, specificities for CE-MRA and colour duplex demonstrated significant heterogeneity (p = 0.003 and p = 0.002, respectively). Conclusions: CE-MRA and possibly CTA may be more sensitive in diagnosing vertebral artery stenosis than DUS. However, data are limited and further high quality studies comparing DUS, MRA and CTA with IAA are required.

A 67-year-old woman presented with left-sided headache and blurred vision, worse during hypertensive episodes. CT angiography showed a 4 mm left internal carotid artery (ICA) aneurysm incorporating the ophthalmic artery. She passed a test balloon occlusion, so the aneurysm was coil occluded, without immediate complication. Four days postprocedure she experienced sudden loss of vision in the left eye and funduscopy showed central retinal artery occlusion secondary to emboli from the coiled aneurysm. She was treated promptly with intravenous acetazolamide and ocular massage and regained full visual acuity. Thromboembolism to the eye during or after neurointerventional treatment is a relatively rare but devastating complication. This report demonstrates the effectiveness of combined intravenous acetazolamide and ocular massage in dealing with this complication when delivered promptly.

Stenosis of the vertebral artery (VA) in either its extra- or intracranial portions is an important cause of posterior circulation stroke. Diagnosis of VA stenosis by noninvasive imaging techniques is improving and new endovascular and medical treatments are now available. However, the natural history of VA stenotic lesions is not known and its optimum management is unclear. Symptomatic VA stenosis should be initially treated with established antiplatelet agents. There is no proven indication for anticoagulation in cases of VA stenosis. Case series have shown that angioplasty and stenting for proximal extracranial VA stenosis have a low perioperative complication rate and are effective in restoring luminal diameter. Evidence from randomized trials on its long-term efficacy versus medical therapy is not available. Regarding current evidence where symptoms are refractory to antiplatelet treatment, or where recurrent stroke risk is considered increased due to either an incomplete circle of Willis or an anomalous VA circulation, it can be considered in centers with experience of the procedure. Randomized trials comparing stenting with medical therapy are required. Surgery may be a viable alternative to angioplasty and stenting, but only in a few specialist centers. Evidence from randomized controlled trials of medical and other interventions for VA stenosis are required.

Case report: an 83-year-old heterosexual man with malaise tested positive for HIV infection antibodies and has responded well to triple antiretroviral therapy. Discussion: HIV should not be discounted on the basis of age when an elderly patient presents for the investigation of illness.

Background and Purpose— Twin and family history studies support a role for genetic factors in stroke risk. Because the etiology of ischemic stroke is heterogeneous, genetic factors may vary by etiologic subtype. We determined the familial aggregation of stroke risk in different stroke phenotypes and used the results to model estimated sample size requirements for case-control studies. Methods— One thousand consecutive white subjects with ischemic stroke and 800 white controls matched for age and sex were recruited. A first-degree family history of stroke and myocardial infarction was obtained by structured interview. Stroke subtype was determined with the use of modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Results— A family history of stroke at ≤65 years was a significant risk factor for large-vessel disease (odds ratio [OR], 2.24; 95% CI, 1.49 to 3.36; P P =0.003). When only cases aged ≤65 years were considered, these ORs increased to 2.93 (95% CI, 1.68 to 5.13) ( P P Conclusions— A family history of vascular disease is an independent risk factor for both large-vessel atherosclerosis and small-vessel disease, especially in cases presenting before age 65 years. The estimated sample sizes for case-control studies illustrate how candidate gene studies for ischemic stroke might be made more effective by focusing on these specific phenotypes, in which the genetic component of the disease appears to be strongest.

Approximately one‐quarter of ischaemic strokes involve the posterior or vertebrobasilar circulation.1,,2 Stenosis of the vertebral artery can occur in either its extra‐ or intracranial portions, and may account for up to 20% of posterior circulation ischaemic strokes.3–,6 Stenotic lesions, particularly at the origin of the vertebral artery, are not uncommon. In an angiographic study of 4748 patients with ischaemic stroke, some degree of proximal extracranial vertebral artery stenosis was seen in 18% of cases on the right and 22.3% on the left.7 This was the second most common site of stenosis after internal carotid artery stenosis at the carotid bifurcation. Such stenotic lesions are now potentially treatable by endovascular techniques.8 In marked contrast with carotid artery stenosis, the optimal management of vertebral artery stenosis has received limited attention, and is poorly understood. This partly reflects difficulties in imaging the vertebral artery adequately, and limited surgical treatment options. Recent improvements in imaging and the arrival of vertebral artery angioplasty, however, have opened up new opportunities for intervention in this disease. We review vertebral artery anatomy, what is known of the natural history of vertebral artery disease, the role of imaging in the diagnosis of vertebral artery stenosis, and treatments for vertebral artery stenosis. The vertebral artery arises from the supraposterior aspect of the first part of the subclavian artery. In 6% of cases, the left vertebral artery arises directly from the aortic arch. Unlike the internal carotid artery, which is an almost direct extension of its parent vessel the common carotid artery, the vertebral artery branches almost at right angles to its feeding vessel. The vertebral artery, being 3–5 mm in diameter, is of much smaller relative calibre than the subclavian, with only a small amount of subclavian blood flow normally being directed into …

Cerebral mycotic or infective aneurysms are a rare complication of infectious illness, and such aneurysms of the intracavernous portion of the internal carotid artery are rare. They have been described as a consequence of cavernous sinus infection in an immunocompromised host, but not previously in a renal transplant recipient. We present such a case with serial MRI showing progression from arterial narrowing to aneurysm formation. Transcranial Doppler sonography of the middle cerebral artery showed distal asymptomatic embolisation from the aneurysm.

Background Intravenous recombinant tissue plasminogen activator (rtPA) is approved in Europe for use in patients with acute ischaemic stroke who meet strictly defined criteria. IST-3 sought to improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of rtPA in acute ischaemic stroke, and to determine whether a wider range of patients might benefit. Design International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rtPA in acute ischaemic stroke. Suitable patients had to be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracranial haemorrhage and stroke mimics. Results The initial pilot phase was double blind and then, on 01/08/2003, changed to an open design. Recruitment began on 05/05/2000 and closed on 31/07/2011, by which time 3035 patients had been included, only 61 (2%) of whom met the criteria for the 2003 European approval for thrombolysis. 1617 patients were aged over 80 years at trial entry. The analysis plan will be finalised, without reference to the unblinded data, and published before the trial data are unblinded in early 2012. The main trial results will be presented at the European Stroke Conference in Lisbon in May 2012 with the aim to publish simultaneously in a peer-reviewed journal. The trial result will be presented in the context of an updated Cochrane systematic review. We also intend to include the trial data in an individual patient data meta-analysis of all the relevant randomised trials. Conclusion The data from the trial will: improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of iv rtPA in acute ischaemic stroke; provide: new evidence on the balance of risk and benefit of intravenous rtPA among types of patients who do not clearly meet the terms of the current EU approval; and, provide the first large-scale randomised evidence on effects in patients over 80, an age group which had largely been excluded from previous acute stroke trials. Trial registration ISRCTN25765518

Junior doctors have an important role to play in planning a patient’s discharge form hospital

Systemic thrombolysis with rt-PA is contraindicated in patients with acute ischemic stroke anticoagulated with dabigatran. This expert opinion provides guidance on the use of the specific reversal agent idarucizumab followed by rt-PA and/or thrombectomy in patients with ischemic stroke pre-treated with dabigatran. The use of idarucizumab followed by rt-PA is covered by the label of both drugs.

An 80 year old man presented subacutely with drowsiness and confusion. Subsequent MRI brain imaging demonstrated multiple posterior circulation infarcts. Extracranial vasculitis was suspected when his ESR was found to be high and vascular imaging showed multifocal irregular narrowing of both vertebral arteries. This was confirmed by targeted temporal artery biopsy, which showed chronic granulomatous inflammation typical of giant cell arteritis (GCA). The patient made a significant recovery following treatment with prednisolone.

An 80 year old man presented subacutely with drowsiness and confusion. Subsequent MRI brain imaging demonstrated multiple posterior circulation infarcts. Extracranial vasculitis was suspected when his ESR was found to be high and vascular imaging showed multifocal irregular narrowing of both vertebral arteries. This was confirmed by targeted temporal artery biopsy, which showed chronic granulomatous inflammation typical of giant cell arteritis (GCA). The patient made a significant recovery following treatment with prednisolone.

Background Stroke is the most common neurological disability in the UK. Any activity contributes to recovery, but stroke patients can be inactive for > 60% of their waking hours. This problem remains, despite organisational changes and targeted interventions. A new approach to addressing post-stroke inactivity is needed. Experience-based co-design has successfully initiated improvements for patients and staff in other acute settings. Experience-based co-design uses observational fieldwork and filmed narratives with patients to trigger different conversations and interactions between patients and staff to improve health-care services. Objectives To complete a rapid evidence synthesis of the efficacy and effectiveness of co-production as an approach to quality improvement in acute health-care settings; to evaluate the feasibility and impact of patients, carers and staff co-producing and implementing interventions to increase supervised and independent therapeutic patient activity in acute stroke units; and to understand the experience of participating in experience-based co-design and whether or not interventions developed and implemented in two units could transfer to two additional units using an accelerated experience-based co-design cycle. Design A mixed-methods case comparison using interviews, observations, behavioural mapping and self-report surveys (patient-reported outcome measure/patient-reported experience measure) pre and post implementation of experience-based co-design cycles, and a process evaluation informed by normalisation process theory. Setting The setting was two stroke units (acute and rehabilitation) in London and two in Yorkshire. Participants In total, 130 staff, 76 stroke patients and 47 carers took part. Findings The rapid evidence synthesis showed a lack of rigorous evaluation of co-produced interventions in acute health care, and the need for a robust critique of co-production approaches. Interviews and observations (365 hours) identified that it was feasible to co-produce and implement interventions to increase activity in priority areas including ‘space’ (environment), ‘activity’ and, to a lesser extent, ‘communication’. Patients and families reported benefits from participating in co-design and perceived that they were equal and valued members. Staff perceived that experience-based co-design provided a positive experience, was a valuable improvement approach and led to increased activity opportunities. Observations and interviews confirmed the use of new social spaces and increased activity opportunities. However, staff interactions remained largely task focused, with limited focus on enabling patient activity. Behavioural mapping indicated a mixed pattern of activity pre and post implementation of co-designed changes. Patient-reported outcome measure/patient-reported experience measure response rates were low, at 12–38%; pre- and post-experience-based co-design cohorts reported dependency, emotional and social limitations consistent with national statistics. Post-experience-based co-design patient-reported experience measure data indicated that more respondents reported that they had ‘enough things to do in their free time’. The use of experience-based co-design – full and accelerated – legitimised and supported co-production activity. Staff, patients and families played a pivotal role in intervention co-design. All participants recognised that increased activity should be embedded in everyday routines and in work on stroke units. Limitations Communication by staff that enabled patient activity was challenging to initiate and sustain. Conclusions It was feasible to implement experience-based co-design in stroke units. This resulted in some positive changes in unit environments and increased activity opportunities for patients. There was no discernible difference in experiences or outcomes between full and accelerated experience-based co-design. Future work should consider multiple ways to embed increased patient activity into everyday routines in stroke units. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 35. See the NIHR Journals Library website for further project information.