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Ischemic stroke is a serious disease posing significant threats to human health and life, with the highest absolute and relative risks of a poor prognosis following the first occurrence, and more than 90% of strokes are attributable to modifiable risk factors. Currently, machine learning (ML) is widely used for the prediction of ischemic stroke outcomes. By identifying risk factors, predicting the risk of poor prognosis and thus developing personalized treatment plans, it effectively reduces the probability of poor prognosis, leading to more effective secondary prevention. This review includes 41 studies since 2018 that used ML algorithms to build prognostic prediction models for ischemic stroke, transient ischemic attack (TIA), and acute ischemic stroke (AIS). We analyzed in detail the risk factors used in these studies, the sources and processing methods of the required data, the model building and validation, and their application in different prediction time windows. The results indicate that among the included studies, the top five risk factors in terms of frequency were cardiovascular diseases, age, sex, national institutes of health stroke scale (NIHSS) score, and diabetes. Furthermore, 64% of the studies used single-center data, 65% of studies using imbalanced data did not perform data balancing, 88% of the studies did not utilize external validation datasets for model validation, and 72% of the studies did not provide explanations for their models. Addressing these issues is crucial for enhancing the credibility and effectiveness of the research, consequently improving the development and implementation of secondary prevention measures. [ABSTRACT FROM AUTHOR]

Background Data about the clinical benefit from initial low-density lipoprotein cholesterol (LDL-C) reduction with lipid lowering treatment for secondary prevention and risk of major vascular events amongst older as compared with younger individuals treated during routine clinical care are limited. We investigated this in a nationwide cohort. Methods Individuals aged ≥ 50 years with a first-time hospitalisation for a cardiovascular event (index event, including acute coronary syndrome, non-haemorrhagic stroke, transient ischaemic attack and coronary revascularisation), 1 January 2008 to 31 October 2018, who subsequently used lipid lowering treatment, and had an LDL-C measurement before and after the event were included. Hazard ratios (HRs) for major vascular events per 1 mmol/L reduction in LDL-C were estimated for the included 21,751 older and 22,681 younger individuals (≥/<70 years old) using Cox regression. Results LDL-C lowering was associated with a 12% lower risk of major vascular events in older individuals per 1 mmol/L reduction in LDL-C (HR 0.88, 95% confidence interval [CI] 0.84–0.93), with no significant difference compared with the risk reduction amongst younger individuals (HR 0.88, 95% CI 0.83–0.93; P -value for difference between age groups: 0.86). The risk reduction was more pronounced when post hoc restricting, as a proxy for compliance, to new users with an LDL-C reduction above the lowest decile for both older (0.81, 95% CI 0.73–0.90) and younger (0.81, 95% CI 0.72–0.91) individuals. Conclusions This study strongly supports a similar relative clinical benefit of LDL-C reduction with lipid lowering treatment for secondary prevention of major vascular events amongst individuals aged ≥70 and <70 years. [ABSTRACT FROM AUTHOR]

Background: To assess quality of life and unmet needs after stroke, patient-reported outcome measures (PROMs) have gained increasing attention. However, patients' perspectives on assessing PROMs remain unclear, potentially hindering implementation into clinical practice. Therefore, this study explored patients' preferences on assessing PROMs after ischemic stroke. Methods: A paper-based questionnaire was sent to stroke survivors treated at the Department of Neurology, University of Leipzig, Germany. Health-related quality of life (HRQoL, EQ-5D-5L) and preferences regarding different aspects of data collection to assess PROMs were investigated and linked to socio-demographic and medical characteristics. Results: 158 persons were contacted and 80 replies were subsequently analyzed. Mean age was 70.16 years and mean HRQoL was 68.79 (visual analogue scale with a theoretical maximum of 100). Participants showed positive attitudes towards PROMs as they saw potential to improve care of other patients (n = 66/79; 83.54%) or to improve their own situation (n = 53/74; 71.62%). Participants preferred an annual interview after stroke (n = 39/80; 48.75%) and would preferably spend 15–30 min (n = 41/79; 51.90%) to answer a written survey (n = 69/80; 86.25%). The initially treating clinic was preferred as initiator of such surveys (n = 43/79; 54.43%). Stratification revealed that participants with more than 1 h of daily digital media usage preferred email as way of communication. Conclusions: For the first time, this study showed individual preferences on assessing PROMs after ischemic stroke, focusing on the way, time interval, duration, and initiation site of surveys. These insights might help to successfully implement PROMs after stroke and subsequently detect unmet needs and deficits in stroke care. [ABSTRACT FROM AUTHOR]

Background: National organisational surveys and clinical audits to monitor and guide improvements to the delivery of evidence-based acute stroke care have been undertaken in Australia since 1999. This study aimed to determine the association between repeated national audit cycles on stroke service provision and care delivery from 1999 to 2019. Methods: Cross-sectional study using data from organisational surveys (1999, 2004, 2007–2019) and clinical data from the biennial National Stroke Acute Audit (2007–2019). Age-, sex-, and stroke severity-adjusted proportions were reported for adherence to guideline-recommended care processes. Multivariable, logistic regression models were performed to determine the association between repeated audit cycles and service provision (organisational) and care delivery (clinical). Results: Overall, 197 hospitals provided organisational survey data (1999–2019), with 24,996 clinical cases from 136 hospitals (around 40 cases per audit) (2007–2019). We found significant improvements in service organisation between 1999 and 2019 for access to stroke units (1999: 42%, 2019: 81%), thrombolysis services (1999: 6%, 2019: 85%), and rapid assessment/management for patients with transient ischaemic attack (1999: 11%, 2019: 61%). Analyses of patient-level audits for 2007 to 2019 found the odds of receiving care processes per audit cycle to have significantly increased for thrombolysis (2007: 3%, 2019: 11%; OR 1.15, 95% CI 1.13, 1.17), stroke unit access (2007: 52%, 2019: 69%; OR 1.15, 95% CI 1.14, 1.17), risk factor advice (2007: 40%, 2019: 63%; OR 1.10, 95% CI 1.09, 1.12), and carer training (2007: 24%, 2019: 51%; OR 1.12, 95% CI 1.10, 1.15). Conclusions: Between 1999 and 2019, the quality of acute stroke care in Australia has improved in line with best practice evidence. Standardised monitoring of stroke care can inform targeted efforts to reduce identified gaps in best practice, and illustrate the evolution of the health system for stroke. [ABSTRACT FROM AUTHOR]

Stroke patients discharged home often require prolonged assistance from caregivers. Little is known about the real-world effectiveness of a comprehensive stroke transitional care intervention on relieving caregiver strain. To describe the effect of the COMPASS transitional care (COMPASS-TC) intervention on caregiver strain and characterize the types, duration, and intensity of caregiving. The cluster-randomized COMPASS pragmatic trial evaluated the effectiveness of COMPASS-TC versus usual care with patients with mild stroke and TIA at 40 hospitals in North Carolina, USA. Of 5882 patients enrolled, 4208 (71%) identified a familial caregiver. A follow-up Caregiver Questionnaire, including the Modified Caregiver Strain Index, was administered at approximately three months post-discharge. Demographics and frequency, duration, and intensity of caregiving were compared between groups. 1228 caregivers (29%) completed the questionnaire. Completion was positively associated with older patient age, white race, and spousal relationship. One-third of the caregivers provided ≥30 hours of care per week and 889 (79%) provided care ≥9 weeks. Average standardized caregiver strain was 21.9 (0–100), increasing with stroke severity and comorbidity burden. Women caregivers reported higher strain than men. Treatment allocation was not associated with caregiver strain. This sample of mild stroke and TIA survivors received significant assistance from familial caregivers. However, caregiver strain was relatively low. Findings support the importance of familial caregiving in stroke, the continued disproportionate burden on women within the family, and the need for future research on caregiver support. [ABSTRACT FROM AUTHOR]

Objectives: To compare processes of care and clinical outcomes of community‐based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia. Design: Inception cohort study between 2012 and 2016 with 12‐month follow‐up after index event (sub‐study of INSIST). Setting: Hunter and Manning valley regions of New South Wales, within the referral territory of the John Hunter Hospital Acute Neurovascular Clinic (JHHANC). Participants: Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care. Main Outcome Measures: Processes of care (referrals, key management processes, time‐based metrics) and clinical outcomes. Results: Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to a JHHANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p < 0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants. Conclusions: Although TIAMS prognosis in rural settings where solely GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patients. [ABSTRACT FROM AUTHOR]

Objectives: To describe the clinical characteristics and outcomes of Code Stroke activations in an ED and determine predictors of a final diagnosis of stroke or transient ischemic attack (TIA) diagnosis. Methods: This was a retrospective analysis of Code Stroke activations through an ED over 2 years at a quaternary stroke referral centre. Stroke Registry data was used to identify cases with clinical information abstracted from electronic medical records. The primary outcome was a final diagnosis of acute stroke or TIA and the secondary outcome was access to reperfusion therapies (thrombolysis and or endovascular clot retrieval). Results: The study analysed data from 1354 Code Stroke patients in ED. Of all Code Strokes, 51% had a stroke or TIA diagnosis on discharge. Patient characteristics independently associated with increased risk of stroke were increasing age, pre‐arrival notification by ambulance, elevated BP or presence of weakness or speech impairment as the initial presenting symptoms. Dizziness/vertigo/vestibular neuritis were the most common alternative diagnoses. One hundred and thirty‐five patients (10%) underwent reperfusion therapy. Pre‐arrival notification by ambulance was associated with higher proportion of eventual stroke/TIA diagnosis (68% vs 46%, P < 0.001) and significantly lower door to CT and door to needle times for patients undergoing thrombolysis. Conclusions: In a cohort of patients requiring Code Stroke activation in an ED, increased age, systolic blood pressure and weakness and speech impairment increased the risk of stroke. Prehospital notification was associated with lower door to needle times for patients undergoing thrombolysis. [ABSTRACT FROM AUTHOR]

This study has been undertaken to evaluate the effect of butylphthalide combined with ozagrel sodium on cerebral perfusion and oxidative stress indexes in patients with transient ischemic attack. In this study, a total of 116 patients diagnosed as transient ischemic attack in our hospital (February 2018-February 2020) have been selected and divided into two groups according to the treatment methods.58 cases in the control group have been treated with ozagrel sodium, 58 cases in the observation group have been treated with butylphthalide combined with ozagrelsodium. The CT perfusion imaging parameters, oxidative stress indexes, plaque area, and the levels of platelet activating factor (PAF), α-granule membrane protein-140 (GMP-140), fibrinogen (FIB), platelet aggregation rate (PAgT), neuron-specific enolase (NSE), oxygen-inducible factor-1α ( HIF-1α ), and matrix metalloproteinases-9 ( MMP-9) in the two groups have been recorded, and the total effective rate and adverse reaction rate have been counted. The results shown that the total effective rate of the observation group is higher than that of the control group, and the difference is statistically significant (Χ² = 4.640, P = 0.031). The average time (MTT) required for the two groups of contrast agents to pass through the local brain tissue and the time (TTP) required starting the injection of contrast agents to reach the peak concentration decreased compared to that with before treatment. After treatment, the MTT and TTP of the observation group are shorter than those of the control group (P < 0.05). Compared with before treatment, superoxide dismutase (SOD) in the two groups has higher than that in the control group, PAF, GMP-140, FIB, PAgT, NSE, HIF-1α, MMP-9, malondialdehyde (MDA) and plaque area has decreased. After treatment, the levels of related factors in the observation group are better than those in the control group, and the plaque area is less than that in the control group (P < 0.05).There has been no significant difference in the adverse reaction rate between the observation group and the control group (Χ² = 0.438, P = 0.508). [ABSTRACT FROM AUTHOR]

Computed tomography identifies patients at high risk for stroke after transient ischemic attack/nondisabling stroke: prospective, multicenter cohort study. See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.221415 KEY POINTS Patients with suspected cerebral ischemia should be urgently assessed to distinguish between transient ischemic attack (TIA), minor stroke or mimics such as migraine, seizure, vertigo or syncope. The Canadian TIA Score can be used to determine risk for early subsequent stroke in patients with a suspected TIA or minor stroke. The Canadian TIA Score (Figure 2) has been derived and validated in 2 large, multicentre cohort studies to accurately stratify patients with TIA or minor stroke as low-, medium- or high-risk for a subsequent stroke within 7 days.[16],[17] Low-risk patients have a risk of less than 1%, medium-risk patients have a 1%-5% risk and high-risk patients have a risk of more than 5% for a subsequent stroke within 7 days. [Extracted from the article]

Atherosclerosis at the carotid bifurcation in the neck is common and the result of turbulent hemodynamics in the bulb. Carotid bulb plaques cause disabling strokes. Carotid vessel wall imaging characterizes the atherosclerotic plaque, documents disease progression, and assesses lesion severity by plaque morphology in addition to the degree of stenosis. This in turn optimizes treatment selection for the individual patient. The aim of vessel wall imaging in patients of stroke is to distinguish stable plaques that may be conserved with best medical management from unstable or vulnerable plaques that require more aggressive medical treatment, carotid stenting, or carotid endarterectomy. Growing evidence suggests that depending on luminal stenosis measurements alone for management decisions will result in underestimating a number of plaques whose size may be small, but where the plaque morphology is unstable, there is a high likelihood of the patient developing a thromboembolic stroke in the near future. In today's context of aggressive management of even transient ischemic attacks and minor strokes, vessel wall imaging should be particularly performed in cryptogenic strokes without significant luminal narrowing on angiography to identify a subset of patients with nonstenotic but unstable atherosclerotic plaques that may be covert etiologies of stroke. If patients receiving the best medical management have recurrent strokes on the same side as a carotid plaque with "vulnerable" plaque features, they may deserve surgical or endovascular intervention even if they do not meet the conventional stenosis thresholds. Improved techniques for stroke imaging and consequent management have a remarkable effect in decreasing individual and public health burdens. [ABSTRACT FROM AUTHOR]

Background: Ischemic and hemorrhagic cerebrovascular accidents remain common among patients with centrifugal-flow left ventricular assist devices, despite improvements in survival and device longevity. We compared the incidence of neurologic adverse events (NAEs) associated with 2 contemporary centrifugal-flow left ventricular assist devices: the Abbott HeartMate3 (HM3) and the Medtronic HeartWare HVAD (HVAD).Methods: Using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs), we collected data on adult patients who received a centrifugal-flow left ventricular assist device as a primary isolated implant between January 1, 2017, and September 30, 2019. Major NAEs were defined as transient ischemic attack, ischemic cerebrovascular accident, or hemorrhagic cerebrovascular accident. The association of HVAD with risk of NAE in the first year after implant was evaluated using propensity score matching to balance for preimplant risk factors. After matching, freedom from first major NAE in the HM3 and HVAD cohorts was compared with Kaplan-Meier curves. A secondary analysis using multivariable multiphase hazard models was used to identify predictors of NAE, which uses a data-driven parametric fit of the early declining and constant phase hazards and the associations of risk factor with either phase.Results: Of 6205 included patients, 3129 (50.4%) received the HM3 and 3076 (49.6%) received the HVAD. Median follow-up was 9 and 12 months (HM3 and HVAD, respectively). Patients receiving HVAD had more major NAEs (16.4% versus 6.4%, P<0.001) as well as each subtype (transient ischemic attack: 3.3% versus 1.0%, P<0.001; ischemic cerebrovascular accident: 7.7% versus 3.4%, P<0.001; hemorrhagic cerebrovascular accident: 7.2% versus 2.0%, P<0.001) than did patients receiving HM3. A propensity-matched cohort balanced for preimplant risk factors showed that HVAD was associated with higher probabilities of major NAEs (% freedom from NAE 82% versus 92%, P<0.001). Device type was not significantly associated with NAEs in the early hazard phase, but HVAD was associated with higher incidence of major NAEs during the constant hazard phase (hazard ratio, 5.71 [CI, 3.90-8.36]).Conclusions: HM3 is associated with lower hazard of major NAEs than is HVAD beyond the early postimplantation period and during the constant hazard phase. Defining the explanation for this observation will inform device selection for individual patients. [ABSTRACT FROM AUTHOR]

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability.Methods: QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA).Results: Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team's self-efficacy to improve quality of care. Guided by the TFA, the QI teams' acceptability was represented by the respective seven components of the multifaceted acceptability construct.Conclusions: Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.Trial Registration: clinicaltrials.gov : NCT02769338 . [ABSTRACT FROM AUTHOR]

Post-traumatic stress disorder (PTSD) can develop after a life-threatening medical event. According to the enduring somatic treat (EST) model, internal somatic cues (e.g., rapid heart rate) may contribute to symptoms of stroke/TIA-induced PTSD. To address this possibility, the present study tested the association of stroke-induced disability with PTSD symptoms in patients treated for stroke or transient ischemic attack (TIA). Participants (n = 300) were drawn from an observational cohort study examining PTSD symptoms in patients admitted to the NewYork Presbyterian Hospital between 2015 and 2017 for a stroke/TIA. Patients self-reported acute stress symptoms in-person approximately 3 days post-stroke/TIA and PTSD symptoms via telephone one month later. Severity of stroke symptoms (i.e., stroke disability) was evaluated using the NIH Stroke Scale prior to hospital discharge. Stroke disability had a significant, positive association with acute stress symptoms early post-stroke/TIA, B = 0.46, se = 0.15, p =.002, and with PTSD symptoms one month later, B = 0.56, se = 0.19, p =.003. Stroke disability is positively associated with both acute distress and PTSD symptoms one month later following a stroke/TIA, supporting the hypothesis that internal somatic symptoms contribute to the development stroke/TIA-induced PTSD symptoms. [ABSTRACT FROM AUTHOR]

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA).Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019).Design: A stepped-wedge implementation trial with six geographically diverse sites.Participants: The six facility QI teams were multi-disciplinary, clinical staff.Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback.Main Measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year.Key Results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation.Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.Trial Registration: clinicaltrials.gov: NCT02769338. [ABSTRACT FROM AUTHOR]

Tetramethylpyrazine (TMP) has been widely used in ischemic stroke in China. The regulation of neuroplasticity may underlie the recovery of some neurological functions in ischemic stroke. Middle cerebral artery occlusion (MCAO) model was established in this study. Rats were divided into three groups: sham group, model group, and TMP group. The neurological function was evaluated using modified neurological severity score (mNSS). Following the neurological function test, expression of synaptophysin (SYP) and growth-associated protein 43 (GAP-43) were analyzed through immunohistochemistry at 3 d, 7 d, 14 d, and 28 d after MCAO. Finally, the synaptic structural plasticity was investigated using transmission electron microscopy (TEM). The TMP group showed better neurological function comparing to the model group. SYP levels increased gradually in ischemic penumbra (IP) in the model group and could be enhanced by TMP treatment at 7 d, 14 d, and 28 d, whereas GAP-43 levels increased from 3 d to 7 d and thereafter decreased gradually from 14 d to 28 d in the model group, which showed no significant improvement in the TMP group. The results of TEM showed a flatter synaptic interface, a thinner postsynaptic density (PSD), and a wider synaptic cleft in the model group, and the first two alterations could be ameliorated by TMP. Then, a Pearson's correlation test revealed mNSS markedly correlated with SYP and synaptic ultrastructures. Taken together, TMP is capable of promoting functional outcome after ischemic stroke, and the mechanisms may be partially associated with regulation of neuroplasticity. [ABSTRACT FROM AUTHOR]

Background: Transient ischaemic attack (TIA) is a transient episode of neurological dysfunction. Rapid access TIA clinics have been set up as integrated 'one-stop' clinics that aim to investigate, diagnose, educate and implement treatment to reduce the risk of further TIA/stroke.Objective: This study aimed to examine how TIA consultations were conducted by observing the consultations and then interviewing patients.Methods: This ethnographic study observed fifteen patient-clinician consultations where a diagnosis of TIA was made within three different TIA outpatient clinics in the East Midlands. All fifteen patients, their accompanying family-members/carers and three stroke clinicians were interviewed. Data analysis was informed by the constant comparative approach.Results: There was considerable variation in the conduct of these consultations across sites and clinicians. This resulted in variation in patient experience and knowledge after the consultation including the ability to recognize TIA-associated risk factors and their management. As TIA symptoms resolve, patients may reduce their need to seek health care services in addition to demonstrating reduced concordance with secondary stroke prevention. Health professionals recognize that this single appointment provides patients with a large amount of information which may be difficult to process. Importantly, there was little discussion about future symptoms and how to respond. A management plan, which considered a patient's health belief, knowledge and encouraged the involvement of family members, improved information recall.Conclusions: TIA is a complex medical diagnosis with multiple risk factors that may make the management complex and hence difficult for patients to undertake. Our findings found variability in the conduct, provision of information and patient understanding. Guidance on nationally agreed consultation framework may prove useful. Improved patient education may include individualized/sustained education utilizing multidisciplinary team members across family/primary and secondary care, video or greater online education and improved general public education. [ABSTRACT FROM AUTHOR]

Objective: The Victorian Emergency Minimum Dataset (VEMD) collects administrative and clinical data for all presentations to Victorian public ED. The present study aimed to examine the level of agreement between the VEMD data and the medical record for a sample of patients coded as having acute cardiovascular conditions (acute coronary syndrome, stroke and transient ischaemic attack [TIA]) and unspecified chest pain in the VEMD. Methods: Six months of data provided to the VEMD from a large metropolitan hospital was obtained, and a random sample of 10% of cases (n = 310) were selected for review. Data for eight VEMD items were compared for concordance to data recorded in the ED medical record. Results: Complete concordance between the VEMD and medical records for all eight items was observed only for 101 (33%) presentations. Overall, the least concordant variables were those with a high number of coding options: usual type of accommodation (76%), referral pattern (84%) and primary diagnosis (85%). The concordance of the VEMD primary diagnosis varied when examined as individual codes (range 75%–100%) and when combined (acute coronary syndrome = 94%, stroke or TIA = 85% and chest pain unspecified = 75%). The level of agreement for some items improved when VEMD codings were combined. Conclusion: When compared to the medical record, our data suggest there is likely variation in the accuracy of some VEMD items, and suggests a larger prospective validation of the VEMD is warranted. For researchers using existing VEMD data, combining of some codes may be necessary. [ABSTRACT FROM AUTHOR]

Background: Evidence about how primary care can best enable survivors of transient ischaemic attack (TIA)/stroke return to work is limited.Aim: This study explored the role of primary care in supporting survivors of transient ischaemic attack (TIA)/stroke return to work with stakeholders from a local UK community.Design: A qualitative study using framework analysis.Method: Four focus groups were carried out in Cambridgeshire, UK, between September and November 2015. The 18 participants included survivors of TIA/stroke, carers, an employer representative, GPs, occupational therapists (OTs), and clinical commissioners.Results: There was a mismatch between patient and carer needs and what is provided by primary care. This included: lack of GP awareness of invisible impairments; uncertainty how primary care could help in time-limited consultations; and complexity of return-to-work issues. Primary care physicians were not aware of relevant services they could refer patients to, such as OT support. In addition, there was an overall lack of coordination between different stakeholders in the return-to-work process. Linking with other services was considered important but challenging because of ongoing changes in service structure and the commissioning model. Suggestions for improvement include: a central contact in primary care for signposting to available services; a rehabilitation assessment integrated with the electronic record; and a patient-held shared-care plan at discharge from stroke wards.Conclusion: Improving the role for primary care in helping survivors of TIA/stroke return to work is challenging. However, primary care could play a central role in initiating/coordinating vocational rehabilitation. Through focus group discussions with stakeholders from a local community, patients, carers, and clinical commissioners were able to put forward concrete proposals to address the barriers identified. [ABSTRACT FROM AUTHOR]

Objective: To assess the quality of medication optimization for transient ischemic attack (TIA) and minor stroke patients across the Veterans Health Administration (VHA), and to identify characteristics predicting medication optimization for hypertension, hyperlipidemia, and diabetes. The scope of this study focuses on these three medication‐related conditions and defines optimization as medication changes or additions made within a guideline‐defined timeframe. Methods: We constructed a retrospective cohort including all patients discharged with a TIA or minor stroke (index event) in any VHA Emergency Department (ED) or inpatient setting during fiscal year 2011. Inpatient and outpatient medical/pharmacy data were collected from a variety of electronic health sources for 1 year prior to and up to 90 days after discharge. Medication optimization for hypertension, hyperlipidemia, and diabetes was defined using relevant VHA and American Heart Association/American Stroke Association guidelines. For each of the three medication‐based outcomes, multivariable logistic regression models examined demographic, past medical history, and other clinical variables to identify predictors of optimization. Results: Among 8427 patients, 33.7% (n = 2837) were eligible for medication optimization for hypertension, 55.2% (n = 4655) for hyperlipidemia, and 7.2% (n = 606) for diabetes. Guideline‐concordant medication optimization occurred for 28% of eligible patients with hypertension, 28% of patients with hyperlipidemia, and 34% of patients with diabetes. Factors that were associated with medication optimization included younger age, inpatient stay (vs discharge from the ED), greater baseline disease severity (higher blood pressure, low‐density lipoprotein [LDL] cholesterol, or hemoglobin A1c [glycated hemoglobin]), and primary care follow‐up within 30 days after the index event. Conclusion: One‐third or fewer eligible patients with TIA or minor stroke had their medications optimized in a timely manner in concordance with evidence‐based guidelines. Interventions to improve timely medication optimization are needed to reduce the risk of recurrent vascular events in this high‐risk population. [ABSTRACT FROM AUTHOR]

Objectives. Stroke is a common condition after a transient ischemic attack (TIA) or minor ischemic stroke (IS). Adding clopidogrel to aspirin may yield more beneficial outcomes than aspirin mono-therapy; meanwhile, the risk of bleeding in the acute phase remains poorly understood. Therefore, there is increasing emphasis on the risks and benefits of clopidogrel with aspirin compared with aspirin mono-therapy in an effort to treat TIA/IS. Design. We searched several electronic databases, including PubMed, Cochrane, and Embase, to identify eligible randomized controlled trials (RCTs) based on the index words comparing dual-antiplatelet therapy to aspirin mono-therapy for secondary stroke prevention updated to December, 2018. Results. A total of 11 RCTs met our inclusion criteria. The pooled analysis showed that clopidogrel plus aspirin was associated with a trend toward a reduction in recurrent IS (RR = 0.72, 95%CI = 0.65-0.81, p < .001), but not the recurrent stroke rate (RR = 0.81, 95% CI = 0.63-1.03, p = .09) than aspirin mono-therapy. There were differences in bleeding episodes (RR = 1.81, 95%CI = 1.65-1.99, p < .001), moderate-severe major bleeding (RR = 1.64, 95% CI = 1.24-2.16, p = .0005), or mild bleeding (RR = 2.25, 95%CI = 1.54-3.31, p < .001) between the study groups. Meanwhile, no benefit of reducing the risk of intracranial hemorrhage with dual-antiplatelet therapy was found in TIA/IS patients (RR = 1.44, 95% CI = 0.95-2.19, p = .09). Conclusions. The addition of clopidogrel to aspirin for patients with TIA or IS appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone. [ABSTRACT FROM AUTHOR]

Background: National guidelines recommend patients with suspected transient ischaemic attack (TIA) should be seen by a specialist within 24 h. However, people with suspected TIA often present to non-specialised services, particularly primary care. Therefore, general practitioners (GPs) have a crucial role in recognition and urgent referral of people with suspected TIA. This study aims to explore the role of GPs in the initial management of suspected TIA in the United Kingdom (UK). Methods: One-to-one, semi-structured interviews with GPs, TIA clinic staff and patients with suspected TIA from two sites in the UK: Cambridge and Birmingham. Thematic analysis was undertaken to explore views on the role of the GP in managing suspected TIA. Thirty semi-structured interviews were conducted with stroke patients (n = 12), GPs (n = 9) and TIA clinic hospital staff (n = 9) from two hospitals and nine GP practices in surrounding areas. Results: Three overarching themes were identified: (1) multiple management pathways for suspected TIA; (2) uncertainty regarding suspected TIA as an emergency or routine situation; and (3) influences on the urgency of GP management. Conclusions: Guidelines on the primary care management of TIA describe only a small proportion of the factors which influence GP management and referral of suspected TIA. Efforts to improve treatment, appropriate referral and patient experience should use a real rather than idealised model of the GP role in managing suspected TIA. [ABSTRACT FROM AUTHOR]

Objective To investigate the safety of triple antiplatelet therapy (TaT) with cilostazol in patients undergoing stenting for extracranial and/or intracranial artery stenosis. Methods a prospectively collected database was reviewed to identify patients who underwent stenting for extracranial and/or intracranial artery stenosis and showed resistance to aspirin and/or clopidogrel as assessed by pre-stenting thromboelastography (Teg) testing. Patients were assigned to a TaT group and a dual antiplatelet therapy (DaT) group. Major complications were defined as thromboembolic events (transient ischemic attack (Tia), ischemic stroke, and stent thrombosis) or major bleeding events within 30 days, and minor complications were defined as extracranial bleeding that did not require vascular surgery or transfusion within 30 days. results a total of 183 patients were identified. The incidence of major complications was significantly lower in the TaT group than in the DaT group (TaT group vs. DaT group, 1/110 vs. 6/73; P=0.017). Tias occurred in four patients, with one in the TaT group and three in the DaT group (1/110 vs. 3/73; P=0.303). ischemic strokes occurred in three patients in the DaT group (TaT group vs. DaT group, P=0.062). no major bleeding events or stent thrombosis was recorded in either group. Two patients (one in each group) experienced minor complications that resolved without additional treatment (1/110 vs. 1/73; P>0.999). Conclusions TaT under Teg guidance appears to be a safe antiplatelet strategy in patients undergoing stenting for extracranial and/or intracranial artery stenosis. By employing TaT under Teg guidance, favorable outcomes can be achieved in these patients. [ABSTRACT FROM AUTHOR]

Background: Most patients with transient ischaemic attack (TIA) present to their GP. Early identification and treatment reduces the risk of subsequent stroke and consequent disability and mortality.Objective: To explore GPs' views on the diagnosis and immediate management of suspected TIA, and the potential utility of a diagnostic tool.Methods: This is a qualitative interview study based in Leicestershire, UK. A purposive sample of 10 GPs participated in 30-minute semi-structured telephone interviews. Data were analysed thematically.Results: GPs reported that TIA was more likely to be suspected when patients were more obvious candidates for TIA based on their history, characteristics and symptom presentation. Referrals were in part a strategy to manage risk under conditions of uncertainty and to seek reassurance. GPs valued using a TIA risk stratification tool but felt this did not inform their diagnostic decision making. A diagnostic tool for TIA in primary care was seen to have potential to improve the decision-making process about diagnosis and management and enhance confidence of GPs, particularly in ruling out TIAs. GPs saw benefits of using hard thresholds, but remained concerned about missing TIAs and saw a tool as an adjunct to clinical judgement.Conclusions: GPs weigh up the likelihood of TIA in the context of assessments of candidacy and diverse, often vague, symptoms. A diagnostic tool could support GPs in this process and help reduce reliance on referrals to TIA clinics for reassurance, provided the tool was designed to support decision making in cases of less 'typical' presentations. [ABSTRACT FROM AUTHOR]

Background: Predictors of recurrent ischemic stroke are less well known in patients with a recent ischemic stroke than in patients with transient ischemic attack (TIA). We identified clinical and radiological factors for predicting recurrent ischemic stroke in patients with recent ischemic stroke. Methods: A systematic search in PubMed, Embase, Cochrane Library, and CINAHL was performed with the terms “ischemic stroke,” “predictors/determinants,” and “recurrence.” Quality assessment of the articles was performed and the level of evidence was graded for the articles included for the meta-analysis. Pooled risk ratios (RR) and heterogeneity (I2) were calculated using inverse variance random effects models. Results: Ten articles with high-quality results were identified for meta-analysis. Past medical history of stroke or TIA was a predictor of recurrent ischemic stroke (pooled RR 2.5, 95% CI 2.1–3.1). Small vessel strokes were associated with a lower risk of recurrence than large vessel strokes (pooled RR 0.3, 95% CI 0.1–0.7). Patients with stroke of an undetermined cause had a lower risk of recurrence than patients with large artery atherosclerosis (pooled RR 0.5, 95% CI 0.2–1.1). We found no studies using CT or ultrasound for the prediction of recurrent ischemic stroke. The following MRI findings were predictors of recurrent ischemic stroke: multiple lesions (pooled RR 1.7, 95% CI 1.5–2.0), multiple stage lesions (pooled RR 4.1, 95% CI 3.1–5.5), multiple territory lesions (pooled RR 2.9, 95% CI 2.0–4.2), chronic infarcts (pooled RR 1.5, 95% CI 1.2–1.9), and isolated cortical lesions (pooled RR 2.2, 95% CI 1.5–3.2). Conclusions: In patients with a recent ischemic stroke, a history of stroke or TIA and the subtype large artery atherosclerosis are associated with an increased risk of recurrent ischemic stroke. Predictors evaluated with MRI include multiple ischemic changes and isolated cortical lesions. Predictors of recurrent ischemic stroke concerning CT or ultrasound have not been published. [ABSTRACT FROM AUTHOR]

The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system. [ABSTRACT FROM AUTHOR]

Background Transient ischemic attack incurs a risk of recurrent stroke that can be dramatically reduced by urgent guideline-recommended management at the point of first medical contact. Aims This study describes the prevalence and associations of new transient ischemic attack presentations to general practice registrars and the management undertaken. Methods A cross-sectional analysis of the Registrar Clinical Encounters in Training cohort study. General practice registrars from five Australian states (urban to very remote practices) collected data on 60 consecutive patient encounters during each of their three six-month training terms. The proportion of problems managed being new transient ischemic attacks and proportion of transient ischemic attacks with guideline-recommended management were calculated. Univariate and multivariable logistic regression established associations of patient, registrar, and practice factors with a problem being a new transient ischemic attack. Results A total 1331 general practice registrars contributed data (response rate 95.8%). Of the 250,625 problems, there were 65 new transient ischemic attacks diagnosed (0.03% [95% confidence interval: 0.02–0.03%]). General practice registrars were more likely to seek help, generate learning goals, and spend more time for a new transient ischemic attack compared to other problems. Compliance with management guidelines was modest: 15.4% ordered brain and arterial imaging, 36.9% prescribed antiplatelet medication, and 3.1% prescribed antihypertensive medication. Conclusions Transient ischemic attack is a very infrequent presentation for general practice registrars, giving little clinical opportunity to reinforce training program education regarding guideline-recommended management. General practice registrars found transient ischemic attacks challenging and management was not ideal. Since most transient ischemic attacks first present to general practice and urgent management is essential, an enhanced model of care utilizing rapid access to specialist transient ischemic attack support and follow-up could improve guideline compliance. [ABSTRACT FROM AUTHOR]

Introduction: Our goal was to assess whether use of a standardized clinical protocol improves efficiency for patients who present to the emergency department (ED) with symptoms of transient ischemic attack (TIA). Methods: We performed a structured, retrospective, cohort study at a large, urban, tertiary care academic center. In July 2012 this hospital implemented a standardized protocol for patients with suspected TIA. The protocol selected high-risk patients for admission and low/intermediate-risk patients to an ED observation unit for workup. Recommended workup included brain imaging, vascular imaging, cardiac monitoring, and observation. Patients were included if clinical providers determined the need for workup for TIA. We included consecutive patients presenting during a six-month period prior to protocol implementation, and those presenting between 6-12 months after implementation. Outcomes included ED length of stay (LOS), hospital LOS, use of neuroimaging, and 90-day risk of stroke or TIA. Results: From 01/2012 to 06/2012, 130 patients were evaluated for TIA symptoms in the ED, and from 01/2013 to 06/2013, 150 patients. The final diagnosis was TIA or stroke in 45% before vs. 41% after (p=0.18). Following the intervention, the inpatient admission rate decreased from 62% to 24% (p<0.001), median ED LOS decreased by 1.2 hours (5.7 to 4.9 hours, p=0.027), and median total hospital LOS from 29.4 hours to 23.1 hours (p=0.019). The proportion of patients receiving head computed tomography (CT) went from 68% to 58% (p=0.087); brain magnetic resonance (MR) imaging from 83% to 88%, (p=0.44) neck CT angiography from 32% to 22% (p=0.039); and neck MR angiography from 61% to 72% (p=0.046). Ninety-day stroke or recurrent TIA among those with final diagnosis of TIA was 3% for both periods. Conclusion: Implementation of a TIA protocol significantly reduced ED LOS and total hospital LOS. [ABSTRACT FROM AUTHOR]

A series of pyrano[3,2- a ]carbazole alkaloids were designed and synthesized as analogues of Claulansine F (Clau F, 10a ) isolated from Clausena lansium . Some of compounds showed strong neuroprotective effects and were promising agents against ischemic stroke. Among these compounds, 7c was the most active in inhibiting the programmed death of PC12 cells and primary cortical neurons. This compound induced neuroprotection following ischemic reperfusion and decreased neurological deficit scores in treated animals. Furthermore, 7c could penetrate the blood-brain barrier (BBB) in rats, and its exposure in the brain was 4.3-fold higher than that in plasma. More importantly, compared to edaravone, 7c exhibited stronger free radical scavenging activity. Our findings suggest that 7c may be promising for further evaluation as an intervention for ischemic stroke. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To systematically review the efficacy and safety of Butylphthalide soft capsules combined with alprostadil injection in treatment of ischemic cerebral infarction or transient ischemic attack. METHODS: Cochrane library, PubMed, Em base, CNK1, VIP and Wanfang were overall retrieved lor randomized controlled trials of Butylphthalide soil capsules combined with alprostadil injection in treatment of ischemic cerebral infarction or transient ischemic attack (die observation group was given conventional treatment combined with alprostadil injection and Butylphthalide soil capsules, the control group was given conventional treatment combined with other therapy) , RevMan 5. 2 was adopted to conduct Meta analysis. RESULTS: A total ol 8 studies were involved, including 822 patients with ischemic cerebral infarction or transient ischemic attack. Results ol Meta analysis indicated that the cure rate (RR = 1.31, 95% Cl = 1. 04-1. 66, P = 0. 02) and effective rate (RR = 1.19, 95% Cl = 1.09-1. 30, P < 0. 000 1)of observation group were significantly higher titan those of the control group, die NIHSS of observation group was significantly lower than that of die control group(MD = - 3. 67 , 95% Cl = - 5. 40- - 1.95 , P < 0. 000 1) ; 4 studies had reported adverse drug reactions, there was no statistical significance in the difference of incidences of adverse drug reactions between two groups (RR =0. 54, 95% Cl =0. 23-1. 28, P > 0. 05). CONCLUSIONS: The efficacy of Butylphthalide soil capsules combined with alprostadil injection in treatment of ischemic cerebral infarction or transient ischemic attack is remarkable, with high safety. However, due to the low quality of involved studies, litis conclusion still needs further verification by randomized controlled trials with high quality and larger sample. KEYWORDS Butylphthalide soft capsules; [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is reported to be a less frequent cause of ischemic stroke in China than in Europe and North America, but it is not clear whether this is due to underestimation. Our aim was to define the true frequency of AF-associated stroke, to determine the yield of 6-day Holter ECG to detect AF in Chinese stroke patients, and to elucidate predictors of newly detected AF.Methods: Patients with acute ischemic stroke or transient ischemic attack (TIA) were enrolled in a prospective, multicenter cohort study of 6-day Holter monitoring within 7 days after stroke onset at 20 sites in China between 2013 and 2015. Independent predictors of newly-detected AF were determined by multivariate analysis.Results: Among 1511 patients with ischemic stroke and TIA (mean age 63 years, 33.1% women), 305 (20.2%) had either previously known (196, 13.0%) or AF newly-detected by electrocardiography (53, 3.5%) or by 6-day Holter monitoring (56/1262, 4.4%). A history of heart failure (OR = 4.70, 95%CI, 1.64-13.5), advanced age (OR = 1.06, 95%CI, 1.04-1.09), NIHSS at admission (OR = 1.06, 95%CI, 1.02-1.10), blood high density lipoprotein (HDL) (OR = 1.52, 95%CI, 1.09-2.13), together with blood triglycerides (OR = 0.64, 95%CI, 0.45-0.91) were independently associated with newly-detected AF.Conclusions: Contrary to previous reports, AF-associated stroke is frequent (20%) in China if systemically sought. Prolonged noninvasive cardiac rhythm monitoring importantly increases AF detection in patients with recent ischemic stroke and TIA in China. Advanced age, history of heart failure, and higher admission NIHSS and higher level of HDL were independent indicators of newly-detected AF.Trial Registration: NCT02156765 (June 5, 2014). [ABSTRACT FROM AUTHOR]

Cerebral hypoperfusion induced by transient bilateral common carotid arteries occlusion (tBCCAO), is associated with deleterious alterations in several physiological parameters of the animals. This study aims to investigate the effects of vanillic acid (VA) on memory impairment, locomotion and exploratory deficits, as well as histological and hippocampal long-term potentiation (LTP) injuries induced by tBCCAO procedure followed by reperfusion (BCCAO/R) in rats. Adult male Wistar rats (250–300 g) were divided randomly into four groups: Sham-Operated group “Sham”; Vehicle + BCCAO/R group “BCCAO/R”; Vehicle+ Vanillic acid group “VA”; VA (100 mg/kg) +BCCAO/R group “VA +BCCAO/R”. Cerebral hypoperfusion was induced after 14 days of pretreatment with VA and/or normal saline. To induce the animal model of hypoperfusion, bilateral common carotid arteries were occluded for 30 min, followed by 72 h of reperfusion. Subsequently, behavioral, histopathological and electrophysiological parameters were evaluated after BCCAO/R. Data showed that pretreatment of VA markedly improved locomotion in tBCCAO rats compared with the untreated BCCAO/R rats (p < 0.05). Moreover, pretreatment of VA significantly ameliorated memory impairment in “VA + BCCAO/R” group compared with the “BCCAO/R” group (P < 0.01). The field excitatory postsynaptic potential (fEPSP) amplitude and slope were significantly decreased in “BCCAO/R” group compared with Sham group (P < 0.001). Data indicate that fEPSP amplitude and slope were increased in “VA + BCCAO/R” group compared with the “BCCAO/R” group (P < 0.001). Furthermore, histopathological observation in VA pretreated tBCCAO rats showing markedly attenuated of cell death (P < 0.01) and arrangement of CA1 neurons as compared with the untreated BCCAO/R rats. Our data confirm the protective role of VA against transient cerebral ischemia and reperfusion in rats. Moreover, it proposes that VA has a beneficial role in cerebrovascular insufficiency states. [ABSTRACT FROM AUTHOR]

Introduction: Interpretation of the extent of perfusion deficits in stroke MRI is highly dependent on the method used for analyzing the perfusion-weighted signal intensity time-series after gadolinium injection. In this study, we introduce a new model-free standardized method of temporal similarity perfusion (TSP) mapping for perfusion deficit detection and test its ability and reliability in acute ischemia. Materials and methods: Forty patients with an ischemic stroke or transient ischemic attack were included. Two blinded readers compared real-time generated interactive maps and automatically generated TSP maps to traditional TTP/MTT maps for presence of perfusion deficits. Lesion volumes were compared for volumetric inter-rater reliability, spatial concordance between perfusion deficits and healthy tissue and contrast-to-noise ratio (CNR). Results: Perfusion deficits were correctly detected in all patients with acute ischemia. Inter-rater reliability was higher for TSP when compared to TTP/MTT maps and there was a high similarity between the lesion volumes depicted on TSP and TTP/MTT (r(18) = 0.73). The Pearson's correlation between lesions calculated on TSP and traditional maps was high (r(18) = 0.73, p<0.0003), however the effective CNR was greater for TSP compared to TTP (352.3 vs 283.5, t(19) = 2.6, p<0.03.) and MTT (228.3, t(19) = 2.8, p<0.03). Discussion: TSP maps provide a reliable and robust model-free method for accurate perfusion deficit detection and improve lesion delineation compared to traditional methods. This simple method is also computationally faster and more easily automated than model-based methods. This method can potentially improve the speed and accuracy in perfusion deficit detection for acute stroke treatment and clinical trial inclusion decision-making. [ABSTRACT FROM AUTHOR]

Background: Health-related quality of life measured with the EuroQol Group 5-Dimension Self-Report Questionnaire was one of the secondary outcomes in the Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN).We reported no statistically significant difference in EuroQol Group 5-Dimension Self-Report Questionnaire score between the intervention and control groups, but deaths were not included. Aims: Reanalyze the effect of intra-arterial treatment for large vessel occlusion in acute ischemic stroke patients on health-related quality of life in more detail. We now include patients who died during follow-up. Methods: The EuroQol Group 5-Dimension Self-Report Questionnaire questionnaires were obtained 90 days after treatment. We used the Dutch tariff to derive a utility index from the EuroQol Group 5-Dimension Self-Report Questionnaire score. Treatment effect was estimated with the Mann-Whitney U test and linear regression. The effect of treatment on the distribution of EuroQol Group 5-Dimension Self-Report Questionnaire dimension scores was assessed with ordinal logistic regression. Results: We obtained EuroQol Group 5-Dimension Self-Report Questionnaire scores from 457 (91.7%) of the 500 patients, including 108 who died before follow-up. Median EuroQol Group 5-Dimension Self-Report Questionnaire score in the intervention group was 0.57, and 0.39 in the control group (p=0.03). Treatment effect estimated with linear regression was 0.07 (95%CI: -0.001 to 0.143). Treatment specifically affected EuroQol Group 5-Dimension Self- Report Questionnaire dimensions "mobility" (OR: 0.43, 95%CI: 0.29-0.66), "self-care" (OR: 0.60, 95%CI: 0.41-0.89), and "usual activities" (OR: 0.53, 95%CI: 0.36-0.79). Conclusion: Treatment had a limited effect on quality of life, as measured with the EuroQol Group 5-Dimension Self-Report Questionnaire. Nevertheless, patients with acute ischemic stroke caused by an intracranial occlusion in the anterior circulation, who had intra-arterial treatment, experience better health-related quality of life than patients without intra-arterial treatment. Trial Registration: URL: http://www.isrctn.com/ISRCTN10888758 Unique identifier: ISRCTN10888758 [ABSTRACT FROM AUTHOR]

Rationale: Paroxysmal atrial fibrillation is a common and preventable cause of devastating strokes. However, currently available monitoring methods, including Holter monitoring, cardiac telemetry and event loop recorders, have drawbacks that restrict their application in the general stroke population. AliveCor™ heartmonitor, a novel device that embedsminiaturized electrocardiography (ECG) in a smartphone case coupled with an application to record and diagnose the ECG, has recently been shown to provide an accurate and sensitive single lead ECG diagnosis of atrial fibrillation. This device could be used by nurses to record a 30-s ECG instead of manual pulse taking and automatically provide a diagnosis of atrial fibrillation. Aims: To compare the proportion of patients with paroxysmal atrial fibrillation detected by AliveCor™ ECG monitoring with current standard practice. Sample size: 296 Patients. Design: Consecutive ischemic stroke and transient ischemic attack patients presenting to participating stroke units without known atrial fibrillation will undergo intermittent AliveCor™ ECG monitoring administered by nursing staff at the same frequency as the vital observations of pulse and blood pressure until discharge, in addition to the standard testing paradigm of each participating stroke unit to detect paroxysmal atrial fibrillation. Study outcome: Proportion of patients with paroxysmal atrial fibrillation detected by AliveCor™ ECG monitoring compared to 12-lead ECG, 24-h Holter monitoring and cardiac telemetry. Discussion: Use of AliveCor™ heart monitor as part of routine stroke unit nursing observation has the potential to be an inexpensive non-invasive method to increase paroxysmal atrial fibrillation detection, leading to improvement in stroke secondary prevention. [ABSTRACT FROM AUTHOR]

Background: Stroke risk after transient ischaemic attack (TIA) is highest in the first few days. It is greatly reduced by commencing commonly used medications. Current Australian guidelines recommend that all TIAs be managed urgently by secondary-care specialists (mandatory for high-risk TIAs). The majority of TIAs present to general practice which creates a dilemma when specialist care is not readily accessible. There is a lack of evidence relating to the determinants of general practitioners' (GPs) actions in this situation.Objective: To explore GP management of TIA presentations.Methods: A qualitative study using semi-structured interviews of a maximum variation sample of senior and trainee GPs from New South Wales, Australia. Data collection and thematic analysis were concurrent and iterative, employing constant comparison, co-coding, participant transcript review, reflexivity and continued until thematic saturation was achieved.Results: Management of TIA was heterogeneous and depended upon the GP's engagement with the individual case. The level of engagement was predicated on the GP's predisposition toward managing transient neurological presentations generally, the clinical phenotype of the presentation and logistical or health system factors. Management was categorised as triage, guided collaboration, consultative collaboration and independent management. Collaboration with secondary care increased the GP's capability to diagnose and manage future TIAs.Conclusion: Heterogeneity of TIA management equates with variation from guideline recommendations. However, Australian guidelines may not be practicable due to variability in access to secondary-care specialists. Future models of care should consider systems approaches such as telemedicine to promote collaboration and assist GPs to comply with guidelines. [ABSTRACT FROM AUTHOR]

Acute ischemic stroke is a neurological emergency that can be treated with time-sensitive interventions, including both intravenous thrombolysis and endovascular approaches to thrombus removal. Extensive study has demonstrated that rapid, protocolized, assessment and treatment is essential to improving neurological outcome. For this reason, acute ischemic stroke was chosen as an emergency neurological life support protocol. The protocol focuses on the first hour of medical care following the acute onset of a neurological deficit. [ABSTRACT FROM AUTHOR]

Background: Restless legs syndrome (RLS) is a movement disorder that is associated with poor quality of life and depressive symptoms in the general population. Emerging evidence suggests that RLS is closely associated with cerebrovascular disease. We assessed the effect of RLS on quality of life after stroke and transient ischemic attack (TIA).Methods: In this single-center prospective study, we recruited patients within 14 days of high-risk TIA or minor stroke. Patients were diagnosed with RLS using a questionnaire based on the 2003 International RLS Study Group criteria, and diagnoses were confirmed by a sleep neurologist. Follow-up assessments were conducted within 2-6 months of recruitment. The outcome of quality of life was measured using the Stroke-specific Quality of Life (SS-QoL).Results: Of the 94 patients recruited into the study, 23 (24.4%) were diagnosed with RLS: 11 were newly diagnosed with RLS and 12 had RLS preceding the index stroke/TIA. There were no significant differences in baseline characteristics between those with or without RLS. Median SS-QoL in patients with RLS was lower at baseline (p = 0.008) and at follow-up (p = 0.002). RLS patients had more depressive symptoms at follow-up (p = 0.007). Ordinal logistic regression demonstrated that RLS was negatively associated with quality of life at baseline (OR = 0.28; p = 0.010) and at follow-up (OR = 0.14; p = 0.029), independent of functional outcome and depressive symptoms.Conclusions: RLS is common after stroke or TIA and negatively affects the quality of life. Screening for RLS after cerebrovascular events may be warranted, and future research should assess whether treatment of RLS can improve post-stroke quality of life. [ABSTRACT FROM AUTHOR]

Background: Despite interest in using electronic health record (EHR) data to assess quality of care, the accuracy of such data is largely unknown. We sought to develop and validate transient ischemic attack and minor ischemic stroke electronic quality measures (eQMs) using EHR data.Methods and Results: A random sample of patients with transient ischemic attack or minor ischemic stroke, cared for in Veterans Health Administration facilities (fiscal year 2011), was identified. We constructed 31 eQMs based on existing quality measures. Chart review was the criterion standard for validating the eQMs. To evaluate eQMs in terms of eligibility, we calculated the proportion of patients who were genuinely not eligible to receive a process (based on chart review) and who were correctly identified as not eligible by the EHR data (specificity). To assess eQMs about classification of whether patients received a process, we calculated the proportion of patients who actually received the process (based on chart review) and who were classified correctly by the EHR data as passing (sensitivity). Seven hundred sixty-three patients were included. About eligibility, specificity varied from 25% (brain imaging; carotid imaging) to 99% (anticoagulation quality). About pass rates, sensitivity varied from 30% (antihypertensive class) to 100% (coronary risk assessment; international normalized ratio measured). The 16 eQMs with ≥70% specificity in eligibility and ≥70% sensitivity in pass rates included coronary risk assessment, international normalized ratio measured, HbA1c measurement, speech language pathology consultation, anticoagulation for atrial fibrillation, discharge on statin, lipid management, neurology consultation, Holter, deep vein thrombosis prophylaxis, oral hypoglycemic intensification, cholesterol medication intensification, antihypertensive intensification, antihypertensive class, carotid stenosis intervention, and substance abuse referral for alcohol.Conclusions: It is feasible to construct valid eQMs for processes of transient ischemic attack and minor ischemic stroke care. Healthcare systems with EHRs should consider using electronic data to evaluate care for their patients with transient ischemic attack and to complement and expand quality measurement programs currently focused on patients with stroke. [ABSTRACT FROM AUTHOR]

Chrysanthemum indicum Linné extract (CIL) is used in herbal medicine in East Asia. In the present study, gerbils were orally pre-treated with CIL, and changes of antioxidant enzymes including superoxide dismutase (SOD) 1 and SOD2, catalase (CAT) and glutathione peroxidase (GPX) in the hippocampal CA1 region following 5 min of transient cerebral ischemia were investigated and the neuroprotective effect of CIL in the ischemic CA1 region was examined. SOD1, SOD2, CAT and GPX immunoreactivities were observed in the pyramidal cells of the CA1 region and their immunoreactivities were gradually decreased following ischemia-reperfusion and barely detectable at 5 days post-ischemia. CIL pre-treatment significantly increased immunoreactivities of SOD1, CAT and GPX, but not SOD2, in the CA1 pyramidal cells of the sham-operated animals. In addition, SOD1, SOD2, CAT and GPX immunoreactivities in the CA1 pyramidal cells were significantly higher compared with the ischemia-operated animals. Furthermore, it was identified that pre-treatment with CIL protected the CA1 pyramidal cells in the CA1 region using neuronal nuclei immunohistochemistry and Fluoro-Jade B histofluorescence staining; the protected CA1 pyramidal cells were 67.5% compared with the sham-operated animals. In conclusion, oral CIL pre-treatment increased endogenous antioxidant enzymes in CA1 pyramidal cells in the gerbil hippocampus and protected the cells from transient cerebral ischemic insult. This finding suggested that CIL is promising for the prevention of ischemia-induced neuronal damage. [ABSTRACT FROM AUTHOR]

Objective Stroke in young adults is uncommon and rarely described. Moyamoya disease is one of the leading causes of stroke in young adults. We aimed to study the prognostic factors for stroke recurrences and functional outcomes in young stroke patients with moyamoya disease after revascularization. Methods We reviewed 696 consecutive patients with moyamoya disease admitted to our hospital from 2009–2015 and identified patients aged 18–45 years with first-ever stroke. Follow-up was conducted via face-to-face or structured telephone interviews. Outcome measures were recurrent stroke events and unfavorable functional outcomes (modified Rankin Scale >2). Results We included 121 young patients with moyamoya disease suffering from stroke (initial presentation age, 35.4 ± 7.5 years). All patients underwent revascularization after the acute phase of initial stroke events as the secondary prevention for recurrences. During follow-up (median, 40 months), 9 patients (7.4%) experienced recurrent strokes and 8 of them (6.6%) suffered unfavorable functional outcomes. In the multivariate analysis, diabetes was an independent predictor for stroke recurrences (hazard ratio 6.76; 95% confidence interval 1.30–35.11; P = 0.02) and was significantly associated with unfavorable functional outcomes (odds ratio 7.87; 95% confidence interval 1.42–38.74; P = 0.01). Conclusions We identified diabetes as an independent risk factor for recurrent strokes and unfavorable functional outcomes after revascularization in young stroke patients with moyamoya disease. [ABSTRACT FROM AUTHOR]

Background Care gaps for stroke lead to preventable disability and deaths. The Victorian State Government implemented a programme of employing clinical Facilitators on a fixed-term basis for up to 3 years (2008-2011) in eight hospitals to improve stroke care. The Facilitators were to establish stroke units where absent, implement evidence-based management protocols and provide staff education within an agreed work plan. Aim To determine if the Facilitator role was associated with improved stroke care and to describe factors supporting or mitigating enhancements to care. Methods A mixed methods design was employed with historical control using patient-level audit data (pre-Facilitator: n = 600; post-Facilitator: n = 387) and qualitative data from independently conducted semistructured interviews with hospital staff, including clinicians, executives and facilitators ( n = 10 focus groups; 75 respondents). Results Stroke units, clinical pathways and outpatient clinics for managing transient ischaemic attacks ( TIA) were established. Compared with the pre-Facilitator period, significant increases in patient access to stroke unit care (53% vs 86%, P < 0.001) and intravenous thrombolysis (2% vs 9%, P < 0.001) were achieved. Hospital staff reported that the Facilitator was integral to system improvements by fostering communication, encouraging team motivation and cohesiveness and increasing interest in stroke care. Ongoing barriers included limited resources to operate TIA clinics effectively, staff turnover requiring ongoing education, inconsistency in compliance with protocols and, in some hospitals, the need for formalised medical leadership. Conclusion Fixed-term employment of Facilitators was effective in positively influencing stroke care in hospitals through a range of change management strategies where stroke-specific expertise had been previously limited. [ABSTRACT FROM AUTHOR]

A case study of 68-year-old woman with the history of hypertension and hyperlipidemia, and with complaint of sudden-onset right-hand weakness and difficulty speaking that occurred 4 days earlier is presented. Topics discussed includes strategies for subacute care of stroke and transient ischemic attacks, employment of the ABCD risk stratification tool to evaluate urgency of treatment, and use of tissue plasminogen activator for treatment.

Purpose To implement a fast (~ 15 min) MRI protocol for carotid plaque screening using 3D multi-contrast MRI sequences without contrast agent on a 3 Tesla MRI scanner. Materials and methods 7 healthy volunteers and 25 patients with clinically confirmed transient ischemic attack or suspected cerebrovascular ischemia were included in this study. The proposed protocol, including 3D T1-weighted and T2-weighted SPACE (variable-flip-angle 3D turbo spin echo), and T1-weighted magnetization prepared rapid acquisition gradient echo (MPRAGE) was performed first and was followed by 2D T1-weighted and T2-weighted turbo spin echo, and post-contrast T1-weighted SPACE sequences. Image quality, number of plaques, and vessel wall thicknesses measured at the intersection of the plaques were evaluated and compared between sequences. Results Average examination time of the proposed protocol was 14.6 min. The average image quality scores of 3D T1-weighted, T2-weighted SPACE, and T1-weighted magnetization prepared rapid acquisition gradient echo were 3.69, 3.75, and 3.48, respectively. There was no significant difference in detecting the number of plaques and vulnerable plaques using pre-contrast 3D images with or without post-contrast T1-weighted SPACE. The 3D SPACE and 2D turbo spin echo sequences had excellent agreement ( R = 0.96 for T1-weighted and 0.98 for T2-weighted, p < 0.001) regarding vessel wall thickness measurements. Conclusion The proposed protocol demonstrated the feasibility of attaining carotid plaque screening within a 15-minute scan, which provided sufficient anatomical coverage and critical diagnostic information. This protocol offers the potential for rapid and reliable screening for carotid plaques without contrast agent. [ABSTRACT FROM AUTHOR]

Introduction The risk of recurrent stroke is high in patients with intracranial atherosclerotic stenosis ( ICAS). Statin use has been demonstrated to decrease the incidence of stroke by reducing atherosclerotic plaque burden. However, its effect on the hemodynamic situation and cerebral perfusion status has not yet been validated. With the use of computed tomography perfusion ( CTP), we aim to evaluate the impact of Rosuvastatin on cerebral hemodynamic changes, as well as the downstream perfusion. Method Cerebral bood flow evaluation of intensive rosuvastatin therapy in patients with intracranial arterial atherosclerotic stenosis ( CEIRIS) is a single-center, prospective, randomized, parallel-group, and open-label trial, and it will include 50 participants as estimated. Patients with moderate to severe (50%-99%) ICAS are randomized 1:1 to 10 mg/day or 20 mg/day Rosuvastatin and followed every 13 weeks until 52 weeks. The primary outcome for the trial is the change in the relative regional cerebral blood flow evaluated by CTP after 52 weeks of Rosuvastatin treatment. The secondary outcomes are cerebral blood volume, change in the degree of stenosis of the target vessel and lipid parameters. Conclusion The CEIRIS trial about the effects of statin on the temporal hemodynamic progression of ICAS may extend our understanding of the basic pathophysiology and mechanisms of stroke in ICAS patients. [ABSTRACT FROM AUTHOR]

Self-preservation is required for life. At the cellular level, this fundamental principle is expressed in the form of molecular mechanisms for preconditioning and tolerance. When the cell is threatened, internal cascades of survival signaling become triggered to protect against cell death and defend against future insults. Recently, however, emerging findings suggest that this principle of self-preservation may involve not only intracellular signals; the release of extracellular signals may provide a way to recruit adjacent cells into an amplified protective program. In the central nervous system where multiple cell types co-exist, this mechanism would allow threatened neurons to “ask for help” from glial and vascular compartments. In this review, we describe this new concept of help-me signaling, wherein damaged or diseased neurons release signals that may shift glial and vascular cells into potentially beneficial phenotypes, and help remodel the neurovascular unit. Understanding and dissecting these non-cell autonomous mechanisms of self-preservation in the CNS may lead to novel opportunities for neuroprotection and neurorecovery. [ABSTRACT FROM AUTHOR]

The risk of recurrent stroke after transient ischemic attack (TIA) is high. In the past 10 years, TIA has increasingly been recognized as amedical emergency. Health systems have adapted toward rapid evaluation, investigation, and secondary prevention in patients with presumed TIA and minor stroke, and the significant benefits in reducing recurrent stroke and mortality have been borne out in several landmark studies. Various scores have been developed and debated to better risk stratify patients with TIA for hospitalization or urgent referral. However, scoring systems face challenges in identifying all patients with high-risk etiologies such as atrial fibrillation and carotid stenosis, and therefore require further refinement before widespread use. Further challenges include the role of advanced imaging in TIA, and ensuring rapid access to specialist care for all patients. In the absence of definitive risk stratification methods, the authors conclude that all patients with suspected TIA and minor stroke should be assessed and treated on an urgent basis, ideally through rapid outpatient referral programs. [ABSTRACT FROM AUTHOR]

Background: Thrombus aspiration during percutaneous coronary intervention (PCI) for the treatment of ST-segment-elevation myocardial infarction (STEMI) has been widely used; however, recent trials have questioned its value and safety. In this meta-analysis, we, the trial investigators, aimed to pool the individual patient data from these trials to determine the benefits and risks of thrombus aspiration during PCI in patients with ST-segment-elevation myocardial infarction.Methods: Included were large (n≥1000), randomized, controlled trials comparing manual thrombectomy and PCI alone in patients with ST-segment-elevation myocardial infarction. Individual patient data were provided by the leadership of each trial. The prespecified primary efficacy outcome was cardiovascular mortality within 30 days, and the primary safety outcome was stroke or transient ischemic attack within 30 days.Results: The 3 eligible randomized trials (TAPAS [Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction], TASTE [Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia], and TOTAL [Trial of Routine Aspiration Thrombectomy With PCI Versus PCI Alone in Patients With STEMI]) enrolled 19 047 patients, of whom 18 306 underwent PCI and were included in the primary analysis. Cardiovascular death at 30 days occurred in 221 of 9155 patients (2.4%) randomized to thrombus aspiration and 262 of 9151 (2.9%) randomized to PCI alone (hazard ratio, 0.84; 95% confidence interval, 0.70-1.01; P=0.06). Stroke or transient ischemic attack occurred in 66 (0.8%) randomized to thrombus aspiration and 46 (0.5%) randomized to PCI alone (odds ratio, 1.43; 95% confidence interval, 0.98-2.10; P=0.06). There were no significant differences in recurrent myocardial infarction, stent thrombosis, heart failure, or target vessel revascularization. In the subgroup with high thrombus burden (TIMI [Thrombolysis in Myocardial Infarction] thrombus grade ≥3), thrombus aspiration was associated with fewer cardiovascular deaths (170 [2.5%] versus 205 [3.1%]; hazard ratio, 0.80; 95% confidence interval, 0.65-0.98; P=0.03) and with more strokes or transient ischemic attacks (55 [0.9%] versus 34 [0.5%]; odds ratio, 1.56; 95% confidence interval, 1.02-2.42, P=0.04). However, the interaction P values were 0.32 and 0.34, respectively.Conclusions: Routine thrombus aspiration during PCI for ST-segment-elevation myocardial infarction did not improve clinical outcomes. In the high thrombus burden group, the trends toward reduced cardiovascular death and increased stroke or transient ischemic attack provide a rationale for future trials of improved thrombus aspiration technologies in this high-risk subgroup.Clinical Trial Registration: URLs: http://www.ClinicalTrials.gov http://www.crd.york.ac.uk/prospero/. Unique identifiers: NCT02552407 and CRD42015025936. [ABSTRACT FROM AUTHOR]