Intima-Media Thickness and Pulsatility Index of Common Carotid Arteries in Acute Ischaemic Stroke Patients with Diabetes Mellitus.

Ultrasonographic parameters such as the common carotid artery (CCA) pulsatility index (PI) and CCA intima-media thickness (IMT) have been associated with an increased mortality and risk of recurrent stroke, respectively. We hypothesized that these ultrasonographic parameters may be useful for monitoring diabetic patients after an acute stroke. We analysed retrospective data of consecutive acute ischaemic stroke patients from the ASTRAL registry who underwent pre-cerebral ultrasonographic evaluation within 7 days of symptom onset. We compared clinical, demographic, radiological and ultrasonographic parameters in diabetic versus non-diabetic patients (univariable and multivariable analyses) and the association of these parameters with CCA PI and CCA IMT. We analysed 1507 carotid duplex ultrasound examinations from patients with a median age of 74 years. Cardiovascular co-morbidities, including hypertension, hypercholesterolemia, obstructive sleep apnoea syndrome, higher body-mass index (BMI) and peripheral artery disease, were associated with diabetes mellitus (DM). Diabetics were more often under antiplatelet therapy and had atrial fibrillation at admission. Diabetic patients showed an increased CCA PI and IMT in line with more atherosclerotic changes on acute CTA compared to non-diabetic patients. Taking IMT as the dependent variable in a second analysis, DM, higher age, hypertension, smoking and CCA PI were associated with higher IMT. Taking CCA PI as the dependent variable in a third analysis, DM, higher age and higher NIHSS at admission were associated with higher CCA PI values. Increased IMT was also associated with higher PI. We show that CCA PI and IMT are higher in diabetic patients in the first week after an initial stroke.

Distance Neurological Supervision Using Telestroke Does Not Increase Door-to-Needle Time in Acute Ischemic Stroke Management: The Experience of Two Regional Stroke Units.

Background and Aims: Timely administration of recombinant tissue plasminogen activator (r-tPA) improves clinical outcomes in acute ischemic stroke patients. This study aims to explore the influence of the systematic presence on site of a neurologist compared with telestroke management on door-to-needle time in acute ischemic stroke outside of working hours (OWH). Methods: This retrospective cohort study included all r-tPA-treated patients in the emergency rooms of two Swiss stroke units, Nyon Hospital [Groupement Hospitalier de l'Ouest Lémanique (GHOL)] and Fribourg Hospital [Hôpital de Fribourg (HFR)], between February 2014 and September 2018. Door-to-needle time was analyzed for patients admitted during working hours (WH' weekdays 08:00-18:00) and OWH (weekdays 18:00-08:00, weekends, and public holidays). The latter was compared between centers; OWH, every patient was evaluated prior to thrombolysis by a neurologist on site in GHOL, while HFR adopted distance neurological supervision with teleradiology, performed by telephone evaluation of relevant clinical information with online real-time access to brain imaging. Results: Data were analyzed for 157 patients in HFR and 101 patients in GHOL. No statistically significant differences in baseline characteristics were found for the 258 r-tPA-treated acute ischemic stroke patients, in terms of age, gender, cardiovascular risk factors (hypertension, diabetes, and atrial fibrillation), and pre-Modified Rankin Scale (pre-mRs) between centers, with the exception of smoking and anticoagulation status. Patients in HFR presented with more severe strokes {median National Institutes of Health Stroke Scale (NIHSS) [6 (SD 6.88) (GHOL), 8 (SD 6.98) (HFR), p = 0.005]}. No significant differences in baseline characteristics were found as per admission time independently of the center. Door-to-needle time was significantly longer in the HFR cohort when compared with GHOL, irrespective of admission time. Both centers demonstrated significantly longer median door-to-needle time OWH. However, analysis of the door-to-needle time differences between WH and OWH showed no significant interaction using robust ANCOVA WRS2 analysis (p = 0.952) and a Bayesian model (BF01 = 3.97). Conclusions: On-site systematic evaluation by a neurologist did not appear to influence door-to-needle time OWH, suggesting distance supervision may be time-efficient in thrombolysis. This supports existing prospective studies in hyperacute telestroke management. The relevance lies in optimizing resource use considering the increasing demand for emergency neurological management.

Predictors of the pulsatility index in the middle cerebral artery of acute stroke patients.

Cervical and transcranial Doppler (TCD) are widely used as non-invasive methods in the evaluation of acute ischemic stroke (AIS) patients. High-grade carotid artery stenosis induces haemodynamic changes such as collateral flow and a so-called post-stenotic flow pattern of the middle cerebral artery (MCA), which appears flattened, with a reduction of the velocity difference between systole and diastole. We studied the influence of carotid artery stenosis and other variables on the flow pattern in the MCA using the pulsatility index (PI), a quantitative TCD parameter reflecting the flow spectrum in a large of cohort AIS patients. We performed ultrasound examinations of 1825 AIS patients at the CHUV from October 2004 to December 2014. We extracted patient characteristics from the ASTRAL registry. Carotid stenosis severity was classified as < 50%, 50-70%, 70-90% and > 90%, or occlusion, according to Doppler velocity criteria. We first determined variables associated with stenosis grade. Then we performed a multivariate analysis after adjusting for baseline differences, using MCA PI as dependent variable. Carotid stenosis > 70% (- 0.07) and carotid stenosis > 90%, or occlusion (- 0.14) and left side (- 0.02) are associated with lower MCA PI values. Age (+0.006 PI units per decade), diabetes (+0.07), acute ischemic changes on initial CT (+0.03) and severe plaque morphology (+0.18) are associated with higher MCA PI values. We found a number of clinical and radiological conditions that significantly influence the PI of the MCA, including high-grade ipsilateral carotid stenosis in AIS patients. We provide for the first time a quantitative evaluation of the effect of these influencing factors from a large cohort of AIS patients.

Intravenous thrombolysis and platelet count.

OBJECTIVE: To study the effect of platelet count (PC) on bleeding risk and outcome in stroke patients treated with IV thrombolysis (IVT) and to explore whether withholding IVT in PC < 100 × 109/L is supported. METHODS: In this prospective multicenter, IVT register-based study, we compared PC with symptomatic intracranial hemorrhage (sICH; Second European-Australasian Acute Stroke Study [ECASS II] criteria), poor outcome (modified Rankin Scale score 3-6), and mortality at 3 months. PC was used as a continuous and categorical variable distinguishing thrombocytopenia (<150 × 109/L), thrombocytosis (>450 × 109/L), and normal PC (150-450 × 109/L [reference group]). Moreover, PC < 100 × 109/L was compared to PC ≥ 100 × 109/L. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) from the logistic regression models were calculated. RESULTS: Among 7,533 IVT-treated stroke patients, 6,830 (90.7%) had normal PC, 595 (7.9%) had thrombocytopenia, and 108 (1.4%) had thrombocytosis. Decreasing PC (every 10 × 109/L) was associated with increasing risk of sICH (ORadjusted 1.03, 95% CI 1.02-1.05) but decreasing risk of poor outcome (ORadjusted 0.99, 95% CI 0.98-0.99) and mortality (ORadjusted 0.98, 95% CI 0.98-0.99). The risk of sICH was higher in patients with thrombocytopenic than in patients with normal PC (ORadjusted 1.73, 95% CI 1.24-2.43). However, the risk of poor outcome (ORadjusted 0.89, 95% CI 0.39-1.97) and mortality (ORadjusted 1.09, 95% CI 0.83-1.44) did not differ significantly. Thrombocytosis was associated with mortality (ORadjusted 2.02, 95% CI 1.21-3.37). Forty-four (0.3%) patients had PC < 100 × 109/L. Their risks of sICH (ORunadjusted 1.56, 95% CI 0.48-5.07), poor outcome (ORadjusted 1.63, 95% CI 0.82-3.24), and mortality (ORadjusted 1.38, 95% CI 0.64-2.98) did not differ significantly from those of patients with PC ≥ 100 × 109/L. CONCLUSION: Lower PC was associated with increased risk of sICH, while higher PC indicated increased mortality. Our data suggest that PC modifies outcome and complications in individual patients, while withholding IVT in all patients with PC < 100 × 109/L is challenged.

[Creating a stroke unit in a community hospital improves the management of stroke patients]. / Création d'une « stroke unit ¼ dans un hôpital de zone : une optimisation de la prise en charge des patients AVC.

Dramatic advances in recent years have changed the care of stroke patients. Creation of stroke hubs with centers and units achieved a significant reduction in mortality and morbidity. The indications for acute therapies such as intravenous thrombolysis and endovascular treatment target an increasing proportion of stroke patients. Early rehabilitation and multidisciplinary approaches have become part of the gold standard in stroke care. The creation of additional stroke units and strengthening local synergies should continue in order to propose the best medical treatments for all stroke patients.

La prise en charge des patients souffrant d'accident vasculaire cérébral (AVC) a connu des avancées spectaculaires dans les dernières années. Le développement de réseaux de « stroke units ¼ et « stroke centers ¼ a permis une nette diminution de mortalité et morbidité. Les indications aux traitements aigus, tels que la thrombolyse intraveineuse et le traitement endovasculaire, visent une proportion croissante de patients. La rééducation précoce et la prise en charge multidisciplinaire font désormais partie des traitements de référence. Les efforts de création d'unités spécialisées et le renforcement des synergies locales devront être poursuivis afin de proposer les meilleurs traitements disponibles à l'ensemble de la population.

Sex Differences and Functional Outcome After Intravenous Thrombolysis.

BACKGROUND AND PURPOSE: Women have a worse outcome after stroke compared with men, although in intravenous thrombolysis (IVT)-treated patients, women seem to benefit more. Besides sex differences, age has also a possible effect on functional outcome. The interaction of sex on the functional outcome in IVT-treated patients in relation to age remains complex. The purpose of this study was to compare outcome after IVT between women and men with regard to age in a large multicenter European cohort reflecting daily clinical practice of acute stroke care. METHODS: Data were obtained from IVT registries of 12 European tertiary hospitals. The primary outcome was poor functional outcome, defined as a modified Rankin scale score of 3 to 6 at 3 months. We stratified outcome by age in decades. Safety measures were symptomatic intracranial hemorrhage and mortality at 3 months. RESULTS: In this cohort, 9495 patients were treated with IVT, and 4170 (43.9%) were women with a mean age of 71.9 years. After adjustments for baseline differences, female sex remained associated with poor functional outcome (odds ratio, 1.15; 95% confidence interval, 1.02-1.31). There was no association between sex and functional outcome when data were stratified by age. Symptomatic intracranial hemorrhage rate was similar in both sexes (adjusted odds ratio, 0.93; 95% confidence interval, 0.73-1.19), whereas mortality was lower among women (adjusted odds ratio, 0.83; 95% confidence interval, 0.70-0.99). CONCLUSIONS: In this large cohort of IVT-treated patients, women more often had poor functional outcome compared with men. This difference was not dependent on age.

Applying openEHR's Guideline Definition Language to the SITS international stroke treatment registry: a European retrospective observational study.

BACKGROUND: Interoperability standards intend to standardise health information, clinical practice guidelines intend to standardise care procedures, and patient data registries are vital for monitoring quality of care and for clinical research. This study combines all three: it uses interoperability specifications to model guideline knowledge and applies the result to registry data. METHODS: We applied the openEHR Guideline Definition Language (GDL) to data from 18,400 European patients in the Safe Implementation of Treatments in Stroke (SITS) registry to retrospectively check their compliance with European recommendations for acute stroke treatment. RESULTS: Comparing compliance rates obtained with GDL to those obtained by conventional statistical data analysis yielded a complete match, suggesting that GDL technology is reliable for guideline compliance checking. CONCLUSIONS: The successful application of a standard guideline formalism to a large patient registry dataset is an important step toward widespread implementation of computer-interpretable guidelines in clinical practice and registry-based research. Application of the methodology gave important results on the evolution of stroke care in Europe, important both for quality of care monitoring and clinical research.

Intravenous Thrombolysis in Patients Dependent on the Daily Help of Others Before Stroke.

BACKGROUND AND PURPOSE: We compared outcome and complications in patients with stroke treated with intravenous thrombolysis (IVT) who could not live alone without help of another person before stroke (dependent patients) versus independent ones. METHODS: In a multicenter IVT-register-based cohort study, we compared previously dependent (prestroke modified Rankin Scale score, 3-5) versus independent (prestroke modified Rankin Scale score, 0-2) patients. Outcome measures were poor 3-month outcome (not reaching at least prestroke modified Rankin Scale [dependent patients]; modified Rankin Scale score of 3-6 [independent patients]), death, and symptomatic intracranial hemorrhage. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (OR [95% confidence interval]) were calculated. RESULTS: Among 7430 IVT-treated patients, 489 (6.6%) were dependent and 6941 (93.4%) were independent. Previous stroke, dementia, heart, and bone diseases were the most common causes of preexisting dependency. Dependent patients were more likely to die (ORunadjusted, 4.55 [3.74-5.53]; ORadjusted, 2.19 [1.70-2.84]). Symptomatic intracranial hemorrhage occurred equally frequent (4.8% versus 4.5%). Poor outcome was more frequent in dependent (60.5%) than in independent (39.6%) patients, but the adjusted ORs were similar (ORadjusted, 0.95 [0.75-1.21]). Among survivors, the proportion of patients with poor outcome did not differ (35.7% versus 31.3%). After adjustment for age and stroke severity, the odds of poor outcome were lower in dependent patients (ORadjusted, 0.64 [0.49-0.84]). CONCLUSIONS: IVT-treated stroke patients who were dependent on the daily help of others before stroke carry a higher mortality risk than previously independent patients. The risk of symptomatic intracranial hemorrhage and the likelihood of poor outcome were not independently influenced by previous dependency. Among survivors, poor outcome was avoided at least as effectively in previously dependent patients. Thus, withholding IVT in previously dependent patients might not be justified.

Changes in European Label and Guideline Adherence After Updated Recommendations for Stroke Thrombolysis: Results From the Safe Implementation of Treatments in Stroke Registry.

BACKGROUND: Intravenous thrombolysis (IVT) for acute ischemic stroke is subject to label and guideline contraindications. Updated European guidelines in 2008/2009 recommended IVT in selected patients aged >80 years and stroke onset-to-treatment time 3 to 4.5 hours, which the label still prohibited. Our aim was to compare contraindication nonadherence before and after the guideline update. METHODS AND RESULTS: Data on IVT-treated patients with stroke at 232 European hospitals participating in the Safe Implementation of Treatments in Stroke registry during both periods 2006 to 2007 (n=6354) and 2010 to 2011 (n=12 046). After the 2008/2009 guideline update, the proportion of patients nonadherent to label increased from 23.6% to 51.1% (P<0.001). Specifically, nonadherence to onset-to-treatment time >3 hours increased from 8.2% to 27.9% and IVT in patients aged >80 years from 8.9% to 17.2% (both P<0.001). Nonadherence also increased to the contraindications severe stroke (National Institutes of Health Stroke Scale score >25), onset-to-treatment time >4.5 hours, blood pressure >185/110 mm Hg, and ongoing oral anticoagulation (all P≤0.001). Higher hospital IVT patient volumes were associated with higher nonadherence rates. CONCLUSIONS: After the European guideline update, new recommendations were promptly adopted and nonadherence to the unchanged label increased. Label contraindications should be updated.

Anti-TNF alpha medications and neuropathy.

We studied the clinical, electrophysiological, and pathological features, outcome, and frequency of anti-tumor necrosis factor alpha (a-TNF) medications-induced neuropathies (ATIN) in patients with inflammatory disorders. Of 2,017 patients treated with a-TNF medication, 12 patients met our inclusion criteria for a prevalence of 0.60% and an incidence of 0.4 cases per 1,000 person-years. The median time from a-TNF medication treatment to ATIN was 16.8 months (range 2-60 months). Six patients had focal or multifocal peripheral neuropathies. The other six had generalized neuropathies. For all, a-TNF medication was stopped. Seven patients received immunoglobulin infusions. ATIN outcome was favorable in all but one patient. ATINs are rare and heterogeneous neuropathies. In 10 patients, the neuropathy was "inflammatory", suggesting that it could be due to systemic pro-inflammatory effects of a-TNF agents.

Implementability of stroke guidelines: a pragmatic comparison between US and European recommendations using eGLIA.

Due to the prevalence and severity of stroke, and the emergency of its management, the need of reaching a consensus towards its treatment is of prime importance. This paper's aim is to compare two stroke guidelines by using eGLIA in order to evaluate their implementability. Methods included a systematic assessment of the European (ESO) and American (AHA/ASA) guidelines with eGLIA and a review of literature and analysis of each recommendation with the program. The ESO performs better in Executability and Decidability, as 91.5% and 34.8% of recommendations show no barriers, compared to 81.0% and 14.0% in the AHA/ASA guidelines. On the other hand, AHA/ASA guideline have more recommendations with positive assessments in the Validity and Effect on the Process of Care (91.4% vs 83.0% and 58.1% vs 25%). Results show that ESO guidelines address a wider patient view and that the AHA/ASA guidelines are stricter, only publishing recommendations with a high level of evidence; AHA/ASA guidelines are updated with more frequency and have a clearer sequence of action. Both guidelines show some contradictions, but of minor importance. The strength of this study is the fact that the whole guidelines were read and analysed, and, although we would suggest an improvement of the tool by adding an automatic statistics chart and clarifying some questions, it showed that eGLIA should be used whenever such a text is published.