How to improve access to appropriate therapy and outcome of the acute ischemic stroke: a 24-month survey of a specific pre-hospital planning in Northern Italy.

Few patients with acute cerebral infarction are medicated with thrombolysis as yet. Thus, a specific plan was created in the area of Bergamo in Northern Italy to increase the number of procedures. The plan, started in 2010, consisted of: (1) subdivision of the area of Bergamo into three zones, each one served by a single Stroke-Unit (SU) licensed to thrombolysis; (2) information to population via newspapers and local broadcasting; and (3) teachings both to personnel of Emergency Medical Service and General Practitioners. Here, we have compared the results of the SU of Policlinico San Marco in the years 2008-2009 versus those in the years 2010-2011. During 2008 and 2009, SU admitted 376 acute ischemic strokes, 60 of whom (16 %) within 3 h of the event. Of those patients, 8 (2 %) were treated with thrombolysis. At 3 months of stroke, 61 patients (16 %) were alive and self-independent. During 2010 and 2011, SU admitted 401 acute ischemic strokes, 91 of whom (22 %) within 3 h of stroke. Of those patients, 23 (6 %) were treated with thrombolysis. At 3 months of stroke, 100 patients were alive and self-independent (25 %). The increases of thrombolytic procedures (p = 0.0171), of self-independent patients (p = 0.0036), and of patients arriving within 3 h of stroke (p = 0.0226) were statistically significant. In conclusion, our study shows that a specific plan increases the numbers of thrombolysis and of self-independent patients at 3 months of stroke.

Predictors of re-canalisation in acute cerebral infarction from occlusion of the terminal internal carotid artery or of the middle cerebral artery mainstem treated with thrombolysis.

OBJECTIVE: We have evaluated the factors of unsuccessful re-canalisation in a large series of patients with hemispheric cerebral infarction treated with thrombolysis. PATIENTS AND METHODS: All patients aged 18-80 years with an acute hemispheric infarction, admitted within the first few hours of symptoms onset, were immediately submitted to Magnetic Resonance both Imaging (MRI) and Angiography (MRA). MRI and MRA were repeated at 24 h of stroke. Re-canalisation was attributed if grade 2 or 3 of Thrombolysis in Myocardial Infarction (TIMI) criteria for the myocardial infarction. Outcome was rated at three months of stroke. Re-canalisation was matched with ageing and with the common risk factors for stroke. RESULTS: One hundred and twenty-one patients, 70 men and 51 women, with a median age of 67 years, were included. Re-canalisation was seen in 62 patients (51%). Twenty-three patients (19%) died by 90 days of stroke. Re-canalisation was associated to survival (1 death vs. 22, p < 0.0001). Regression analysis retained advanced age (Odds ratio 0.37, 95% Confidence interval 0.13-0.98), baseline National Institute of Health Stroke Scale (NIHSS) (Odds ratio 0.94, 95% Confidence interval 0.89-0.98) and diabetes mellitus (Odds ratio 0.28, 95% Confidence interval 0.09-0.84) as factors contrasting re-canalisation. CONCLUSIONS: Our study indicates that in patients with proven occlusion of the terminal segment of the internal carotid artery and/or of the mainstem of the Middle Cerebral Artery, re-canalisation at 24 h of the acute ischemic stroke is dramatically associated with survival, and halted by advanced age and diabetes mellitus.

Stroke-Unit and emergency medical service: a 48-month experience in northern Italy.

Since the therapeutic window for acute ischaemic stroke is very short, early arrival at emergency care rooms is mandatory. Emergency medical service (EMS), assuring fast patients transportations, plays a fundamental role in the management of stroke. We have prospectively analysed the utilisation of EMS in the management of stroke patients in a countryside area of northern Italy. Among patients presenting with an acute stroke during the period January 2007-December 2010, those with an ascertained time of onset and documented ongoing brain ischaemia at neuroimaging were included in the study. For all of those patients, the personal data, means of arrival, nature of stroke, whether first stroke or recurrence, severity of stroke and the in-hospital outcome were recorded. Of 1,188 patients hospitalised with a definite diagnosis of stroke, 757 patients were included in the study. Of those, 285 patients (37.6 %) were transported by EMS. EMS allowed earlier admissions (75 % within 3 h of stroke onset), but also transportation of patients of an older age (75 vs. 71 years, p < 0.001), and with more severe strokes (62 % of total anterior circulation infarctions). Our study confirms that EMS is essential in delivering the earliest therapy to patients with acute cerebral infarction living in an extra-urban area of northern Italy. However, work is needed in optimising EMS, since transported patients are often not prone to therapy.

C-reactive protein levels in the first three hours after acute cerebral infarction.

BACKGROUND: Although thought to be involved in the precipitation of the acute ischemic stroke, C-reactive protein (CRP) was scarcely investigated in the first few hours of a cerebral infarction. PATIENTS AND METHODS: CRP was measured in a consecutive series of patients within the first 3 h of the onset of a first-ever acute cerebral infarction, and in control inpatients, matched for sex and age (±2 years). RESULTS: Three hundred eighty-seven stroke patients and 387 controls were enrolled. There were 215 men and 172 women in each group. Mean age was 66 years for both. CRP was significantly higher in stroke patients (median 5.0 mg/L, interquartile range [IQR] 2.0-10.0) than controls (median 1.9 mg/L, IQR 0.7-3.9), p < .0001. CRP remained a variable independently associated with stroke in the multiple logistic regression model. CONCLUSIONS: CRP appears to be significantly increased already in the first 3 h because of the acute ischemic stroke.

Migraine and cerebral infarction in young people.

The objective of this study is to investigate relationship between migraine and cerebral infarction in young people. Patients aging 16-44 years, referred for stroke and age- and gender-matched controls were investigated for migraine following the International Headache Society criteria. Included people were 314 strokes and 314 controls. Each group consisted of 150 men and 164 women. Of the 105 persons with migraine (16.7%), 57 had migraine with aura (9.1%). In women, migraine with aura was related to stroke [35 women among strokes (21.3%) vs. 9 among controls (5.5%), P < 0.0001], whereas migraine without aura was not. After multivariate analysis, migraine with aura remained independently associated with stroke together with hypertension, and the estro-progestinic utilization. In men, migraine was not associated with stroke. In conclusion, migraine with aura appears to be associated with ischemic stroke in young women, independently from other common risk factors.

C-reactive protein and aetiological subtypes of cerebral infarction.

OBJECTIVE: We have sought to relate C-reactive protein (CRP), a peripheral marker of inflammation frequently elevated in stroke patients, with aetiology and prognosis of acute cerebral infarction. PATIENTS AND METHODS: Patients were included after a first-ever CT/MR documented cerebral infarction. CRP was measured from blood samples taken within the 6th hour of the onset. Titres of C-reactive protein were stratified in quartiles. Aetiology of stroke was from TOAST criteria. Prognosis was mortality within 14 days of stroke. RESULTS: The study included 648 stroke patients. They were 335 women and 313 men, with a mean age of 70.3 years (median 72). CRP quartiles were mostly increased in cardioembolic strokes, After logistic regression analysis CRP remained an independent factor of 14-day mortality. CONCLUSIONS: Our study suggests that in the acute phase of the cerebral infarction CRP might be either a marker of cardioembolism or a predictive factor for short-term mortality.

Headache and botulinum toxin.

The authors discuss clinical and international experience about botulinum toxins (BTX types A and B) in headache treatment. Data from literature suggest good results for the treatment of tension-type headache, migraine and chronic tension-type headache. In the present paper mechanisms of action and injection sites will also be discussed.

Intravenous heparin started within the first 3 hours after onset of symptoms as a treatment for acute nonlacunar hemispheric cerebral infarctions.

BACKGROUND AND PURPOSE: Heparin is widely used for acute stroke to prevent thrombus propagation and/or multiple emboli generation, although there is, as yet, no demonstrated efficacy. However, all of the available clinical studies allowed long intervals from stroke to treatment. The purpose of this study was to try an intravenous regimen of unfractionated heparin the acute cerebral infarction starting treatment within the first 3 hours of the onset of symptoms. METHODS: The study was an outcome evaluator-blind design trial. Patients had to display signs of a nonlacunar hemispheric infarction. Selected patients were randomly allocated to receive intravenous heparin sodium or saline. Heparin was infused at a rate to maintain activated partial thromboplastin time ratio 2.0 to 2.5 x control for 5 days. The primary end point was recovery of a modified Rankin score zero to 2 at 90 days of stroke at phone interview by a single physician blind to treatment. Safety end points were death, symptomatic intracranial hemorrhages, and major extracranial bleedings by 90 days of stroke. RESULTS: A total of 418 stroke patients were included. In the heparin group, there were more self-independent patients (38.9% versus 28.6%; P=0.025). In addition, in the same group, there were fewer deaths (16.8% versus 21.9%; P=0.189), more symptomatic brain hemorrhages (6.2% versus 1.4%; P=0.008), and more major extracerebral bleedings (2.9% versus 1.4%; P=0.491). CONCLUSIONS: Intravenous heparin sodium could be of help in the earliest treatment of acute nonlacunar hemispheric cerebral infarction, even keeping into account an increased frequency of intracranial symptomatic brain hemorrhages.