Acute care bundles should be used for patients with intracerebral haemorrhage: An expert consensus statement.

PURPOSE: Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality. Currently, not enough patients receive these interventions in the acute phase. METHODS: We convened an expert group to discuss best practices in ICH and to develop recommendations for bundled care that can be delivered in all settings that treat acute ICH, with a focus on European healthcare systems. FINDINGS: In this consensus paper, we argue for widespread implementation of formalised care bundles in ICH, including specific metrics for time to treatment and criteria for the consideration of neurosurgical therapy. DISCUSSION: There is an extraordinary opportunity to improve clinical care and clinical outcomes in this devastating disease. Substantial evidence already exists for a range of therapies that can and should be implemented now.

Performance of a Hospital Pathway for Patients With a New Single Brain Mass.

PURPOSE:: To reduce care variation and improve the management of patients with newly identified single brain masses and no history of cancer, we implemented a dedicated admission protocol. METHODS:: We reviewed records of 206 patients who presented to our emergency department between January 2010 and May 2016 with a new single brain mass but no history of cancer. Patients admitted before the protocol implementation were designated the pre-implementation group (PRE), and those admitted after implementation were designated the post-implementation group (POST). RESULTS:: Ninety-six patients were in the PRE group and 110 in the POST group. Length of stay for POST patients was significantly shorter than for PRE patients (6 v 7 days, respectively; P = .042), and this effect was more robust after excluding the 66 patients who were discharged to rehabilitation, skilled nursing, or hospice facilities (5 v 7 days, respectively; P = .001). Additional comparison of POST with PRE patients showed that time to surgery was significantly reduced (2.7 v 3.5 days, respectively; P = .006) and that computed tomography scans of the chest, abdomen, and pelvis were reduced (12% v 47%, respectively; P < .001). No difference was found in the 30-day readmission rates. For patients with GBM, there also was no significant difference in time to initiation of chemoradiation or in median overall survival. CONCLUSION:: Implementation of a specialized admission pathway for patients with a new single brain mass decreased average length of hospital stay and time to surgery and reduced unnecessary diagnostic imaging tests in patients with primary brain tumors.

Implementation of a Rapid, Protocol-based TIA Management Pathway.

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.

Brachial artery hyperaemic blood flow velocity in relation to established indices of vascular function and global atherosclerosis: the Prospective Investigation of the Vasculature in Uppsala Seniors study.

BACKGROUND: Systolic to diastolic blood flow velocity (SDFV) ratio in the brachial artery recently proved to be related to cardiovascular risk and carotid atherosclerosis. We hypothesized that the SDFV ratio was related to established markers of vascular function and global atherosclerosis. METHODS: Established markers of endothelial function in forearm resistance vessels, flow-mediated vasodilation and arterial stiffness were assessed in the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study including 1016 individuals aged 70. Whole-body magnetic resonance angiography was performed in a random 306 of the participants. Atherosclerotic lesions were summarized in a total atherosclerotic score (TAS). Before and during hyperaemia of the brachial artery, systolic and diastolic blood flow velocities were measured by Doppler. RESULTS: The SDFV ratio was positively related to endothelium-independent vasodilatation, while inverse relations were found to flow-mediated dilation, common carotid artery distensibility and the stroke volume to pulse pressure ratio. Endothelium-dependent vasodilatation and total peripheral resistance index were not significantly related to the SDFV ratio. The SDFV ratio (P = 0·015) and the blood flow increase (BFI) during hyperaemia (P = 0·020) were both significantly related to TAS after gender adjustment. When adjusted for the Framingham risk score, both the SDFV ratio (P = 0·057) and BFI (P = 0·078) lost somewhat in significance. CONCLUSION: The SDFV ratio was related to established markers of both vasodilation and arterial compliance, and to global atherosclerosis. Future larger studies have to evaluate whether the SDFV ratio is related to global atherosclerosis independently of traditional risk factors.

Brachial artery hyperemic blood flow velocities are related to carotid atherosclerosis.

OBJECTIVE: Cardiovascular (CV) risk relates to the blood flow velocity pattern in the brachial artery during hyperemia, especially to the hyperaemic systolic to diastolic mean blood flow velocity (SDFV) ratio. Here, we investigated the relations between SDFV in the brachial artery and different characteristics of carotid atherosclerosis. MATERIAL AND METHODS: Data were collected from 1016 70-year-olds participating in the Prospective Investigation of Uppsala Seniors study. Doppler recordings of blood flow velocity during hyperemia were analysed in the brachial artery. In the carotid artery, intima-media thickness (IMT) was recorded together with an assessment of echogenicity by the Grey scale median (GSM) method in both overt plaques and in the intima-media complex (IM-GSM). RESULTS: The SDFV ratio was related to the number of carotid arteries affected by plaque (P = 0.018) and inversely to plaque echogenicity (P = 0.0003). The SDFV ratio was also related to IMT (P = 0.0022) and inversely to IM-GSM (P = 0.0001). These relations were statistically significant also after adjusting for major CV risk factors, individually as well as summarised as the Framingham risk score. CONCLUSION: Our results indicate that the hyperemic systolic to diastolic blood flow velocity ratio in the brachial artery is related to atherosclerosis in the carotid artery.

Hyperaemic blood-flow velocities in systole and diastole relate to coronary risk in divergent ways.

BACKGROUND: A recent study suggested blood-flow velocity in diastole during reactive hyperaemia as a major driver of flow-mediated vasodilation (FMD) of the brachial artery, also being related to cardiovascular risk factors. The present study aimed to investigate the relative importance of hyperaemic systolic and diastolic blood-flow velocity in the forearm regarding both FMD and cardiovascular risk factors. METHODS: In the Prospective Investigation of the Vasculature in Uppsala Seniors study, conducted in 1016 subjects aged 70 years, FMD, systolic and diastolic blood hyperaemic flow velocities in the brachial artery were evaluated by ultrasound. RESULTS: Hyperaemic blood-flow velocity both in systole and diastole were related to FMD (r = 0.14-0.19, P<0.0001). However, while hyperaemic systolic blood-flow velocity was related to coronary risk (Framingham risk score) in a positive way (r = 0.08, P = 0.013), diastolic blood-flow velocity was inversely related to coronary risk (r = -0.08, P = 0.016). Therefore, the systolic to diastolic hyperaemic blood-flow velocity ratio was more powerful related to coronary risk (r = 0.23, P = 0.0001). In a multiple regression model, both FMD and the systolic to diastolic hyperaemic blood-flow velocity ratio were independent predictors of coronary risk (P = 0.018 and P = 0.0001). CONCLUSION: As hyperaemic blood-flow velocities in systole and diastole in the brachial artery were related to coronary risk in divergent ways, the ratio thereof is a promising index of vascular function providing independent information regarding coronary risk when compared with FMD.