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.

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.

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.