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Background: The treatment of acute ischemic stroke in Ontario is coordinated through a network of stroke centers, supplemented by emergency telemedicine consultations to nonstroke centers through the Ontario Telemedicine Network's province-wide Telestroke program. Using geoinformatics, we sought to evaluate the overall impact of Telestroke on access to stroke thrombolysis in Ontario.Methods: Ontario population data (census) were used to overlay polygons created by Service Area Analysis using ArcGIS 10.1. Service areas were divided into predefined driving times toward the nearest stroke center. Centers were compared after they were categorized as being able to administer stroke thrombolysis either independently or through the Telestroke program.Results: Of the 12,857,821 people living in Ontario in 2011, 99.83% had timely access to stroke thrombolysis, leaving 21,829 people, exclusively within Northern Ontario, without access. Of the population, 71.86% was within a 30-minute drive of a regional or district stroke center, increasing to 91.28% when the Telestroke program was included, for an additional 2,501,121 people. Of the population, 1.85% had access to stroke thrombolysis only through the extended time window (between 3 and 4.5 hours), increasing to 3.86% with Telestroke, for an additional 258,618 people.Conclusion: The vast majority of people in Ontario have access to stroke thrombolysis. The provincial Telestroke program improves timeliness of access for those living in Southern Ontario, although some remote rural and Northern communities remain without access. Geoinformatics may likewise prove useful in coordinating provincial access to endovascular thrombectomy. [ABSTRACT FROM AUTHOR]

Background: Despite concerns regarding hypoperfusion in patients with large-artery occlusive disease, strict blood pressure (BP) control has become adopted as a safe strategy for risk reduction of stroke. We examined the relationship between BP control, blood flow, and risk of subsequent stroke in the prospective Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study.Methods: The VERiTAS study enrolled patients with recent vertebrobasilar (VB) transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion of vertebral or basilar arteries. Hemodynamic status was designated as low or normal based on quantitative magnetic resonance angiography. Patients underwent standard medical management and follow-up for primary outcome event of VB territory stroke. Mean BP during follow-up (<140/90 versus ≥140/90 mm Hg) and flow status were examined relative to subsequent stroke risk using Cox proportional hazards analysis.Results: The 72 subjects had an average of 3.8 ± 1.2 BP recordings over 20 ± 8 months of follow-up; 39 (54%) had mean BP of<140/90 mm Hg. The BP groups were largely comparable for baseline demographics, risk factors, and stenosis severity. Comparing subgroups stratified by BP and hemodynamic status, we found that patients with both low flow and BP <140/90 mm Hg (n = 10) had the highest risk of subsequent stroke, with hazard ratio of 4.5 (confidence interval 1.3-16.0, P = .02), compared with the other subgroups combined.Conclusions: Among a subgroup of patients with VB disease and low flow, strict BP control (BP <140/90) may increase the risk of subsequent stroke. [ABSTRACT FROM AUTHOR]

Objectives To conduct a systematic review to elucidate the frequency, recovery, and associated outcomes for poststroke aphasia over the long-term. Data Sources Using the Cochrane Stroke Strategy, we searched 10 databases, 13 journals, 3 conferences, and the gray literature. Study Selection Our a priori protocol criteria included unselected samples of adult stroke patients from randomized controlled trials or consecutive cohorts. Two independent reviewers rated abstracts and articles for exclusion or inclusion, resolving discrepancies by consensus. Data Extraction We documented aphasia frequencies by stroke type and setting, and computed odds ratios (ORs) with their 95% confidence intervals (CIs) for outcomes. Data Synthesis We retrieved 2168 citations, reviewed 248 articles, and accepted 50. Median frequencies for mixed stroke (ischemic and hemorrhagic) were 30% and 34% for acute and rehabilitation settings, respectively. Frequencies by stroke type were lowest for acute subarachnoid hemorrhage (9%) and highest for acute ischemic stroke (62%) when arrival to the hospital was ≤3 hours from stroke onset. Articles monitoring aphasia for 1 year demonstrated aphasia frequencies 2% to 12% lower than baseline. Negative outcomes associated with aphasia included greater odds of in-hospital death (OR=2.7; 95% CI, 2.4–3.1) and longer mean length of stay in days (mean=1.6; 95% CI, 1.0–2.3) in acute settings. Patients with aphasia had greater disability from 28 days (OR=1.5; 95% CI, 1.3–1.7) to 2 years (OR=1.7; 95% CI, 1.6–2.0) than those without aphasia. By 2 years, they used more rehabilitation services (OR=1.5; 95% CI, 1.3–1.6) and returned home less frequently (OR=1.4; 95% CI, 1.2–1.7). Conclusions Reported frequencies of poststroke aphasia range widely, depending on stroke type and setting. Because aphasia is associated with mortality, disability, and use of health services, we recommend long-term interdisciplinary vigilance in the management of aphasia. [ABSTRACT FROM AUTHOR]

Highlights: [•] Dysphagia, dysarthria, and aphasia co-occur frequently after a first ischemic stroke. [•] Most patients with dysphagia have concomitant dysarthria or aphasia after a first ischemic stroke. [•] Non-alert level of consciousness and increased stroke severity predict the risk of dysphagia after stroke onset. [•] Physicians are usually the first health professionals to identify dysarthria and aphasia. [Copyright &y& Elsevier]

Study Design: Population-based, case-control and case-crossover study. Objective: To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke. Summary of Background Data: Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke. Methods: Cases included eligible incident VBA strokes admitted to Ontario hospitals from April I, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls. Results: There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke. Conclusion: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. [ABSTRACT FROM AUTHOR]

Abstract: This paper discusses the early lessons learned in establishing the Registry of the Canadian Stroke Network (RCSN), particularly the pitfalls related to the requirement for informed patient (or surrogate) consent for inclusion in the registry. The need for stroke registries to collect accurate data that are representative of all patients with acute stroke in a given community is emphasized, and how the current methodology strives to reach this goal is outlined. [Copyright &y& Elsevier]

Introduction Thrombocytopenia may be associated with a greater risk of cerebral hemorrhage and thrombocytosis may be associated with a greater risk of cerebral thrombosis. There is a paucity of studies focused on the potential association between blood platelet count (BPC) and outcomes after acute ischemic stroke (AIS). We hypothesized that abnormal BPC is associated with poorer outcomes after AIS. Methods This study included data from the Ontario Stroke Registry on consecutive patients with AIS admitted between July 2003 and March 2008. Patients were divided into groups as follows: low BPC (< 150,000/mm 3 ), normal BPC (150,000 to 450,000/mm 3 ) and high BPC (> 450,000/mm 3 ). Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurologic Scale: < 8), greater degree of disability at discharge (modified Rankin score: 3–6), and 30-day and 90-day mortality. Results We included 9230 patients. Both low and high BPC were associated with higher 30-day mortality (p ≤ 0.0335) and 90-day mortality (p ≤ 0.048) following AIS. The Kaplan–Meier curves indicate that abnormal BPC is associated with greater mortality after AIS (p = 0.0002). Nonetheless, abnormal BPC was not associated with initial stroke severity (p ≥ 0.225), degree of disability (p ≥ 0.3761), or length of stay in the acute stroke care center (p ≥ 0.7818) after adjustment for major potential confounders. Conclusions Thrombocytopenia and thrombocytosis on the initial admission are associated with higher mortality after AIS. Abnormal BPC does not adversely affect the degree of initial impairment, disability at discharge, or length of stay in the acute care hospital after AIS. [ABSTRACT FROM AUTHOR]

Background: Neuroprotection with NA-1 (Tat-NR2B9c), an inhibitor of postsynaptic density-95 protein, has been shown in a primate model of stroke. We assessed whether NA-1 could reduce ischaemic brain damage in human beings.Methods: For this double-blind, randomised, controlled study, we enrolled patients aged 18 years or older who had a ruptured or unruptured intracranial aneurysm amenable to endovascular repair from 14 hospitals in Canada and the USA. We used a computer-generated randomisation sequence to allocate patients to receive an intravenous infusion of either NA-1 or saline control at the end of their endovascular procedure (1:1; stratified by site, age, and aneurysm status). Both patients and investigators were masked to treatment allocation. The primary outcome was safety and primary clinical outcomes were the number and volume of new ischaemic strokes defined by MRI at 12-95 h after infusion. We used a modified intention-to-treat (mITT) analysis. This trial is registered with ClinicalTrials.gov, number NCT00728182.Findings: Between Sept 16, 2008, and March 30, 2011, we randomly allocated 197 patients to treatment-12 individuals did not receive treatment because they were found to be ineligible after randomisation, so the mITT population consisted of 185 individuals, 92 in the NA-1 group and 93 in the placebo group. Two minor adverse events were adjudged to be associated with NA-1; no serious adverse events were attributable to NA-1. We recorded no difference between groups in the volume of lesions by either diffusion-weighted MRI (adjusted p value=0·120) or fluid-attenuated inversion recovery MRI (adjusted p value=0·236). Patients in the NA-1 group sustained fewer ischaemic infarcts than did patients in the placebo group, as gauged by diffusion-weighted MRI (adjusted incidence rate ratio 0·53, 95% CI 0·38-0·74) and fluid-attenuated inversion recovery MRI (0·59, 0·42-0·83).Interpretation: Our findings suggest that neuroprotection in human ischaemic stroke is possible and that it should be investigated in larger trials.Funding: NoNO Inc and Arbor Vita Corp. [ABSTRACT FROM AUTHOR]

Abstract: Background: Studies of potential gender differences in stroke care and outcomes have yielded inconsistent findings. The Project for an Ontario Women’s Health Evidence-based Report study measured established stroke care indicators in a large, representative sample of women and men with stroke or transient ischemic attack (TIA) admitted to acute care institutions in the province of Ontario, Canada. Methods: The Registry of the Canadian Stroke Network performs a biennial audit on a random sample of 20% of patients with stroke or TIA seen at more than 150 acute care institutions across Ontario. We used data from the 2004/05 audit to compare stroke care by gender, with stratification by age and neighborhood income. Results: The sample consisted of 4,046 patients (51% women). There were no significant gender differences in the use of thrombolysis, neuroimaging, carotid imaging, dysphagia screening, antithrombotic therapy, or neurology and other consultations. Women with ischemic stroke or TIA were less likely than men to be prescribed statins or undergo carotid imaging and endarterectomy within 6 months of stroke; women were more likely than men to receive antihypertensives. There were no significant gender differences in readmission or mortality rates after stroke. Interpretation: In this population-based study, we found little evidence of gender differences in stroke care or outcomes other than lipid-lowering therapy, carotid imaging, and endarterectomy. Further study is needed to assess the contribution of the provincial stroke strategy in eliminating gender differences in management of acute stroke and to better understand and target remaining gender differences in management. [Copyright &y& Elsevier]