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Purpose: Endovascular thrombectomy (EVT) treatment for acute ischemic stroke is now recommended as a standard of care. However, implementing EVT in routine clinical practice poses many challenges, even in countries with advanced health-care systems. The aim of the current study is to delineate if EVT at our institution is an effective treatment for acute ischemic stroke. Methods: All patients who underwent EVT at our institution between December 2011 and July 2017 were retrospectively assessed from our prospective registry. Clinical and imaging (including the Alberta Stroke Program Early CT [ASPECT] score, single-phase computed tomography angiography, and computed tomography perfusion) criteria were utilized to determine EVT suitability. Primary outcomes included modified Rankin score (mRS) at 90 days and recanalization determined by the modified Treatment in Cerebral Infarction score. Effectiveness was assessed by comparing our cohort with patients receiving EVT in the ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) trial. Results: Eighty-eight patients presented to our hospital after a median of 87 minutes last seen normal. Of these, median ASPECT score was 9. A majority (72%) also received intravenous alteplase. Successful recanalization (≥TICI 2b) was achieved in 79%. At 90 days, 48% (36/75) were functionally independent (mRS score of 0-2) and 28% (21/75) were disabled (mRS score of 3-5); 24% (18/75) died (mRS of 6) within 90 days. Conclusions: An audit of our initial experience with EVT for the treatment of acute ischemic stroke in a small tertiary care center yielded similar results compared to the ESCAPE trial, which is encouraging for implementing this treatment in routine clinical practice.

Objective: The Clock Drawing Test (CDT) is commonly used as a screening tool for the assessment of dementia. The association between the CDT in acute stroke and long-term functional and cognitive outcomes in this population is unknown. The present prospective study is the first to examine if CDT scores in the acute stage after stroke are related to long-term outcomes and to compare the predictive ability of two scoring systems in a large sample of stroke patients. Method: A total of 340 patients admitted to an acute stroke unit were included in the present study. Separate stepwise multiple linear regression analyses were performed with eight independent variables (demographic/pre-stroke variables - age, sex, premorbid functioning; stroke-related variables - stroke severity, localization; cognitive variables - Orientation Test, CDT [2 scoring systems]), and four dependent variables administered one year post-stroke (Barthel Index, modified Rankin Scale, Reintegration to Normal Living index, Global Deterioration Scale). Results: Although both CDT scoring methods were related to all long-term outcome measures, the more comprehensive scoring system was the only baseline variable that significantly explained the variance in outcome measures in all four multiple regression models. Conclusion: Performance on the CDT in acute stroke is related to long-term outcomes including patients' degree of independence in performing activities of daily living, the degree to which they achieved reintegration into daily occupations, and the degree of cognitive decline observed one-year post-stroke. Future studies are needed to clarify the nature of the relationship between different CDT scoring systems and post-stroke outcomes.

Introduction Debate exists as to whether wake-up stroke (WUS) (i.e. symptoms first noted on waking) differs from stroke developing while awake [awake onset stroke (AOS)]. Unknown onset stroke (UOS) with unclear symptom onset time is infrequently studied. Aims This study aimed to examine differences in stroke characteristics and outcomes in these three groups. Methods The stroke registry database from Halifax Infirmary, Canada, was interrogated for hospitalised stroke patients between 1999–2011. Information was available on demographics, stroke characteristics, and functional status at discharge and six months (modified Rankin score [mRS]). Results Of 3890 patients, 65% had AOS, 21% WUS and 14% UOS. UOS patients were significantly older, more commonly female and living alone than AOS patients, with no difference between AOS and WUS. UOS rates increased from 10 to 16% of patients during the study period ( P < 0·0001). UOS but not WUS had a higher stroke severity than AOS. Intracerebral hemorrhage was less common (9 vs. 13%) and lacunar stroke more common (23 vs. 19%) in WUS compared to AOS. In UOS left hemisphere location was more likely, and lacunar stroke less common. Excellent outcomes were slightly lower for WUS. UOS had significantly higher rates of in-hospital mortality (23 vs. 16%, P < 0·0001) and poorer functional outcome six months after stroke (mRS < 3 in 26% of UOS and 46% of AOS, P = 0·02). Conclusion WUS has lower rates of ICH but similar stroke severity and outcomes to AOS. UOS prevalence appears to be increasing, with higher stroke severity and worse prognosis.

Contexte: Entre 33 et 77% des patients qui survivent a un accident vasculaire cerebral (AVC) eprouvent de la fatigue. Il n'existe pas de consensus concernant les facteurs de risque de la fatigue post AVC, ce qui temoigne peut-etre des multiples facettes de la fatigue. Nous avons caracterise la fatigue post AVC au moyen de l'Echelle des repercussions de la fatigue (ERF), un questionnaire valide qui englobe les aspects physiques, cognitifs et psychosociaux de la fatigue. Methode: Le Stroke Outcomes Study a recrute de facon prospective des patients atteints d'un AVC ischemique en 2001-2002. Les donnees demographiques, le niveau de fonction premorbide (Oxford Handicap Scale, OHS), la severite de l'AVC (Stroke Severity Scale, SSS), le sous-type d'AVC (Oxfordshire Community Stroke Project Classification, OCSP) et le niveau de fonctionnement au moment du conge hospitalier (OHS; Indice de Barthel, IB) ont ete colliges. Une entrevue a ete effectuee 12 mois apres l'AVC pour evaluer le fonctionnement (IB; score de Rankin modifie, SRm), la qualite de vie (Indice de reintegration a la vie normale, IRVN), la depression (echelle de depression geriatrique, EDG) et la fatigue (ERF). Resultats: Nous avons recrute 522 patients atteints d'un AVC ischemique et 228 des patients (57,6%) survivants ont participe au suivi d'un an post AVC. Trente-six pour cent des patients accusaient de la fatigue et 59,5% d'entre eux la consideraient comme l'un des pires symptomes post AVC. L'analyse de regression lineaire a montre une association entre un âge inferieur et une frequence de la fatigue plus elevee ( β = ―0,20 ; p = 0,01), plus prolongee (β =-0,22 ; p < 0,01) et plus invalidante (β = -0,24; p < 0,01). Les patients plus jeunes etaient plus susceptibles de decrire la fatigue comme l'un des pires symptomes post AVC (β = -0,24 ; p < 0,05). Les patients plus jeunes accusaient un impact plus considerable de la fatigue sur la fonction cognitive (β = 0,-27; p < 0,05) et sur la fonction psychosociale (β = -0,27 ; p < 0,05). La fatigue etait correlee aux symptomes depressifs et alterait leur qualite de vie. La fatigue sans depression etait presente chez 49,0% des repondants dont la fatigue etait l'un des pires symptomes bien qu'ils n'avaient pas un score GDS eleve. Conclusions: L'âge etait le seul facteur de prediction constant de la severite de la fatigue lors du suivi un an apres l'AVC: les participants plus jeunes accusaient une fatigue cognitive et psychosociale plus severe.

Background:weaimedtoassesswhethertheperformanceofstrokeoutcomemodelscomprisingsimpleclinicalvariablescould beimprovedbytheadditionofmorecomplexclinicalvariablesandinformationfromthe firstcomputedtomography(CT)scan. Methods: 538 consecutive acute ischaemic and haemorrhagic stroke patients were enrolled in a Stroke Outcome Study between 2001 and 2002. Independent survival (modified Rankin scale ≤2) was assessed at 6 months. Models based on clinical and radiological variables from the first assessment were developed using multivariate logistic regression analysis. Results: three models were developed (I–III). Model I included age, pre-stroke independence, arm power and a stroke severity score (area under a receiver operating characteristic curve, AUC = 0.882) but performed no better than Model II, which comprised age, pre-stroke independence, normal verbal component of the Glasgow coma score, arm power and being able to walk without assistance (AUC 0.876). Model III, including two radiological variables and clinical variables, was not statistically superior to model II (AUC 0.901, P = 0.12). Model II was externally validated in two independent datasets (AUCs of 0.773 and 0.787). Conclusion: this study demonstrates an externally validated stroke outcome prediction model using simple clinical variables. Outcome prediction was not significantly improved with CT-derived radiological variables or more complex clinical variables.

BackgroundCaregiver burden following stroke can have significant adverse health consequences for caregivers and threatens the recovery and successful rehabilitation of patients. Our objective was to identify patient factors that contribute to higher levels of caregiver burden.MethodsWe prospectively studied patients admitted to our stroke unit over a 2-year period (2001-2002). Data were collected at baseline and at 1 year. Caregiver burden was measured at 1 year using the Relatives Stress Scale (completed by 155 caregivers) and the Bakas Caregiver Outcomes Scale (143 caregivers). Explanatory patient factors at baseline included sociodemographic status, stroke severity, stroke sub-type, functional disability (Barthel Index), functional handicap (Oxford Handicap Scale and Modified Rankin Scale), and cognitive status (orientation, clock drawing). At 1 year, mental health and health-related quality of life were assessed using the Fatigue Impact Scale, Geriatric Depression Scale, Global Deterioration Scale, and 36-item Short Form Health Survey.ResultsThe baseline patient factors predictive of caregiver burden by multiple regression analysis were older patient age ( PConclusionsThe functional status of patients can be used to identify caregivers at risk of caregiver burden. Patient demographic variables, cognitive function, and mental health status may further expose vulnerable caregivers. These factors should be considered in the development of strategies to offset caregiver burden.

Contexte : Des etudes cliniques randomisees ont demontre que l'activateur du plasminogene tissulaire (tPA) administre par voie intraveineuse ameliore l'issue dans l'accident vasculaire cerebral ischemique aigu (AVCIA). Nous avons effectue une etude cas-temoin chez des patients d'un hopital presentant un AVCIA afin d'evaluer si l'efficacite potentielle du traitement par le tPA se traduit par une efficacite reelle en pratique clinique. Methodes : 151 patients, ayant subi un AVCIA et ayant ete traites par tPA entre 1996 et 2005, ont ete apparies 1:1 quant a l'âge, au sexe, au score pre-AVC a l'Oxford Handicap Scale (OHS), a la severite de l'AVC et au sous-type, et en aveugle quant a l'issue, a des temoins tires d'un registre prospectif. Les criteres d'evaluation etaient le deces pendant l'hospitalisation, l'hemorragie intracrânienne symptomatique (HICS), la duree du sejour hospitalier (DSH), le score OHS au moment du conge et la survie a long terme. Resultats : Nous n'avons constate aucune difference entre les cas et les temoins (p = 0,83) quant a la mortalite intra-hospitaliere (23% vs 24%) et a la survie a long terme (suivi median de 2 ans). 7,8% des patients traites par le tPA ont presente une HICS (IC de 95%: 4,2 a 13,5%). La DSH mediane des cas etait plus courte (13 [7-29] vs 16 [8-32] jours, p = 0,14) mais la difference n'etait pas significative. Cependant elle etait significative pour les femmes traitees par le tPA par rapport a celles qui n'avaient pas recu ce traitement (14 [7-28] vs 20 [11-34] jours, p = 0,04). Au moment du conge hospitalier, les patients traites par le tPA qui n'avaient aucune invalidite etaient de 6,6% plus nombreux (IC de 95% : 1,1 a 12,0%) que les temoins (OHS < 1,p = 0,02). Cependant, il n'y avait pas de difference quant au taux d'independance au moment du conge hospitalier ou quant a la proportion des patients qui retournaient a domicile. Conclusion: Nous demontrons qu'il existe une amelioration mineure quant a la recuperation precoce apres un AVCIA si on administre du tPA, mais l'impact est moins dramatique que celui qui a ete rapporte dans les etudes randomisees. Ceci pourrait etre du au moment ou le traitement est administre et au type de patients traites.

Background models to predict functional status post-stroke have utility in balancing groups in randomised trials, for outcome comparison between stroke centres and may assist in outcome prediction. This study aimed to develop models of both excellent [modified Rankin score (mRS) 0-1] and devastating outcomes (mRS of 5-6). Methods patients admitted with ischaemic or haemorrhagic stroke in 2001-02 to the Halifax Infirmary, Canada, were enrolled. Sixteen clinical variables from the first neurological assessment and six radiological variables from the acute CT scan were used to the model outcome at 6 months. Results five hundred and thirty-eight stroke patients were enrolled. Thirty per cent had an excellent outcome and 30% had a devastating outcome. Three models of the excellent outcome were developed [area under the receiver operator curve (AUC) 0.866-882] including the variables age, pre-stroke functional status, stroke severity, ability to lift both arms, walk independently, normal verbal Glasgow Coma Scale and leukoaraiosis. Predictive models of the devastating outcome (AUC of 0.859-0.874) included additional variables living alone pre-stroke and total anterior circulation stroke. The simplest models of both outcomes were externally validated (AUC of 0.856-0.885). Conclusion this study demonstrates new externally validated predictive models of both excellent and devastating outcomes. Leukoaraiosis was the only independent radiological predictor of both outcomes. Living alone pre-stroke predicted devastating outcome post-stroke.

Background and Purpose— Studies suggest that women with stroke are investigated less aggressively and receive tissue plasminogen activator less frequently than men. We tested whether gender differences in the investigation, treatment, and outcome of stroke are due to confounding factors. Methods— Gender differences in the use of investigations, trial enrollment, treatment with intravenous tissue plasminogen activator, and in-hospital outcomes were examined in data from our prospective registry using multivariate analysis to adjust for age, prestroke functional status, stroke subtype and severity, and atrial fibrillation. Results— Of 2725 consecutive hospitalized patients (1996 to 2006), 88% had ischemic stroke and 48% were women. Women were older (median age, 77 versus 70 years), had more severe strokes, and were less likely to be independent prestroke (78% versus 87%) compared with men (all P Conclusion— The majority of the gender differences in stroke were explained by confounding. More research is required to understand gender differences in stroke pathophysiology and the utilization of thrombolytic therapy.