Search

Background: A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. There is still conflicting evidence whether reperfusion is associated with a lower risk for CED in acute ischemic stroke. Aim: To investigate the association of reperfusion with development of early CED after stroke thrombectomy. Methods: From the SITS-International Stroke Thrombectomy Registry, we selected patients with occlusion of the intracranial internal carotid or middle cerebral artery (M1 or M2). Successful reperfusion was defined as mTICI ⩾ 2b. Primary outcome was moderate or severe CED, defined as focal brain swelling ⩾1/3 of the hemisphere on imaging scans at 24 h. We used regression methods while adjusting for baseline variables. Effect modification by severe early neurological deficits, as indicators of large infarct at baseline and at 24 h, were explored. Results: In total, 4640 patients, median age 70 years and median National Institutes of Health Stroke Score (NIHSS) 16, were included. Of these, 86% had successful reperfusion. Moderate or severe CED was less frequent among patients who had reperfusion compared to patients without reperfusion: 12.5% versus 29.6%, p < 0.05, crude risk ratio (RR) 0.42 (95% confidence interval (CI): 0.37–0.49), and adjusted RR 0.50 (95% CI: 0.44-0.57). Analysis of effect modification indicated that severe neurological deficits weakened the association between reperfusion and lower risk of CED. The RR reduction was less favorable in patients with severe neurological deficits, defined as NIHSS score 15 or more at baseline and at 24 h, used as an indicator for larger infarction. Conclusion: In patients with large artery anterior circulation occlusion stroke who underwent thrombectomy, successful reperfusion was associated with approximately 50% lower risk for early CED. Severe neurological deficit at baseline seems to be a predictor for moderate or severe CED also in patients with successful reperfusion by thrombectomy. [ABSTRACT FROM AUTHOR]

Background: Transcranial Doppler (TCD) ultrasonography is the only noninvasive examination that provides a reliable evaluation of intracranial blood flow patterns in real-time, adding physiological information to the anatomical information obtained from other neuroimaging modalities. TCD is relatively cheap, can be performed bedside, and allows monitoring both in acute emergency settings as well as over prolonged periods; it has a high temporal resolution, making it ideal for studying dynamic cerebrovascular responses. Objective: To define the role of TCD in the evaluation of patients with acute ischemic stroke. Material and methods: We have analyzed the existing literature on the protocols for performing TCD in the evaluation of patients with acute cerebral ischemia. Extended applications of TCD in enhancing intravenous thrombolysis in acute stroke, emboli monitoring, right-to-left shunt detection, and vasomotor reactivity have also been described. Results: In acute cerebral ischemia, TCD is capable of providing rapid information about the hemodynamic status of the cerebral circulation, monitoring recanalization in real-time and, additionally, has a potential for enhancing tissue plasminogen activator (TPA)-induced thrombolysis. Extended applications of TCD make it an important and valuable tool for evaluating stroke mechanisms, for planning and monitoring treatment, and for determining prognosis. Discussion and conclusion: TCD has an established clinical value in the diagnostic workup of stroke patients and is suggested as one of the essential components of a comprehensive stroke center. TCD is also an evolving ultrasound method with increasing diagnostic value and a therapeutic potential in cerebral ischemia

The ongoing pandemic of COVID-19 is a global public health emergency. This has led to challenges for healthcare facilities to optimally manage other important medical emergencies. Stroke is an important public health emergency with significant mortality and morbidity. Timely treatment of acute stroke is critical to prevent disability. The current expert consensus statement on behalf of the Indian Stroke Association outlines the issues and suggestions related to the management of stroke during this ongoing COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Intravenous thrombolysis (IVT) for lacunar stroke (LS) is debated, as the underlying pathophysiological mechanism may not be thrombogenic. Aims: To investigate outcomes after IVT in LS in the SITS International Stroke Thrombolysis Register and perform a meta-analysis. Methods: LS was identified by both baseline NIHSS-subscores and discharge ICD-10 codes, and contrasted by IVT to non-IVT treated. IVT patients were predominantly from Europe, non-IVT patients predominantly from South America and Asia. Outcome measurements were functional independence (modified Rankin Scale [mRS] score ≤2), excellent outcome (mRS ≤ 1), and mortality at three months. Matched-control comparisons of symptomatic intracerebral hemorrhage (SICH) between IVT-treated LS and IVT-treated non-LS patients were performed. Additionally, we performed a meta-analysis. Results: Median age for IVT-treated LS patients (n = 4610) was 66 years vs. 64 years and NIHSS score was 6 vs. 3, compared to non-IVT-treated LS (n = 1221). Univariate outcomes did not differ; however, IVT-treated LS patients had higher adjusted odds ratios (aOR) for functional independence (aOR = 1.65, 95% CI = 1.28–2.13) but similar mortality at three months (aOR = 0.57, 0.29–1.13) than non-IVT-LS. Propensity-score matched analysis showed that IVT-treated LS patients had a 7.1% higher chance of functional independency than non-IVT LS patients (p < 0.001). IVT-treated LS patients had lower odds for SICH (aOR = 0.33, 0.19–0.58 per SITS, aOR = 0.40, 0.27–0.57 per ECASS-2) than matched non-LS controls, which was mirrored in the meta-analysis. Conclusions: Our adjusted results show that IVT treatment in LS patients was associated with better functional outcome than non-IVT-treated LS and less SICH than IVT-treated non-LS patients. [ABSTRACT FROM AUTHOR]

In India, stroke care services are not well developed. There is a need to explore alternative options to tackle the rising burden of stroke. Telemedicine has been used by the Indian Space Research Organization (ISRO) to meet the needs of remote hospitals in India. The telemedicine network implemented by ISRO in 2001 presently stretches to around 100 hospitals all over the country, with 78 remote/rural/district health centers connected to 22 specialty hospitals in major cities, thus providing treatment to more than 25 000 patients, which includes stroke patients. Telemedicine is currently used in India for diagnosing stroke patients, subtyping stroke as ischemic or hemorrhagic, and treating accordingly. However, a dedicated telestroke system for providing acute stroke care is needed. Keeping in mind India’s flourishing technology sector and leading communication networks, the hub-andspoke model could work out really well in the upcoming years. Until then, simpler alternatives like smartphones, online data transfer, and new mobile applications like WhatsApp could be used. Telestroke facilities could increase the pool of patients eligible for thrombolysis. But this primary aim of telestroke can be achieved in India only if thrombolysis and imaging techniques are made available at all levels of health care. [ABSTRACT FROM AUTHOR]

As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe. • This multicentric study compares demographic profile, treatment and outcomes of the stroke patients during pre- pandemic and pandemic period. • No significant difference in stroke admissions or thrombolysis was observed apart from a decline during the initial phase of pandemic and lockdown. • A significant reduction in rates of endovascular stroke therapy were observed. • In hospital workflow metrics were affected possibly due to overwhelmed health care systems for COVID care. • Although higher mortality rate was observed during the pandemic study period, the proportion of patients achieving a good outcome were similar. [ABSTRACT FROM AUTHOR]

Posterior circulation strokes (PCS) have been less extensively studied than anterior circulation strokes (ACS), especially regarding revascularization therapies. We analyzed the differences in baseline stroke characteristics, revascularization therapy and 3-month outcomes between PCS and ACS in a large prospective multicentre Indian stroke registry. Patients with acute ischemic stroke recruited in the Indo-US collaborative stroke project from January 2012 to August 2014 were classified into PCS and ACS based on imaging-confirmed infarct location. Demographics, stroke severity, risk factors, and mechanisms were compared. We further compared these parameters in the subgroups who received revascularization therapies (RT) and no revascularization therapies (NRT). The primary outcome was 3-month modified Rankin scale (mRS). Of 1889 patients (1270 males), 1478 (78.2%) had ACS and 411 (21.8%) PCS. The median NIHSS was lower in PCS (7 vs 11, p < 0.001). Diabetes mellitus and hypertension were more common in PCS and rheumatic heart disease in ACS. Small artery occlusion was higher in PCS (23.8% vs 12.9%, p < 0.001). Only 28 (6.8%) PCS received RT compared to 213 (14.4%) ACS. At 90 days, a good functional outcome (mRS 0–2) was more common in PCS (56.4% vs 45.9%, p < 0.001) in NRT group, while no significant difference was noted in RT group. Stroke territory was not an independent predictor of 3-month outcome in regression analysis. In-hospital mortality was not different between the groups. The 3-month functional outcome and in-hospital mortality were not different between ACS and PCS. Compared to ACS, PCS received revascularization therapies less often. • The study compared posterior and anterior circulation strokes from a multicentric prospective acute stroke study from India. • Three-month outcome and mortality were similar in posterior and anterior circulation strokes. • The stroke severity was less in posterior circulation strokes and they received revascularization therapy less often. [ABSTRACT FROM AUTHOR]