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W Oliver Tobin1, Byron R Spencer2, Bart M Demaerschalk21Department of Neurology, Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Ireland; 2Department of Neurology, Mayo Clinic Arizona, USAAbstract: Herpes zoster is caused by varicella zoster virus infection involving the dorsal root ganglia of spinal nerve roots. This common problem can be associated with multiple neurological abnormalities. We present a case of Herpes zoster affecting the T1 dermatome associated with ipsilateral Horner’s syndrome and radicular weakness.Keywords: Herpes zoster, Horner’s syndrome, spinal ganglia, postherpetic neuralgia, spinal nerve roots

See related article, pages 2279–2283 . Symptomatic intracerebral hemorrhage (SICH) risk is the factor most likely to preclude tissue plasminogen activator (tPA) use by emergency physicians. Of the 40% of respondents to the American College of Emergency Physicians survey about tPA for acute ischemic stroke who would not use tPA in the ideal setting reported that this was attributable to SICH risk.1 From the same survey, we learned that in the respondents’ minds, the highest clinically acceptable mean risk of SICH was 3.4% (compared with 6.4% risk reported in the tPA arm of the National Institute of Neurological Disorders and Stroke [NINDS] trial). The American Academy of Emergency Medicine (AAEM) has created an educational tool entitled “tPA for Stroke—Potential Benefit, Risk, and Alternatives,” dated May 3, 2007, that was circulated to its membership.2 The document was designed to help emergency physicians inform patients and family members about the pros and cons of tPA for stroke in appropriate patients. The tool emphasizes how important it is for physicians to weigh the possibility of benefit (improved function at 3 months) against the possibility of harm (severe bleeding or death). The AAEM has produced an accompanying illustration to pictorially and quantitatively convey the probabilities of “good recovery,” “poor or no recovery,” and “brain bleed and death” with and without tPA in cohort of acute ischemic stroke patients. In reviewing the potential benefit, the illustration suggests that 8 of 18 stroke patients who receive tPA will have a good recovery by 3 months after the event. This is compared to 6 of 18 stroke patients who recover substantially with good outcome without tPA. Even more importantly, in reviewing the potential risk, the illustration suggests that bleeding into the brain, with high …

Computerized clinical decision support systems are increasingly popular in health sciences and have been demonstrated to improve practitioner performance.1 For an emergency closely related to ischemic stroke, acute myocardial infarction, a thrombolytic predictive instrument was developed for real-time use in emergency medical-service settings to identify patients likely to benefit from thrombolysis and to facilitate the earliest possible use of this therapy.2,3 A similar instrument, designed for ischemic stroke, could also prove to be useful. Thrombolysis for ischemic stroke remains underused even under ideal circumstances. Approximately 40% of emergency physicians in a national survey report that they would not use recombinant tissue plasminogen activator (rt-PA) for stroke, citing the risk of symptomatic intracranial hemorrhage and relative lack of benefit.4 Similar results were reported by Bobrow et al in a survey of the Arizona chapter of the American College of Emergency Physicians. Only 52% of the emergency physicians who responded to the survey indicated that they would endorse rt-PA use for stroke under ideal conditions.5 Physicians’ perceptions of risks and benefits of rt-PA for stroke are not uniformly accurate.6 Merino et al reported that only 11% (95% CI, 0 to 22) of surveyed emergency medicine physicians and neurologists could correctly convey the expected magnitude of beneficial effect of rt-PA, and that only 39% (95% CI, 21 to 57) could accurately report the expected rate of symptomatic and fatal intracranial hemorrhage of rt-PA.6 This misperception may interfere with their willingness to endorse this treatment. It would be helpful to draw a distinction between true and perceived efficacy and between true and perceived harm associated with rt-PA for stroke. In this issue of Stroke, Kent et al7 developed a Stroke-Thrombolytic Predictive Instrument (TPI) to aid physicians considering thrombolysis for a patient with acute ischemic stroke. The authors …

Cerebrovascular disease, including acute ischemic stroke, remains a major public health problem in the US and throughout the world. There has been a concerted effort to apply evidence-based practices to stroke care to improve primary and secondary prevention as well as poststroke outcomes. Geography and workforce shortages contribute to a disparity in stroke care, however, among the substantial proportion of the US population that lives outside the reach of an acute stroke–ready hospital or a primary or comprehensive stroke center. In an attempt to combat the rural-to-urban disparity and expand the availability of best stroke practices, Levine and Gorman proposed the development of telemedical outreach for acute stroke evaluation and management, which they called “telestroke.” Since then, the practice of telestroke has been found to have a high interrater agreement with a bedside assessment of the National Institutes of Health Stroke Scale score, to enhance correct thrombolysis decision making as compared with telephone-only consultation, and to be cost-effective. In light of these findings and the perception of benefit by acute stroke providers and patients, there has been growing interest in and a rapid expansion of telestroke networks in the US and internationally. There are legal and financial barriers to more widespread use of telemedicine in general, including telestroke. Further research is needed to understand the potential merits of telestroke infrastructure for the many phases of stroke care including poststroke hospitalization, prevention of complications, enhancing secondary prevention, and education of patients and providers.

Minor and major bleeding complications have occurred following thrombolysis in acute ischemic stroke. However, compartment syndrome has not been reported among these incidences.This article presents a case of a forearm compartment syndrome in a patient with stroke who had fallen at the time of the infarction and was treated with tissue plasminogen activator. We wish to forewarn clinicians who may encounter similar cases.Patients suffering from stroke who fall are at risk of developing a compartment syndrome; the early diagnosis is often difficult, the sequelae can be devastating, and wrestling with the benefits and risks of reversing the coagulopathy in the acute phase of a cerebral infarction is a challenge.

Objective: Our objective is to characterize mentorship in vascular neurology and provide recommendations to prepare future leaders. We assess the hypothesis that there is a consensus among neurologists regarding the importance of mentorship in vascular neurology and mechanisms for its enhancement. Background Vascular neurology is an evolving area of medicine that requires specialty-trained clinicians committed to the field. A conduit for this endeavor is mentorship. Many sources cite mentorship as an integral role in clinician development, but information specific to mentorship in vascular neurology is limited. Design/Methods: North American vascular neurologists were surveyed to assess mentorship. Email invitations to participate in an IRB approved, confidential, anonymous survey were sent to American Board of Psychiatry and Neurology Vascular Neurology Diplomates and Canadian Stroke Consortium registered vascular neurologists. The survey included demographic, reflective, and satisfaction questions. Results: The response rates were 123/591 (21%) and 25/95 (26%) among American and Canadian respondents, respectively. All neurologists surveyed received mentorship in their careers, and 57% had served as mentors. Eighty percent (95%CI,72-85%) strongly agreed that mentorship is critical to the training of vascular neurologists. One-third (95%CI,22-41%) cited the opportunity to foster research skills and 23% (95%CI,15-32%) named clinical skill development as the most valuable aspects of mentorship. While 83% (95%CI,76-89%) expressed satisfaction with their mentorship experience, 92% (95%CI,83-96%) felt that the experience could have been enhanced. Sixty-nine percent (95%CI,57-78%) called for formalization of mentorship programs. The most frequently named recommendations for future mentorship experiences were a well-defined curriculum and career-planning services, 28% (95%CI,22-41%) and 13% (95%CI,15-33%), respectively. Conclusions: The allocation of protected time for clinical and research endeavors, as well as career advising are vital to successful mentorship experiences. As evidenced, there is a need for formalization (e.g. mentor-mentee pairing), in addition to developed curricula. Although the value of mentorship in vascular neurology is clear, a more formal analysis is needed. Supported by: Funding for this study was provided by Vladimir Hachinski9s Paul Morley Mentorship Award of the Canadian Stroke Network. Disclosure: Dr. Minzer has nothing to disclose. Dr. Miley has nothing to disclose. Dr. Hachinski has received personal compensation for activities with Boehringer Ingelheim Pharmaceuticals, Inc., Servier, Uriach as a participant in Symposia.Dr. Hachinski has received personal compensation in an editorial capacity for Lippincott Williams & Wilkins for serving as Editor-in-Chief of the American Heart Association Journal STROKE. Dr. Kachroo has nothing to disclose.

Objective: To assess the cost-utility of a telestroke network in the management of acute ischemic stroke (AIS) from the societal perspective. Background A hub-and-spoke telestroke network is an effective way to extend quality emergency stroke care to remote hospitals and improve patient outcomes. The economic consequences of these networks must be considered. Design/Methods: A lifetime Markov model was developed to compare the incremental costs and effectiveness with and without a telestroke network in AIS treatment. One-year transition probabilities between the three health states--minimal to no disability (modified Rankin scale [mRS] 0-2), disability (mRS 3-5), and death--were derived from the literature. Costs included telemedicine set-up and maintenance, treatment for initial and recurrent AIS (including inter-hospital transfers), rehabilitation, long-term care, and caregiver costs and were estimated in 2011 dollars. Effectiveness was defined as quality-adjusted life years (QALYs). Model inputs were obtained from the literature supplemented by data from Georgia Health Sciences University and Mayo Clinic telestroke networks. The base case used a network model with 1 hub and 7 spokes and assumed no survival benefits from acute treatment in a network. Costs and QALYs were discounted at 3% per year. One-way sensitivity analyses were conducted. Results: In the base case, an AIS patient treated in a network incurred $1,436 lower costs and gained 0.02 QALYs over a lifetime compared with one treated without a network. Incremental costs decreased over time from $444 for the first year to -$1,436 over a lifetime; incremental QALYs increased from 0.002 for the first year to 0.02 over a lifetime. Incremental costs increased with higher transfer rates and lower rates of endovascular stroke therapy usage. Conclusions: A telestroke network is cost-saving and more effective compared with no network from the societal perspective in most scenarios. Results may be sensitive to specific network features. Supported by: Genentech, Inc. Disclosure: Dr. Demaerschalk has received personal compensation for activities with Genentech and Otsuka. Dr. Switzer has nothing to disclose. Dr. Xie has received personal compensation for activities with Analysis Group, Inc. as an employee. Mr. Fan has received personal compensation for activities with Analysis Group, Inc., as an employee. Ms. Villa has received personal compensation for activites with Genentech, Inc. as an employee. Dr. Wu has received personal compensation for activities with Analysis Group, Inc. as an employee.

Objective: To assess the cost-effectiveness of a telestroke network in the management of acute ischemic stroke (AIS) from three perspectives: the network, hub, and spoke. Background A hub-and-spoke telestroke network is an effective way to extend quality emergency stroke care to remote hospitals and improve patient outcomes. The costs of these networks to the participating hospitals must be considered. Design/Methods: A decision analytic model was developed to compare cost and effectiveness with and without a telestroke network over a 5-year time horizon. The model considered changes in rates of teleconsultations, intravenous (IV) thrombolysis, endovascular stroke therapies, and spoke-to-hub transfers with and without the network. These inputs were estimated using data from Georgia Health Sciences University and Mayo Clinic telestroke networks. Costs included telemedicine set-up and maintenance costs, treatment costs, and reimbursement for AIS. Effectiveness was defined as discharges to home. Incremental effectiveness was assumed to result only from the increased number of patients treated with IV thrombolysis and/or endovascular stroke therapies. One-way sensitivity analyses were conducted. Results: Compared with no network, a network model with 1 hub and 7 spokes resulted in 45 more patients treated with IV thrombolysis and 20 more with endovascular stroke therapies per year, leading to 5.49 more home discharges per 1000 AIS patients. Across a span of transfer rates from 0% to 100%, incremental costs ranged from -$556,000 to -$6000 for the network, $1,485,000 to -$3,428,000 for the hub, and from -$292,000 to $489,000 for each spoke, with negative costs reflecting savings. Results were sensitive to rates of endovascular stroke therapies and transfers. Conclusions: In most scenarios, a telestroke network costs less and is more effective than no network from the network perspective. With increasing transfer rates, the hub experiences greater cost savings while spokes bear higher costs. Supported by: Genentech, Inc. Disclosure: Dr. Switzer has nothing to disclose. Dr. Demaerschalk has received personal compensation for activities with Genentech and Otsuka. Dr. Xie has received personal compensation for activities with Analysis Group, Inc. as an employee. Mr. Fan has received personal compensation for activities with Analysis Group, Inc., as an employee. Ms. Villa has received personal compensation for activites with Genentech, Inc. as an employee. Dr. Wu has received personal compensation for activities with Analysis Group, Inc. as an employee.

A 42-year-old woman underwent transthoracic echocardiography with agitated saline contrast injection after an ischaemic stroke; a right-to-left shunt was observed ( Figure A ). Transesophageal echocardiography with agitated saline contrast injection (‘bubble study’) was then performed; bubbles were apparent in the left atrium after four …

To the Editor: Emergency room (ER) physicians and neurologists are critical in ensuring a prompt evaluation of patients arriving at the ER within 3 hours of symptom onset and in initiating therapy with tPA. Suboptimal institutional readiness for evaluating patients with acute stroke and fear about the hemorrhagic complications among neurologists are some of the factors that can limit the widespread use of tPA, as reported by Katzan et al.1 Family physicians play an important role in educating patients at risk for stroke about the warning signs of stroke and the importance of contacting 911 as soon as these appear. Limited knowledge about the benefits and an unjustified fear of the side effects may limit stroke patients’ access to this treatment. …

Background The 3-hour window for treating stroke with intravenous tissue plasminogen activator (t-PA) requires well-organized, integrated efforts by emergency physicians and stroke neurologists. Objective To evaluate attitudes and knowledge of emergency physicians about intravenous t-PA for acute ischemic stroke, particularly in primary stroke centers (PSCs) with stroke neurology teams. Methods A 15-question pilot Internet survey administered by the Arizona College of Emergency Physicians. Results Between March and August 2005, 100 emergency physicians responded: 71 in Arizona and 29 in Missouri. Forty-eight percent practiced at PSCs; 48% thought t-PA was effective, 20% did not, and 32% were uncertain. PSC or non-PSC location of practice did not influence endorsement (odds ratio, 0.96; 95% confidence interval, 0.27–1.64). Of those opposing t-PA, 87% cited risk of hemorrhage. Conclusions Most emergency physicians did not endorse t-PA. Improved collaboration between emergency physicians and stroke neurologists is needed.

ACUTE STROKE: BENCH TO BEDSIDE edited by Anish Bhardwaj, Nabil J. Alkayed, Jeffrey R. Kirsch, and Richard J. Traystman, 515 pp., Informa Healthcare, 2006, $229.95 Acute Stroke: Bench to Bedside is an outstanding comprehensive textbook that accomplishes the stated goal of filling a recognized void in the stroke market by offering information about the continuum from basic science research to relevant patient care in the field. The common acute cerebrovascular conditions including intracerebral hemorrhage, subarachnoid hemorrhage, focal and global cerebral ischemia, and infarction are equally well represented in this textbook. Nearly …

Le score ASPECT dans l'evaluation de l'infarctus >1/3 du territoire de l'artere cerebrale moyenne. Objectif: Comparer la fiabilite interobservateur. che/ des neurologues specialises dans l'accident vasculaire cerebral (AVC). pour le score ASPECT et la methode ICE (idealize-close-estimatel d'estimation de l'infarctus >1/3 du territoire de l'artere cerebrale moyenne (TACM) et determiner si le score ASPECT predit bien l'infarctus >1/3 du TACM dans l'AVC ischemique aigu. Contexte: Selon les donnees du European Cooperative Acute Stroke Study. l'atteinte >1/3 du TACM a la tomodensitometrie realisee tot apres l'evenement serait un facteur de risque de l'hemorragie intracerebrale symptomatique (HICS) suite au traitement par l'activateur du plasminogene tissulaire (t-PA) dans l'AVC ischemique aigu. mais sa fiabilite interobservateur serait mediocre (kappa 0.49) en l'absence d'une methode systematique d'estimation. La methode ICE a ete developpee pour standardiser la demarche d'estimation de la taille de l'infarctus du TACM en phase precoce et elle a une tres bonne fiabilite interobservateur (kappa 0.72). ASPECTS possede une fiabilite interobservateur comparable et on considere qu'il peut predire tant l'issue neurologique que l'HICS. Methodes: Cinq neurologues specialistes de l'AVC ont participe a l'etude de 40 tomodensitometries d'AVC ischemique aigu. Chaque neurologue a fait une evaluation independante des changements ischemiques precoces. a l'aveugle, au moyen du score ASPECT et de la methode ICE. Le standard de reference etait l'opinion majoritaire de 1/3 TACM determine par cinq neuroradiologistes. Une courbe ROC a ete etablie et des rapports de vraisemblances ont ete calcules. La concordance aleatoire corrigee (kappa) et la concordance aleatoire independante (phi) ont ete calculees pour les deux methodes et une analyse de variance a ete utilisee pour estimer la fiabilite au missel du coefficient de correlation intraclasse pour ASPECTS. Resultats: Les rapports de vraisemblances pour un test positif (>1/3 TACM) etaient extremement eleves et concluants (pres de l'infini) pour des scores ASPECT de 0 a 3; ils etaient eleves et concluants (30. 20 et 10) pour des scores ASPECT de 4. 5 et 6 respectivement: ils etaient de 1 et inutiles pour un score ASPECT de 7 et de nouveau extremement eleves et concluants (pres de zeron pour des scores ASPECT de 8 a 10. La courbe ROC suggerait qu'un point de coupe ASPECTS de moins de sept etait optimal pour estimer 1/3 TACM (sensibilite de 94% et specificite de 98%). Les statistiques kappa et phi etaient assez bonnes pour ASPECTS et ICE (0.7). Le coefficient de correlation intraclasse etait de 0.8. Conclusions: Quand des neurologues possedant une vaste experience de l'AVC utilisent une methode standard reconnues soit ASPECTS ou ICE. pour l'evaluation quantitative des changements precoces observes a la tomodensitometrie de l'AVC ischemique aigu. la concordance interobservateur et la fiabilite en sont ameliorees et sont satisfaisantes. ASPECTS permet un estime robuste et concluant de la presence de l'atteinte de 1/3 TACM et un point de coupe < 7 donne la meilleure performance.

Amelioration des resultats de la trombolyse chez les patients porteurs d'un accident vasculaire cerebral et rencontrant des criteres specifiques a l'imagerie. Introduction: Une etude du NINDS effectuee en 1995 a demontre les benefices de l'administration intraveineuse de l'activateur du plasminogene tissulaire (tPA) en phase aigue de l'accident vasculaire cerebral ischemique (AVCI). Le taux d'hemorragie intracrânienne symptomatique (HICS) dans l'etude NINDS etait de 6.4%, ce qui peut decourager certains medecins d'utiliser ce medicament. Methodes: Depuis le premier decembre 1998, les patients porteurs d'un AVCI a London, Ontario ont ete traites selon les criteres de l'etude NINDS avec une exception importante: ceux qui avaient une lesion impliquant plus d'un tiers du territoire de l'artere cerebrale moyenne reproduit par la neuro-imagerie ont ete exclus du traitement. La methode utilisee pour estimer le territoire implique porte l'acronyme ICE et avait une valeur kappa mediane de 0.80 parmi cinq medecins. Les resultats ont ete compares a ceux de l'etude NINDS. Resultats: 30 patients ont ete traites entre le premier decembre 1998 et le premier fevrier 2000. Plus de patients de London ont ete traites apres 90 minutes (p