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Background and Purpose: The potential benefit of blood pressure (BP) lowering in intracerebral hemorrhage (ICH) patients is time-dependent and is an easy and modifiable treatment applicable to different hospital scenarios. However, previous clinical trials did not establish consensus about the best BP strategy to achieve a rapid and sustained BP control. We aimed to assess the impact of learning a staged implementation of rapid-intensive-sustained BP protocol on time targets and BP control rate over the first 24 hours of ICH. Methods: We conducted a retrospective analysis of data prospectively collected of consecutive patients with spontaneous ICH (150 mmHg under a rapid (antihypertensive IV bolus by a stroke nurse at CT scan), intensive (SBP target Results: A total of 207 patients were included in the study. Compared between the periods, the frequency of SBP target achievement during the first hour was increased steadily over different periods(33.3% vs. 54.5% vs. 69.2% vs 69.4% vs 75% and 59.7%; P=0.024 ); median time to SBP target achievement tended to be lower during the evolution of protocol assessment (120 [45-240] min; 49.5 [30-101] min; 53 [29-82] min; 47 [28-74] min; 48 [27-66] min; 50 [30-85] min; P=0.054 ) and SBP sustention rate below the target improve during the acute phase at different time frames, including 2h (26.3% vs. 71.9% vs 60% vs 73.9% vs. 57,7% vs 59.5%; P= 0.012 ), 4h (57.1% vs. 63.3% vs 87.5% vs 85% vs. 61.5% vs. 69.2%; P= 0.05 ), 6h (60.9% vs. 58.6%, vs 95.5% vs 84.4% vs 58.3% vs. 75%; P=0.009 ). Conclusions: Rapid-intensive-sustained BP protocol is a good intervention to both achieve a rapid BP target and reduce time delays,and improve the rates of BP control over the acute phase of ICH patients.

Background: Several noncontrast computed tomography (NCCT), single-phase computed tomography angiography (CTA), and multiphase CTA markers of intracerebral hemorrhage (ICH) expansion have been previously proposed. We derived and validated three scores for the prediction of hematoma expansion depending on the use of NCCT, single-phase CTA, or multiphase CTA markers of hematoma expansion. Methods: We prospective studied 276 consecutive patients with ICH within 6 hours from symptom onset. After deriving NCCT, single-phase CTA, and multiphase CTA scores in a 5-year period population (n=156), we validated them in a different 3-year period population (n=120). Outcome parameters included substantial hematoma expansion >6 mL or >33% at 24 hours (primary outcome) and poor outcome (mRS score >2) at 90 days. Results: The most accurate marker of hematoma expansion was spot sign in phase 1 of multiphase CTA (80.3%). The four independent predictors of substantial hematoma expansion included in the different scores were ultraearly hematoma growth (uHG) >5 mL/h, heterogeneous density, spot sign in phase 1 of multiphase CTA, and spot sign in any phase of multiphase CTA (Table). On each of the three scores, the proportion of patients that experienced substantial hematoma expansion increased with each point increase. C-index for both substantial hematoma expansion and poor outcome in the derivation and validation cohort was lower in NCCT expansion score than in single-phase CTA expansion score which, in turn, was lower than in multiphase CTA expansion score (Table). Conclusions: This study demonstrates the added prognostic value of more advanced CT modalities in acute ICH evaluation. Single-phase CTA score and, especially, multiphase CTA score, are more robust than NCCT score in the prediction of hematoma expansion and poor outcome. These scores may help to refine the selection of patients at risk of expansion and poorest outcomes in different decision-making scenarios.

Malaltia d'Alzheimer; Biomarcadors; Microdissecció de captura làser Alzheimer's disease; Biomarkers; Laser capture microdissection Enfermedad de Alzheimer; Biomarcadores; Microdisección por captura láser Brain accumulation of amyloid-beta (Aβ) is a crucial feature in Alzheimer´s disease (AD) and cerebral amyloid angiopathy (CAA), although the pathophysiological relationship between these diseases remains unclear. Numerous proteins are associated with Aβ deposited in parenchymal plaques and/or cerebral vessels. We hypothesized that the study of these proteins would increase our understanding of the overlap and biological differences between these two pathologies and may yield new diagnostic tools and specific therapeutic targets. We used a laser capture microdissection approach combined with mass spectrometry in the APP23 transgenic mouse model of cerebral-β-amyloidosis to specifically identify vascular Aβ-associated proteins. We focused on one of the main proteins detected in the Aβ-affected cerebrovasculature: MFG-E8 (milk fat globule-EGF factor 8), also known as lactadherin. We first validated the presence of MFG-E8 in mouse and human brains. Immunofluorescence and immunoblotting studies revealed that MFG-E8 brain levels were higher in APP23 mice than in WT mice. Furthermore, MFG-E8 was strongly detected in Aβ-positive vessels in human postmortem CAA brains, whereas MFG-E8 was not present in parenchymal Aβ deposits. Levels of MFG-E8 were additionally analysed in serum and cerebrospinal fluid (CSF) from patients diagnosed with CAA, patients with AD and control subjects. Whereas no differences were found in MFG-E8 serum levels between groups, MFG-E8 concentration was significantly lower in the CSF of CAA patients compared to controls and AD patients. Finally, in human vascular smooth muscle cells MFG-E8 was protective against the toxic effects of the treatment with the Aβ40 peptide containing the Dutch mutation. In summary, our study shows that MFG-E8 is highly associated with CAA pathology and highlights MFG-E8 as a new CSF biomarker that could potentially be used to differentiate cerebrovascular Aβ pathology from parenchymal Aβ deposition. This work was funded by the Instituto de Salud Carlos III (ISCIII), (PI20/00465), co-financed by the European Regional Development Fund (FEDER). The Neurovascular Research Laboratory is part of the INVICTUS + network, ISCIII, Spain (RD16/0019/0021). P.M. held a predoctoral fellowship from the Vall d’Hebron Research Institute. MMV is supported by the BIONIC project (no. 733050822, which has been made possible by ZonMW as part of ‘Memorabel’, the research and innovation program for dementia, as part of the Dutch national ‘Deltaplan for Dementia’:the CAFÉ project (the National Institutes of Health, USA, grant number 5R01NS104147-02), and a grant from the Selfridges Group Foundation (NR170024). The BIONIC project is a consortium of Radboudumc, LUMC, ADX Neurosciences, and Rhode Island University.

Methods: We analyzed data from 190 patients in a prospective unicentric study. Thrombi obtained in emergent endovascular treatment ( EVT) were analyzed by MFC order to calculate the percentage of granulocytes , monocytes and lymphocytes, over total leukocyte population as well as monocyte-to-lymphocyte ratio ( MLR) Clinical and interventional parameters were recorded for each patient. Stroke subtypes were defined by the Trial of ORG 10172 in Acute Stroke Treatment classification. We tested MFC predictors of high risk cardioembolic strokes (HR CE) in patients with undetermined stroke etiology . MFC predictor was obtained by comparison of clots due to Large Arterial Atherosclerosis compared with clots due to HR CE. Results: Among 190 clots retrieved, 163 cases were properly analized. 91 cases with known stroke etiology after EVT and 72 cases of Undetermined stroke. In a demographic (age, gender) and EVT matched (time, tpa, number of passes) case -control study of 56 patients: HR CE strokes (28 cases) and LAA strokes (28 cases), the proportion of monocytes ( OR 1.06 , 95% CI 1.01- 1.11) and MLR ( OR 1.83 , 95% CI 1.12- 2.98) independently predicted HR CE detection. A cut-off point of 1.77% in a receiver operating characteristic curve predicted cardiomebolic etiology with sensitivity of 71% and specificity of 82%. Among Undetermined Strokes (n=72) the percentage of HR CE detection was higher in patients with high MLR (n=40 ; 74%) compared with low MLR (n=6; 33%) ( p< 0.001). Patients with high MLR were older than low MLR cases, although MLR > 1.77 independently predicted HR CE detection among Undetermined strokes (OR, 4.50 ,95% CI 1.35-15.04) in a multivariate model adjusted for age. Conclusion: Measurement of monocyte to lymphocyte ratio in clots by multiparametric flow cytometry detected patients at high risk of hidden cardioembolic origin among undetermined stroke population.

Producción Científica, Cerebral amyloid angiopathy (CAA) refers to beta-amyloid (Aβ) deposition in brain vessels and is clinically the main cause of lobar intracerebral hemorrhage (ICH). Aβ can also accumulate in brain parenchyma forming neuritic plaques in Alzheimer’s disease (AD). Our study aimed to determine whether the peripheral lipid profile and lipoprotein composition are associated with cerebral beta-amyloidosis pathology and may reflect biological differences in AD and CAA. For this purpose, lipid and apolipoproteins levels were analyzed in plasma from 51 ICH-CAA patients (collected during the chronic phase of the disease), 60 AD patients, and 60 control subjects. Lipoproteins (VLDL, LDL, and HDL) were isolated and their composition and pro/antioxidant ability were determined. We observed that alterations in the lipid profile and lipoprotein composition were remarkable in the ICH-CAA group compared to control subjects, whereas the AD group presented no specific alterations compared with controls. ICH-CAA patients presented an atheroprotective profile, which consisted of lower total and LDL cholesterol levels. Plasma from chronic ICH-CAA patients also showed a redistribution of ApoC-III from HDL to VLDL and a higher ApoE/ApoC-III ratio in HDL. Whether these alterations reflect a protective response or have a causative effect on the pathology requires further investigation., Instituto de Salud Carlos III y Fondo Europeo de Desarrollo Regional (FEDER) - (grant PI13/00364, PI16/00471, PI14/01134 and PI17/00275), Instituto de Salud Carlos III - (grant FI17/00031), Instituto de Salud Carlos III, Programa Miguel Servet - (grant CPII17/00010), Instituto de Salud Carlos III - (project RD16/0019/0021), Generalitat de Catalunya - (Grupo 2017-SGR-1149)

Resumen Objetivo Proporcionar un conjunto de recomendaciones actualizadas y basadas en la evidencia disponible para el manejo del ictus agudo. Nuestro objetivo es proporcionar una base para el desarrollo de los protocolos internos de cada centro, sirviendo de referencia para los cuidados de enfermeria. Metodos Revision de evidencias disponibles sobre los cuidados del ictus agudo. Se han consultado las guias nacionales e internacionales mas recientes. Los niveles de evidencia y grados de recomendacion se han basado en la clasificacion del Centro de Medicina Basada en la Evidencia de Oxford. Resultados Se describen la atencion y los cuidados del ictus agudo en la fase prehospitalaria, el funcionamiento de codigo ictus, la atencion por el equipo de ictus a la llegada al hospital, los tratamientos de reperfusion y sus limitaciones, el ingreso en la Unidad de Ictus, los cuidados de enfermeria en la Unidad de Ictus y el alta hospitalaria. Conclusiones Estas pautas proporcionan recomendaciones generales basadas en la evidencia actualmente disponible para guiar a los profesionales que atienden a pacientes con ictus agudo. En algunos casos, sin embargo, existen datos limitados demostrando la necesidad de continuar investigando sobre el manejo del ictus agudo.

Background and Purpose: Extracranial internal carotid artery (ICA) lesion in the setting of tandem occlusions is a therapeutic challenge, and hemorrhagic transformation (HT) is one of the leading causes of poor clinical outcome. We aimed to determine determinants of HT for tandem occlusions undergoing emergent extracranial ICA stenting during endovascular treatment (EVT). Methods: We performed a prospective, observational cohort study of consecutive patients with non-cardioembolic ischemic stroke due to tandem occlusion who underwent EVT with extracranial ICA stent placement during the procedure from April 2013 to June 2019 in a single stroke center. We compared clinical (vascular risk factors, previous antiplatelet treatment, and IV rtPA), radiological (ASPECTS at admission and in-stent thrombosis at 24 hours) and serological (platelet count, fibrinogen, total cholesterol, HDL-cholesterol, and LDL-cholesterol) parameters according to the presence of HT in 24 hours CT-scan. Results: One-hundred and eight patients were included: 78.7% were men, mean age 68.5±14.3 years, median time from symptoms onset to treatment was 220 (150-337.5) minutes, median ASPECTS at admission was 9 (8-10). Eighty-six (79.6%) patients presented an extracranial ICA occlusion, and 22 (20.4%) a high-grade (>50%) stenosis. In 88 (81.5%) patients the etiology of extracranial ICA lesion was ateroma, and in 20 (18.5%) was a dissection. Intravenous rtPA was administered in 47 (43.5%) patients. Successful recanalization (mTICI ≥2b) was achieved in 83 (76.9%) patients, and extracranial ICA recanalization in 108 (100%) patients. Type 2 diabetes (OR 1.5, 95% CI 1.1-3.5), higher fibrinogen levels (OR 4.6, 95% CI 1.6-12.9), and ASPECTS Conclusions: Patients with a non-cardioembolic ischemic stroke due to tandem occlusion who present type 2 diabetes, higher fibrinogen levels, or ASPECTS

Background: Endovascular therapies(EVT) have exponentially increased in the last few years. To maximize the benefits of EVT, complications related to the treatment need to be prevented or minimized with early detection and appropriate management. We implemented a specific registry to collect femoral post-puncture complications detected at different timepoints. Our aim was to identify factors associated with severe groin punction complications. Methods: Prospective study of consecutive patients treated with acute EVT or scheduled (angioplasty), admitted to our Stroke Unit from February2017-June2018. Post-catheterization femoral complications included: groin bleeding(GB), groin hematoma(GH), retroperitoneal hematoma(RH), femoral artery pseudoaneurysm(FAP), and artery dissection(AD). A specific registry was created for data collection at different timepoints: During or immediate post-EVT, at 24h post-compression and at discharge. Results: 384patients were treated with EVT(73%acute), mean age 71+/-13y.o, 69% men. Mynxgrip closure system was used in 346(91,8%). Compressive measures needed to be reinforced in 55 cases(14,5%)/changed in 15(4%). Early mobilization protocol(24-48h) was initiated in 335patients(92,3%). 9patients (2,8%) did not maintain the first 24h absolute rest. 57patients(15,1%) presented mild immediate complications(49GH,6GB). At 24h, 181(47,1%)patients presented GH(28,6%superficial, 18,2%internal) and 5GB(1,3%). At discharge, 29(8,1%)patients had presented clinically significant femoral complications: 16GH(13deep), 5FAP, 1AD, 4RH. 2 of those complications were fatal. Variables associated with severe complications at discharge were: age(p=0.037), non-use of mynxgrip(p=0.001), compressive replacement(p Conclusion: In our series, we found a yield of 8,1% of clinically significant groin complications associated with the EVT (0,5% fatal). We indentified age, closure device, requirement to replace compressive and lack of accomplishment of the early mobilization protocol as predictors of these complications.

Background and Purpose: Recent studies have highlighted the key influence of both time to achieve blood pressure (BP) control and the persistence of BP stable in the potential benefit of intensive BP reduction on attenuating intracerebral hemorrhage (ICH) expansion. We aimed to compare two different BP management protocols in acute ICH to determine the influence of stroke nursing practice in BP control over first 24h. Methods: Consecutive patients with spontaneous ICH 150 mmHg under an early (antihypertensive IV bolus by nursing attention at CT scan), intensive (SBP target Results: One hundred and three Early-Intensive-Maintained SBP patients were matched with 103 controls. Mean age was 71.7±13.3 years, 134 (65%) were men, and median SBP was 177 (162-197) mmHg. Median time to SBP target achievement was lower in Early-Intensive-Maintained SBP patients as compared with control group (45 [30-60] vs. 90 [27-167.50] min, P=0.045 ). Early-Intensive-Maintained SBP patients maintained the SBP below the target more frequently than control group at different time points, including 60 min (40.8% vs. 36.9%, P P P P Conclusions: The stroke nurse plays a key role in the management of BP in acute ICH patients. An early and continued nursing care allows a fast and maintained BP reduction in acute ICH patients under an intensive BP reduction protocol.