Symptomatic Intracranial Hemorrhage With Tenecteplase vs Alteplase in Patients With Acute Ischemic Stroke: The Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke (CERTAIN) Collaboration.

Importance: Symptomatic intracranial hemorrhage (sICH) is a serious complication of stroke thrombolytic therapy. Many stroke centers have adopted 0.25-mg/kg tenecteplase instead of alteplase for stroke thrombolysis based on evidence from randomized comparisons to alteplase as well as for its practical advantages.

Racial Disparity in Mechanical Thrombectomy Utilization: Multicenter Registry Results From 2016 to 2020.

Background Previous studies on racial disparity in mechanical thrombectomy (MT) treatment of acute large vessel occlusion stroke lack individual patient data that influence treatment decision-making. We assessed patient-level data in a large US health care system from 2016 to 2020 for racial disparities in MT utilization and eligibility. Methods and Results A retrospective study was performed of 34 596 patients admitted to 43 hospitals from January 2016 to September 2020.

Ceribell EEG shortens seizure diagnosis and workforce time and is useful for COVID isolation.

Objective: To determine whether the portable Ceribell electroencephalograph (EEG) (Mountain View, CA) used for suspected status epilepticus (SE) can reduce time to diagnosis and on-call workforce demands and whether it can be applied to patients in respiratory isolation.

Methods: A multidisciplinary team developed a protocol for the use of the Ceribell EEG. The staff deploying the device, the attending physician, and the interpreting neurologist completed evaluation tools for each patient.

Patient Characteristics and Outcomes Associated with Decline in Stroke Volumes During the Early COVID-19 Pandemic.

Background And Purpose: Delayed evaluation of stroke may contribute to COVID-19 pandemic-related morbidity and mortality. This study evaluated patient characteristics, process measures and outcomes associated with the decline in stroke presentation during the early pandemic.

Methods: Volumes of stroke presentations, intravenous thrombolytic administrations, and mechanical thrombectomies from 52 hospitals from January 1-June 30, 2020 were analyzed with piecewise linear regression and linear spline models.

Diagnosing deep cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) is a relatively rare vascular disorder involving the formation of a thrombus in the venous system of the cerebral vasculature. The nonspecificity of clinical symptoms seen with CVT elicits significant diagnostic challenges with the potential of serious morbidity and mortality associated with delays in therapeutic intervention. We present a case of CVT in a young patient who presented with loss of consciousness with no headache or focal deficits, the usual type of presentation.

A regional system of stroke care provides thrombolytic outcomes comparable with the NINDS stroke trial.

Study Objective: Administration of tissue plasminogen activator (tPA) for acute ischemic stroke remains controversial in community practice. Well-organized hierarchic systems of acute stroke care have been proposed to link community hospitals to comprehensive stroke centers. We report safety and functional outcomes in patients treated with tPA in our regional emergency stroke network and compare them with results reported from the trial conducted by the National Institute of Neurological Disorders and Stroke (NINDS).

Ensuring emergency medicine performance standards for stroke and transient ischemic attack care.

This article reviews emergency medicine evaluation and management performance standards for cerebrovascular event patients and provides a practical process for ensuring high quality care. Areas of practice that most frequently generate questions and controversy are highlighted. The term "cerebrovascular event" is used throughout the text when both stroke and transient ischemic attack apply to the discussion.

Outcomes from a comprehensive stroke telemedicine program.

Our team has studied the use of telemedicine to overcome obstacles to providing acute stroke care and expanding stroke education. We report a summary of our outcomes to provide evidence supporting greater development of stroke telehealth systems. Stroke telemedicine is audio-video communication (teleconferencing) between a stroke specialist and a remote party requiring stroke services.

Shortening time to stroke treatment using ambulance telemedicine: TeleBAT.

Objective: Patients with ischemic stroke treated with tissue plasminogen activator (rt-PA) have better outcomes when treated closer to the time of symptom onset and within the 3-hour window. We previously demonstrated the clinical use of TeleBAT, a mobile telemedicine system for stroke. We tested the impact of that system on time to treatment for patients with acute stroke.

Evaluation and management of transient ischemic attacks.

The risk for disabling stroke is greatest in the period immediately following a transient ischemic attack (TIA), thus, TIA is a medical emergency. A universities medical center's emergency department-based TIA evaluation and management program is presented as an example of the pragmatic enactment of current guidelines for TIA evaluation and management. A discussion of modifications that can be made for an outpatient setting evaluation and a review of the literature follow.

Anticoagulation strategies for treatment of ischemic stroke and antiphospholipid syndrome: case report and review of the literature.

A 49-year-old Caucasian man with antiphospholipid syndrome who experienced an ischemic stroke required multidisciplinary decisions regarding acute and long-term care. The patient first received warfarin and unfractionated heparin, followed by low-molecular-weight heparin. However, he developed complications from these drugs (warfarin-induced necrosis and heparin-induced thrombocytopenia), resulting in thigh necrosis and multiple additional cerebral and peripheral infarcts.

Alternative parenteral anticoagulation with argatroban, a direct thrombin inhibitor.

Argatroban, a direct thrombin inhibitor, effectively inhibits free and clot-bound thrombin without the need of a cofactor and exerts dose-dependent anticoagulant effects that are rapidly active and rapidly reversible (elimination half-life: 39-51 min). Argatroban provides predictable parenteral anticoagulation and is well tolerated with an acceptably low bleeding risk in a variety of clinical settings, including heparin-induced thrombocytopenia, acute ischemic stroke, percutaneous coronary intervention and hemodialysis. This review will discuss the clinical pharmacology and utility of argatroban; in particular, clinical trial experiences will be discussed in patients with, or at risk of, heparin-induced thrombocytopenia (where heparins must be avoided) including those requiring hemodialysis or percutaneous coronary intervention, and in patients with acute ischemic stroke (where heparins are not generally recommended).

A noninvasive portable acoustic diagnostic system to differentiate ischemic from hemorrhagic stroke.

Purpose: To determine if a noninvasive brain acoustic monitor can differentiate acoustic responses from "normal patients" and ischemic from hemorrhagic stroke patients.

Methods: A laptop-sized passive acoustic monitoring system acquires arterial-pressure-generated signals during a 15-second monitoring session from sensors placed at the radial artery and on the fore-head. The arterial pulse waveform from the head is compared with that of the arterial waveform to generate the time-domain signal comparison.

Acute ischemic stroke successfully treated using sequenced intravenous and intra-arterial thrombolysis and argatroban anticoagulation: a case study.

Background: Direct thrombin inhibitors, a class of anticoagulants distinct from heparins, have not been evaluated for immediate use after thrombolytic therapy in acute ischemic stroke. We report a case of ischemic stroke and prothrombotic state treated using sequenced intravenous and intra-arterial thrombolytic therapy and argatroban anticoagulation.

Case Description: A 19-year-old man with a complicated history of recurrent life-threatening thrombosis presented at the emergency department with acute ischemic stroke.

Argatroban anticoagulation in patients with acute ischemic stroke (ARGIS-1): a randomized, placebo-controlled safety study.

Background And Purpose: Direct thrombin inhibitors, including argatroban, represent an anticoagulant class distinct from heparins. We investigated the safety of 2 levels of argatroban anticoagulation in acute ischemic stroke.

Methods: This multicenter, randomized, double-blinded, placebo-controlled study included 171 patients with acute (< or =12 hours from onset) stroke and National Institutes of Health Stroke Scale (NIHSS) scores of 5 to 22.

Stroke in patients with heparin-induced thrombocytopenia and the effect of argatroban therapy.

Objective: To investigate the frequency, mortality rate, and characteristics of stroke in heparin-induced thrombocytopenia and the effect of argatroban therapy in that setting.

Design: Retrospective analysis of two prospective studies of argatroban therapy in heparin-induced thrombocytopenia.

Setting: Hospitalized care.

Argatroban in thrombotic stroke.

Evidence for the potential use of direct thrombin inhibition in the treatment of acute stroke is reviewed. Reduction of secondary microthrombi and improved regional collateral cerebral blood flow is the proposed mechanism of action of thrombin inhibition for the treatment of cerebral ischemia. A clinical study in Japan found that argatroban administered within 48 h of stroke symptom onset is safe and effective in reducing neurological impairment due to ischemic stroke.

Telemedicine for acute stroke: triumphs and pitfalls.

Background And Purpose: Telemedicine is emerging as a potential timesaving, efficient means for evaluating patients experiencing acute stroke. In areas where local stroke care specialists are not available, telemedicine can link an emergency department physician with a specialist in a stroke treatment center. This consultation provides an opportunity for administration of thrombolytic drugs within the short therapeutic time window associated with ischemic stroke.