Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke.

Background And Purpose: Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt).

Methods: Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population-based cohort were enrolled between January 2003 and October 2007.

Joint commission primary stroke centers utilize more rt-PA in the nationwide inpatient sample.

Background: The Joint Commission began certifying primary stroke centers (PSCs) in December 2003 and provides a standardized definition of stroke center care. It is unknown if PSCs outperform noncertified hospitals. We hypothesized that PSCs would use more recombinant tissue plasminogen activator (rt-PA) for ischemic stroke than would non-PSCs.

Headache as a risk factor for neurovascular events in pediatric brain tumor patients.

Objective: To determine whether severe recurrent headache is a risk factor for neurovascular events in children who received radiation for brain tumors.

Methods: This is a retrospective cohort study of children with brain tumors who received cranial irradiation at a large tertiary care center, aged 0-21 years at diagnosis, with initial treatment between January 1, 1993 and December 31, 2002, and 2 or more follow-up visits. Patients were considered to have severe recurrent headache if this appeared as a complaint on 2 or more visits.

Convergent validity and interrater reliability of estimating the ABCD2 score from medical records.

Background And Purpose: The ABCD(2) score is increasingly used for risk stratification of transient ischemic attack patients. We sought to determine the reliability and convergent validity of retrospective ABCD(2) score estimation from medical records.

Methods: We compared ABCD(2) scores that were prospectively determined by a vascular neurology attending to scores determined retrospectively from medical record review.

Treatment of acute stroke in patients on dabigatran: a survey of US stroke specialists.

Background: There are no guidelines for thrombolysis in stroke patients taking dabigatran, or dabigatran reversal strategies in patients with ICH. We sought to assess how vascular neurologists plan to care for these patients.

Methods: An Internet-based questionnaire was sent to US board-certified vascular neurologists.

Seizures do not increase in-hospital mortality after intracerebral hemorrhage in the nationwide inpatient sample.

Background: Seizures are common after intracerebral hemorrhage (ICH) but their impact on outcome is uncertain and prophylactic anti-convulsant use is controversial. We hypothesized that seizures would not increase the risk of in-hospital mortality in a large administrative database.

Methods: The study population included patients in the 2006 Nationwide Inpatient Sample over the age of 18 with a principal diagnosis of ICH (ICD9 = 431).

Anti-Phosphatidylserine-Prothrombin Antibodies are Associated with Outcome in a TIA Cohort.

Background: Antiphospholipid antibodies (aPLs) have been associated with thrombosis in the antiphospholipid antibody syndrome (APS) and with atherosclerotic vascular events in patients without APS. We examined the significance of aPLs in transient ischemic attack (TIA).

Patients/methods: Patients with TIA <48 h from symptom onset were prospectively enrolled.

Cranial irradiation increases risk of stroke in pediatric brain tumor survivors.

Background And Purpose: The purposes of this study were to determine the incidence of neurovascular events as late complications in pediatric patients with brain tumor and to evaluate radiation as a risk factor.

Methods: Patients were ascertained using the tumor database of a pediatric tertiary care center. Included patients had a primary brain tumor, age birth to 21 years, initial treatment January 1, 1993, to December 31, 2002, and at least 2 visits with neuro-oncology.

Frontal lobe abnormalities on MRS correlate with poor letter fluency in ALS.

Objective: To examine whether frontal lobe abnormalities on magnetic resonance spectroscopy (MRS) in amyotrophic lateral sclerosis (ALS) correlate with poor letter fluency (LF).

Methods: Twenty-five patients with ALS (20 with definite, probable, or possible ALS and 5 with progressive muscular atrophy) performed an LF task, involving F word generation in 1 minute, and underwent MRS. Comparisons were made between patients with ALS with impaired LF and unimpaired LF based on an empirically derived cutoff score.

Use of tissue-type plasminogen activator before and after publication of the European Cooperative Acute Stroke Study III in Get With The Guidelines-Stroke.

Background: The European Cooperative Acute Stroke Study (ECASS) III demonstrated benefit to expanding the intravenous tissue-type plasminogen activator (tPA) window from 3 to 4.5 hours for patients with acute ischemic stroke (AIS). We investigated how this trial influenced use of tPA in clinical practice.

A pilot study of darbepoetin alfa for prophylactic neuroprotection in aortic surgery.

Background: Descending aortic (DA) surgery poses a high risk for spinal and cerebral infarction and routine use of lumbar drains allows for measurement of CSF markers of neurologic injury. Erythropoiesis medications have extensive preclinical data demonstrating neuroprotection. We hypothesized that prophylactic darbepoetin alfa (DARB) given before surgery reduces neurologic injury in patients undergoing DA repair.

Risk factors and outcome of patients with symptomatic intracranial stenosis presenting with lacunar stroke.

Background And Purpose: We hypothesized that patients with intracranial stenosis with lacunar stroke presentations would face lower risks of recurrent stroke than those with index nonlacunar strokes, and that their recurrent strokes would predominantly be lacunar.

Methods: We analyzed subjects enrolled with an index stroke into the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial. The index stroke was classified as lacunar or nonlacunar.

Concurrent validity and reliability of retrospective scoring of the Pediatric National Institutes of Health Stroke Scale.

Background And Purpose: The Pediatric National Institutes of Health Stroke Scale (PedNIHSS), an adaptation of the adult National Institutes of Health Stroke Scale, is a quantitative measure of stroke severity shown to be reliable when scored prospectively. The ability to calculate the PedNIHSS score retrospectively would be invaluable in the conduct of observational pediatric stroke studies. The study objective was to assess the concurrent validity and reliability of estimating the PedNIHSS score retrospectively from medical records.

Toll-like receptor 4 contributes to poor outcome after intracerebral hemorrhage.

Objective: Intracerebral hemorrhage (ICH) is a devastating stroke subtype in which perihematomal inflammation contributes to neuronal injury and functional disability. Histologically, the region becomes infiltrated with neutrophils and activated microglia followed by neuronal loss, but little is known about the immune signals that coordinate these events. This study aimed to determine the role of Toll-like receptor 4 (TLR4) in the innate immune response after ICH and its impact on neurobehavioral outcome.

Informed consent: the rate-limiting step in acute stroke trials.

Successful implementation of a randomized clinical trial (RCT) for neuro-vascular emergencies such as cerebral infarction, intracerebral hemorrhage, or subarachnoid hemorrhage is extraordinarily challenging. Besides establishing an accurate, hyper-expedited diagnosis among many mimics in a person with acute neurological deficits, informed consent must be obtained from this vulnerable group of patients who may be unable to convey their own wishes, grasp the gravity of their situation, or give a complete history or examination. We review the influences, barriers, and factors investigators encounter when providing established and putative stroke therapies, and focus on informed consent, the most important research protector of human subjects, as the rate-limiting step for enrollment into acute stroke RCTs.

Predictors of extubation success in patients with middle cerebral artery acute ischemic stroke.

Introduction. Stroke patients often meet respiratory guidelines for extubation, but uncertainty exists if patients will protect their airway due to impaired mental status. Patients with middle cerebral artery (MCA) acute ischemic stroke (AIS) might have specific predictors of successful extubation.

Autologous blood injection to model spontaneous intracerebral hemorrhage in mice.

Investigation of the pathophysiology of injury after intracerebral hemorrhage (ICH) requires a reproducible animal model. While ICH accounts for 10-15% of all strokes, there remains no specific effective therapy. The autologous blood injection model in mice involves the stereotaxic injection of arterial blood into the basal ganglia mimicking a spontaneous hypertensive hemorrhage in man.

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

Background And Purpose: Hospital staffing may be reduced on weekends. Prior studies of weekend disparities in stroke care have focused on in-hospital mortality with variable results. We hypothesized that 90-day mortality was higher in patients with stroke hospitalized on weekends versus weekdays, and this difference has been minimized over time by improvements in organization and delivery of stroke care.

Neutrophil depletion diminishes monocyte infiltration and improves functional outcome after experimental intracerebral hemorrhage.

Inflammation contributes to secondary injury and neuronal loss after intracerebral hemorrhage, but the role of individual immune populations in these processes is unclear. In a mouse model, the injection of autologous blood into the striatum was associated with an intense inflammatory cell infiltrate composed of neutrophils, monocytes, and dendritic cells. Selective depletion of neutrophils resulted in decreased infiltration of monocytes and improved functional outcomes at day 3 post-hemorrhage.

Brain hypoxia is associated with short-term outcome after severe traumatic brain injury independently of intracranial hypertension and low cerebral perfusion pressure.

Background: Brain hypoxia (BH) can aggravate outcome after severe traumatic brain injury (TBI). Whether BH or reduced brain oxygen (Pbto(2)) is an independent outcome predictor or a marker of disease severity is not fully elucidated.

Objective: To analyze the relationship between Pbto(2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) and to examine whether BH correlates with worse outcome independently of ICP and CPP.

Current management of symptomatic intracranial stenosis.

Intracranial arterial stenosis (IAS) is the cause of about 10% of all ischemic strokes in the United States, but may account for about 40% of strokes in some populations. After a stroke or transient ischemic attack due to IAS, patients face a 12% annual risk of recurrent stroke on medical therapy, with most strokes occurring in the first year. Warfarin is no better than aspirin in preventing recurrent strokes but poses a higher risk of serious bleeding and death.

Treatment of acute ischemic stroke: beyond thrombolysis and supportive care.

The initial therapeutic approach to acute ischemic stroke consists of thrombolytic therapy and early initiation of supportive care, usually commenced prior to the determination of the underlying stroke etiology. Varying stroke mechanisms may call for specific, etiology-based treatment. The majority of strokes result from cardioembolism, large-vessel atherothromboembolism, and small-vessel occlusive disease.