Patent foramen ovale closure in stroke patients with migraine in the CLOSE trial. The CLOSE-MIG study.

BACKGROUND AND PURPOSE: The efficacy of patent foramen ovale (PFO) closure to reduce the frequency of migraine attacks remains controversial. METHODS: This was a planned sub-study in migraine patients enrolled in a randomized, clinical trial designed to assess the superiority of PFO closure plus antiplatelet therapy over antiplatelet therapy alone to prevent stroke recurrence in patients younger than 60 years with a PFO-associated cryptogenic ischaemic stroke. The main outcome was the mean annual number of migraine attacks in migraine patients with aura and in those without aura, as recorded at each follow-up visit by study neurologists. RESULTS: Of 473 patients randomized to PFO closure or antiplatelet therapy, 145 (mean age 41.9 years; women 58.6%) had migraine (75 with aura and 70 without aura). Sixty-seven patients were randomized to PFO closure and 78 to antiplatelet therapy. During a mean follow-up of about 5 years, there were no differences between antiplatelet-only and PFO closure groups in the mean annual number of migraine attacks, both in migraine patients with aura (9.2 [11.9] vs. 12.0 [19.1], p = 0.81) and in those without aura (12.1 [16.1] vs. 11.8 [18.4], p > 0.999). There were no differences between treatment groups regarding cessation of migraine attacks, migraine-related disability at 2 years and use of migraine-preventive drugs during follow-up. CONCLUSIONS: In young and middle-aged adults with PFO-associated cryptogenic stroke and migraine, PFO closure plus antiplatelet therapy did not reduce the mean annual number of migraine attacks compared to antiplatelet therapy alone, in migraine patients both with and without aura.

Telemedicine in stroke: organizing a network--rationale and baseline principles.

Telestroke is the specific term used for the application of telemedicine in stroke. It is a consultative modality that facilitates care of patients with acute stroke at underserved hospitals by specialists at stroke centers and can play a vital role in minimizing the overall medicosocial impact of stroke. Telestroke should not be viewed as a new form of stroke therapy, rather as a means of supporting the increased delivery of evidenced-based medicine in stroke. The design and implementation of a hub-and-spoke telestroke network are complex and require state-of-the-art technology and close, organized collaboration between healthcare professionals if they are to be achieved. Telestroke is becoming part of clinical practice in some regions. It provides rapid access to specialized treatment and it could also potentially lead to major improvements in basic on-site management. Telemedicine is also being used for secondary prevention, rehabilitation, education and long-term stroke care. However, for progress to continue and in order to ensure the long-term sustainability of telestroke, various medicolegal, economic and market issues need to be resolved.

Impact of emergency room neurologists on patient management and outcome.

UNLABELLED: The frequency and impact of in-patient assessment by a neurologist in the emergency room (ER) setting remain largely underestimated. The objective of our study was to analyse the impact of neurologist in-patient management. METHODS: Over a period of 12 months, we prospectively recorded the demographics of patients requiring examination in the ER, the ER team's tentative neurological diagnosis, the neurology team's final diagnosis and patient outcomes. The time interval between admission, call for a neurologist and the assessment by the neurologist were recorded. RESULTS: Assessments by neurologists were performed in 14.7% (1,679/11,421) of all patients admitted to the ER. The mean time between admission and examination was 32 (+/- 36) min, irrespective of the day of the week, and dependent on the tentative diagnosis: shorter for stroke and status epilepticus (p < 0.05) and longer for confusion and vertigo (p < 0.05). The initial causes for examination were: stroke (33.1%), epilepsy (20%), loss of consciousness (9%), headaches (9%), confusion (5.4%), peripheral nervous system disorders (4.4%), vertigo (4.2%), cognitive dysfunctions (4%), gait disorders (3.2%) and miscellaneous (7.1%). Overall, false positive or negative diagnoses were produced by the ER in 37.3 and 36.6% of ER admissions, respectively. A complete change of diagnosis by the neurologist was found in 52.5% of patients. Of the patients undergoing a neurological examination, 18.4% were able to go home, 31.8% were admitted to the stroke unit, 32.4% to the general neurology unit and 17.4% to other departments. CONCLUSION: Our study stresses the need for a neurologist in the ER, both in quantitative terms and for the benefit of patient management.