Decreased Observance of Stroke in the Population Associated With COVID-19 Related Distancing Measures.

Stroke is a catastrophic medical disease with roughly 795,000 cases per year in the US. We strove to explore whether stroke admissions to a comprehensive stroke center in an area with moderately-low COVID-19 burden changed and if so, to better define the characteristics of the patients and their presentation. We performed a retrospective analysis of all patients with strokes admitted to Intermountain Medical Center. There was a 43% reduction in patients' presentations across all stroke types compared to average April patient volume over the prior 3 years. Likely this was due to a myriad of complex factors which we may retrospectively be able to more fully understand in the years to come.

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis.

OBJECTIVE: To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. METHODS: We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014-November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. RESULTS: Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. CONCLUSION: Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

Higher plasma fractalkine is associated with better 6-month outcome from ischemic stroke.

BACKGROUND AND PURPOSE: Fractalkine (CX3CL1) is a unique chemokine that is constitutively expressed on neurons where it serves as an adhesion molecule for lymphocytes and monocytes. CX3CL1 may also be cleaved from the surface of these cells and enter the circulation to act as a traditional chemokine. CX3CL1 could thus influence the inflammatory response after stroke. We hypothesized that patients with higher plasma CX3CL1 after stroke would have a more robust inflammatory response and experience worse outcome. METHODS: Plasma CX3CL1 concentrations were assessed in 85 patients who were part of a larger study evaluating immune responses after ischemic stroke; CX3CL1 values were available from Day 1 to Day 180 after stroke onset. CX3CL1 was correlated to measures of inflammation and its effect on outcome assessed. RESULTS: At 1 day after stroke, CX3CL1 was lower in patients with severe strokes. At 180 days after stroke, CX3CL1 concentrations were lower in patients with poor outcome. The association of CX3CL1 and outcome at 180 days was independent of initial stroke severity. Plasma CX3CL1 at 180 days was inversely associated with systemic markers of inflammation, including white blood cell counts and high-sensitivity C-reactive protein. CONCLUSIONS: In contrast to our original hypothesis, lower concentrations of CX3CL1 are associated with worse stroke outcome. In light of recent studies suggesting an immunomodulatory and neuroprotective role for CX3CL1 in a variety of neurodegenerative diseases, a therapeutic role for CX3CL1 in stroke recovery should be considered.

Implications of pharmacogenetic testing for patients taking warfarin or clopidogrel.

Our knowledge of the pharmacogenetics of warfarin and clopidogrel continues to expand as we learn more about the individual genetic variations that contribute to the drugs' efficacy and toxicity. We aim to review the recent developments in the field and discuss the clinical implications for the treatment of ischemic stroke patients. Despite recent advances, there is still insufficient data to suggest that routine genetic testing improves outcomes in patients treated with warfarin or clopidogrel for prevention of stroke.

Concomitant presentation of three rare mesencephalic syndromes: case report.

We describe a unique case of concomitant presentation of three rare mesencephalic syndromes. A 48-year-old man with an acute stoke was found to have an unusual combination of three rare mesencephalic syndromes after detailed neuro-ophthalmic evaluation: the plus-minus lid syndrome, the vertical one-and-a-half syndrome, and Claude's syndrome. We discuss the clinical and anatomical localization of these syndromes. This was corroborated by magnetic resonance imaging (MRI) which revealed areas of infarction at the thalamo-mesencephalic junction and the right rostral midbrain involving the third nerve fascicle and the red nucleus. Our case highlights the importance of a careful ocular motility examination as a tool which has a highly localizing value in the diagnosis of stroke.

Transcranial Doppler ultrasound CO2 challenge complicated by subarachnoid hemorrhage in patient with moyamoya syndrome.

INTRODUCTION: Studies to assess the hemodynamic status of patients with moyamoya syndrome are often done to determine the need for surgical revascularization. These studies, including transcranial Doppler (TCD) ultrasonography to assess vasomotor reactivity (VMR) to CO(2), are generally considered safe. CASE: We describe a patient with moyamoya syndrome who experienced a subarachnoid hemorrhage (SAH) following TCD with CO(2) challenge. CONCLUSION: SAH has not previously been described as a complication of CO(2) challenge in patients with moyamoya syndrome. While such complications are rare, it is important to consider the possibility of harm related to VMR testing in patients with advanced vasculopathy.

Rickets in VDR null mice is secondary to decreased apoptosis of hypertrophic chondrocytes.

Both vitamin D deficiency and the absence of a functional vitamin D receptor (VDR) lead to a growth plate abnormality known as rickets. Prevention of abnormal mineral ion homeostasis by early institution of dietary therapy in VDR null mice prevents rickets, demonstrating that the VDR is not required for normal growth plate maturation. We, therefore, hypothesized that rickets, in the absence of a functional VDR, is due to impaired mineral ion homeostasis. Analyses of growth plate morphology in VDR null mice demonstrated normal resting and proliferating chondrocyte layers; however an expansion of the hypertrophic chondrocyte layer was present by 24 days of age. Because extracellular calcium has been shown to play a role in chondrocyte maturation, we addressed the hypothesis that hypocalcemia led to impaired chondrocyte differentiation. However, in situ hybridization analyses revealed normal expression of hypertrophic chondrocyte markers in the tibial growth plate of 24 day old VDR null mice, suggesting that the increase in the hypertrophic chondrocyte layer was not secondary to impaired differentiation. We then addressed whether expansion of the hypertrophic chondrocyte layer was secondary to increased proliferation or decreased apoptosis. BrdU labeling failed to demonstrate an increase in chondrocyte proliferation in the VDR null mice; however, apoptosis was markedly diminished in the late hypertrophic chondrocytes of the VDR null mice, suggesting that impairment in programmed cell death of these cells leads to the characteristic findings of rickets.