External Validation of SAFE Score to Predict Atrial Fibrillation Diagnosis after Ischemic Stroke: A Retrospective Multicenter Study.

Introduction: The screening for atrial fibrillation (AF) scale (SAFE score) was recently developed to provide a prediction of the diagnosis of AF after an ischemic stroke. It includes 7 items: age ≥ 65 years, bronchopathy, thyroid disease, cortical location of stroke, intracranial large vessel occlusion, NT-ProBNP ≥250 pg/mL, and left atrial enlargement. In the internal validation, a good performance was obtained, with an AUC = 0.88 (95% CI 0.84-0.91) and sensitivity and specificity of 83% and 80%, respectively, for scores ≥ 5. The aim of this study is the external validation of the SAFE score in a multicenter cohort. Methods: A retrospective multicenter study, including consecutive patients with ischemic stroke or transient ischemic attack between 2020 and 2022 with at least 24 hours of cardiac monitoring. Patients with previous AF or AF diagnosed on admission ECG were excluded. Results: Overall, 395 patients were recruited for analysis. The SAFE score obtained an AUC = 0.822 (95% CI 0.778-0.866) with a sensitivity of 87.2%, a specificity of 65.4%, a positive predictive value of 44.1%, and a negative predictive value of 94.3% for a SAFE score ≥ 5, with no significant gender differences. Calibration analysis in the external cohort showed an absence of significant differences between the observed values and those predicted by the model (Hosmer-Lemeshow's test 0.089). Conclusions: The SAFE score showed adequate discriminative ability and calibration, so its external validation is justified. Further validations in other external cohorts or specific subpopulations of stroke patients might be required.

The COVID-19 pandemic effect on the prehospital Madrid stroke code metrics and diagnostic accuracy.

BACKGROUND: Only very few studies have investigated the effect of the COVID-19 pandemic on the pre-hospital stroke code protocol. During the first wave, Spain was one of the most affected countries by the SARS-CoV-2 coronavirus disease pandemic. This health catastrophe overshadowed other pathologies, such as acute stroke, the leading cause of death among women and the leading cause of disability among adults. Any interference in the stroke code protocol can delay the administration of reperfusion treatment for acute ischemic strokes, leading to a worse patient prognosis. We aimed to compare the performance of the stroke code during the first wave of the pandemic with the same period of the previous year. METHODS: This was a multicentre interrupted time-series observational study of the cohort of stroke codes of SUMMA 112 and of the ten hospitals with a stroke unit in the Community of Madrid. We established two groups according to the date on which they were attended: the first during the dates with the highest daily cumulative incidence of the first wave of the COVID-19 (from February 27 to June 15, 2020), and the second, the same period of the previous year (from February 27 to June 15, 2019). To assess the performance of the stroke code, we compared each of the pre-hospital emergency service time periods, the diagnostic accuracy (proportion of stroke codes with a final diagnosis of acute stroke out of the total), the proportion of patients treated with reperfusion therapies, and the in-hospital mortality. RESULTS: SUMMA 112 activated the stroke code in 966 patients (514 in the pre-pandemic group and 452 pandemic). The call management time increased by 9% (95% CI: -0.11; 0.91; p value = 0.02), and the time on scene increased by 12% (95% CI: 2.49; 5.93; p value = <0.01). Diagnostic accuracy, and the proportion of patients treated with reperfusion therapies remained stable. In-hospital mortality decreased by 4% (p = 0.05). CONCLUSIONS: During the first wave, a prolongation of the time "on the scene" of the management of the 112 calls, and of the hospital admission was observed. Prehospital diagnostic accuracy and the proportion of patients treated at the hospital level with intravenous thrombolysis or mechanical thrombectomy were not altered with respect to the previous year, showing the resilience of the stroke network and the emergency medical service.

Varicella-zoster virus vasculopathy. A review description of a new case with multifocal brain hemorrhage.

BACKGROUND: The varicella zoster virus (VZV) is a highly neurotropic virus that, after the primary infection, remains latent in the nerve cells and can reactivate many years later, resulting in various conditions affecting the central nervous system, such as vasculopathy and stroke. METHODS: We report on a review of the published literature that included all case reports identified via PubMed and an additional unpublished case of VZV vasculopathy. All epidemiological, clinical, laboratory, imaging, virologic, treatment and outcome data collected are described. RESULTS: Of the 62 patients, 41.6% were immunocompromised. Ischemic stroke occurred in 77.2% of the patients, comprising cases of isolated (37.1%) and multifocal stroke (17.7%). Multifocal, ischemic and hemorrhagic stroke was only described in the newly reported case. The magnetic resonance imaging results were normal in 2.9% of the cases. The vascular studies (angiography and magnetic resonance angiography [MRA]) revealed signs of angiitis in 74.4% of the cases; the small arteries were involved in 38.5% of the cases, large arteries in 17.7% and mixed in 43.5%. For 95.2% of the patients, the cerebrospinal fluid (CSF) was positive for VZV IgG antibodies, and for 46.1% of the patients, the CSF was positive for polymerase chain reaction (PCR); however, the diagnosis was confirmed in only 3 of 6 biopsies. DISCUSSION: VZV vasculopathy can occur in both immunocompetent and immunosuppressed patients. Neuroimaging can reveal stroke and angiitis, and the detection of VZV-specific IgG antibodies in the CSF is a reliable and highly sensitive diagnostic tool. The multifocal nature of VZV vasculopathy makes biopsy a test with low sensitivity and high morbidity.

Stroke and transient ischemic attack incidence rate in Spain: the IBERICTUS study.

BACKGROUND: In Spain, stroke is a major public health concern, but large population-based studies are scarce and date from the 1990s. We estimated the incidence and in-hospital mortality of stroke through a multicentered population-based stroke register in 5 geographical areas of Spain, i.e. Lugo, Almería, Segovia, Talavera de la Reina and Mallorca, representing north, south, central (×2) and Mediterranean areas of Spain, respectively, the aim and novelty being that all methodologies were standardized, and diagnoses were verified by a neurologist using neuroimaging techniques. METHODS: The register identified subjects >17 years of age who suffered a first-ever stroke or transient ischemic attack (TIA) between 1 January and 31 December 2006. Stroke and TIA were defined according to the WHO criteria. The Lausanne Stroke Registry definitions were used to classify ischemic stroke subtypes, as follows: (1) large-artery atherosclerosis (LAA); (2) cardioembolism (CE); (3) lacunar stroke or small-artery occlusion (SAO); (4) stroke of other infrequent cause (SIC), and (5) stroke of undetermined cause (UND). We used several complementary data sources such as hospital discharge registers, emergency room registers and primary care surveillance systems. RESULTS: In the 1-year study period, we identified 2,700 first-ever cerebrovascular episodes (53% men; 2,257 strokes + 443 TIA episodes). Brain CT in the acute stage was performed in 99% of cases. Of a total of 2,257 stroke patients, 1,817 (81%) had cerebral infarction, 350 (16%) had intracerebral hemorrhage, 59 (3%) had subarachnoid hemorrhage (SAH) and 31 (1%) had unclassifiable stroke. The overall unadjusted annual incidence for all cerebrovascular events was 187 per 100,000 [95% confidence interval (CI) 180-194; incidence for men: 202, 95% CI 189-210; incidence for women: 187, 95% CI 180-194]. The subtype of ischemic stroke could be determined in 1,779 patients and was classified as LAA in 624 (35%), CE in 352 (20%), SAO in 316 (18%), SIC in 56 (3%) and UND in 431 (24%). The incidence rates per 100,000 (95% CI) standardized to the 2006 European population were as follows: all cerebrovascular events, 176 (169-182); all stroke (non-TIA), 147 (140-153); TIA, 29 (26-32); ischemic stroke, 118 (112-123); intracerebral hemorrhage, 23 (21-26), and SAH, 4.2 (3.1-5.2). Incidence rates clearly increased with age in both genders, with a peak at or above 85 years of age. The in-hospital mortality was 14%. CONCLUSIONS: Our results show that the incidence of stroke and TIA in Spain is moderate compared to other Western and European countries. However, it is expected that these figures will change due to progressively aging populations.

[Migraine and interatrial septal abnormalities in patients under 55 with cryptogenic stroke]. / Migraña y alteraciones del septo auricular en pacientes menores de 55 años con infarto cerebral criptogenético.

BACKGROUND AND OBJECTIVE: Patent foramen ovale (PFO) is more frequent in migraine patients and is a cause of brain infarct among patients under 55 years old. Our goal was to study the association between PFO and migraine in ischemic stroke patients under 55 years old. PATIENTS AND METHOD: Observational study with inclusion of consecutive stroke patients admitted to a stroke unit (1995--2005). We selected patients under 55 years of age with first-ever acute cerebral infarction of cryptogenic origin. Demographic data, vascular risk factors, stroke vascular territory, stroke severity, the presence of PFO and/or atrial septal aneurysm (ASA) in echocardiography and functional status at discharge by the modified Rankin Scale score were analysed according to previous migraine. RESULTS: From a total of 130 patients, 76 were males. The 13.8% had previous migraine, 3.9% among male and 27.8% among female (p < 0.001). Migraine patients were younger than non migraine ones (p = 0.041) and had a higher frequency of vascular risk factors (not significant [NS]). Stroke severity and functional status at discharge were similar in both groups. Previous history of migraine was associated with FOP (38.9% vs. 26.8%; NS) and FOP plus ASA (odds ratio = 5; 95% confidence interval, 1.422-17.580). The latter association was higher in female (33.3% vs. 0%; NS). CONCLUSIONS: Previous migraine is more frequently associated with double interatrial septal abnormality (PFO plus ASA) in cerebral infarct patients under 55 years of age. This association could be higher in women.