Tissue Window in Stroke Thrombolysis study (TWIST): a safety study.

BACKGROUND: Stroke thrombolysis is limited by the "last-seen well" principle, which defines stroke onset time. A significant minority of stroke patients (~15%) awake with their symptoms and are by definition ineligible for thrombolysis because they were "last-seen well" at the time they went to bed implying an interval that is most often greater than three hours. METHODS: A single-centre prospective, safety study was designed to thrombolyse 20 subjects with stroke-on-awakening. Patients were eligible for inclusion if they were last seen well less than 12 hours previously, specifically including those who awoke from sleep with their stroke deficits. They had a baseline computed tomogram (CT) scan with an ASPECTS score greater than 5, no evidence of well-evolved infarction and a CT angiogram / Trans-cranial Doppler ultrasound study demonstrating an intracranial arterial occlusion. Patients fulfilled all other standard criteria for stroke thrombolysis. The primary outcome was safety defined by symptomatic ICH or death. RESULTS: Among 89 screened patients, 20 were treated with thrombolysis. Two patients (10%) died due to massive carotid territory stroke and two patients (10%) died of stroke complications. Two patients (10%) showed asymptomatic intracerebral hemorrhage (ICH) (petechial hemorrhage) and none symptomatic ICH. Reasons for exclusion were: (a) ASPECTS ≤ 5 (29); (b) well-evolved infarcts on CT (19); (c) historical mRS > 2 (17); (d) no demonstrable arterial occlusion or were too mild to warrant treatment (10). CONCLUSIONS: Patients who awake with their deficits can be safely treated with thrombolysis based upon a tissue window defined by NCCT and CTA/TCD.

Impact of a stroke unit on length of hospital stay and in-hospital case fatality.

BACKGROUND AND PURPOSE: Randomized trials have demonstrated reduced morbidity and mortality with stroke unit care; however, the effect on length of stay, and hence the economic benefit, is less well-defined. In 2001, a multidisciplinary stroke unit was opened at our institution. We observed whether a stroke unit reduces length of stay and in-hospital case fatality when compared to admission to a general neurology/medical ward. METHODS: A retrospective study of 2 cohorts in the Foothills Medical Center in Calgary was conducted using administrative databases. We compared a cohort of stroke patients managed on general neurology/medical wards before 2001, with a similar cohort of stroke patients managed on a stroke unit after 2003. The length of stay was dichotomized after being centered to 7 days and the Charlson Index was dichotomized for analysis. Multivariable logistic regression was used to compare the length of stay and case fatality in 2 cohorts, adjusted for age, gender, and patient comorbid conditions defined by the Charlson Index. RESULTS: Average length of stay for patients on a stroke unit (n=2461) was 15 days vs 19 days for patients managed on general neurology/medical wards (n=1567). The proportion of patients with length of stay >7 days on general neurology/medical wards was 53.8% vs 44.4% on the stroke unit (difference 9.4%; P<0.0001). The adjusted odds of a length of stay >7 days was reduced by 30% (P<0.0001) on a stroke unit compared to general neurology/medical wards. Overall in-hospital case fatality was reduced by 4.5% with stroke unit care. CONCLUSIONS: We observed a reduced length of stay and reduced in-hospital case-fatality in a stroke unit compared to general neurology/medical wards.

Study of the relationship between social deprivation and outcome after stroke.

BACKGROUND AND PURPOSE: Although the incidence and mortality of stroke are known to be inversely related to socioeconomic status (SES), the relationship between SES and recovery after stroke has been little-studied. This study has investigated the relationship between SES and case fatality, "death or dependency," and "death or institutional care" at 6 months after stroke. METHODS: Patients with acute stroke (n=2709) were identified using routine hospital discharge data and SES was measured using Carstairs scores (an ecological index of social deprivation). Case mix and treatment data were collected by medical chart review, case fatality by record linkage, and functional status and place of residence by questionnaire. Logistic regression was used to adjust the association of social deprivation and outcome for case mix and selected treatment variables. RESULTS: With increasing social deprivation, patients were younger, more likely to live alone, and, on admission, more likely to need help to walk. Social deprivation was not associated with case fatality or with "death or institutional care" in any analysis. However, patients residing in the most deprived areas (deprivation categories 6 and 7) were significantly more likely to be dead or dependent than patients from more affluent areas. This association was weakened but remained after adjusting for case mix and treatment variables. CONCLUSIONS: These findings contribute to growing evidence of an inverse social gradient in disability after stroke. Institutionalization, as a proxy for functional outcome, may not reflect this fact. A marked social gradient in case fatality after stroke seems unlikely.

Stroke prevention. MATCHing therapy to the patient with TIA.

The short-term risk of stroke after transient ischemic attack (TIA) is about 10% to 20% in the first 3 months, with much of the risk front-loaded in the first week. Unfortunately, little is known about the best therapies for hyperacute stroke prevention after TIA. A recent trial referred to by the acronym MATCH (for Management of Atherothrombosis With Clopidogrel in High-risk Patients With Recent Transient Ischemic Attack or Ischemic Stroke) provides hypothesis-generating data to suggest that double antiplatelet therapy in the short term may be appropriate. Here, the authors discuss treatment considerations, outlining the current knowledge and stressing the need for formal randomized trials to definitively establish the effectiveness of preventive therapies after minor stroke or TIA.

How well does ASPECTS predict the outcome of acute stroke treated with IV tPA?

The authors measured the association of early ischemic change on CT scan, measured using the Alberta Stroke Programme Early CT score (ASPECTS), and functional outcome in 825 patients with anterior circulation stroke treated with IV thrombolysis within 3 hours of onset. ASPECTS predicted outcome in a graded fashion (linearly for ASPECTS 6 through 10; pattern ill-defined for ASPECTS 0 through 5) but discriminated individual outcomes weakly. Except perhaps when early ischemic change is extensive, clinicians should not estimate prognosis using ASPECTS alone.