Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program.

BACKGROUND: Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks. METHODS: The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly. RESULTS: Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59). CONCLUSIONS: The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.

Antithrombotic and Statin Prescription After Intracerebral Hemorrhage in the Get With The Guidelines-Stroke Registry.

BACKGROUND: Survivors of intracerebral hemorrhage (ICH) face an increased risk of ischemic cardiovascular events. Current ICH guidelines do not provide definitive recommendations regarding the use of antithrombotic and statin therapies. We, therefore, sought to study practice patterns and factors associated with the use of such medications after ICH. METHODS: This was a cross-sectional study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients transferred to another hospital, those who died during hospitalization, and those with missing information on discharge medications were excluded. The study exposure was the proportion of patients who were prescribed antithrombotic or statin medications. We first ascertained the proportion of patients prescribed antithrombotic and lipid-lowering medications at discharge overall and across strata defined by pre-ICH use and history of previous ischemic vascular disease or atrial fibrillation. We then studied factors associated with the discharge prescription of these medications after ICH, using multiple logistic regressions. RESULTS: In the final cohort, 50 416 (10.4%) of 486 586 patients with ICH were prescribed antiplatelet medications, 173 322 (35.1%) of 493 491 patients with ICH were prescribed statins, and 27 085 (5.4%) of 486 585 patients with ICH were prescribed anticoagulation therapy at discharge. The proportion of patients with antiplatelet therapy was 16.6% with pre-ICH use and 15.6% in those with previous ischemic vascular disease. Statins were prescribed to 41.1% and 43.7% of patients on previous lipid-lowering therapy and ischemic vascular disease, respectively. Anticoagulation therapy was restarted in 11.1% of patients. In logistic regression analysis, factors associated with higher use of antithrombotic or statin therapies after ICH were younger age, male sex, pre-ICH medication use, previous ischemic vascular disease, atrial fibrillation, lower admission National Institutes of Health Stroke Scale, longer length of stay, and favorable discharge outcome. CONCLUSIONS: Few patients with ICH are prescribed antithrombotic or statin therapies at hospital discharge. Given the emerging association between ICH and future major cardiovascular events, trials examining the net benefit of antiplatelet and lipid-lowering therapy after ICH are warranted.

Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke.

Importance: Use of oral vitamin K antagonists (VKAs) may place patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion at increased risk of complications. Objective: To determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice. Design, Setting, and Participants: Retrospective, observational cohort study based on the American Heart Association's Get With the Guidelines-Stroke Program between October 2015 and March 2020. From 594 participating hospitals in the US, 32 715 patients with acute ischemic stroke selected to undergo EVT within 6 hours of time last known to be well were included. Exposure: VKA use within the 7 days prior to hospital arrival. Main Outcome and Measures: The primary end point was symptomatic intracranial hemorrhage (sICH). Secondary end points included life-threatening systemic hemorrhage, another serious complication, any complications of reperfusion therapy, in-hospital mortality, and in-hospital mortality or discharge to hospice. Results: Of 32 715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used a VKA (median international normalized ratio [INR], 1.5 [IQR, 1.2-1.9]) and 29 628 had not used a VKA prior to hospital presentation. Overall, prior VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking a VKA compared with 1904/29 628 patients [6.4%] not taking a VKA; adjusted odds ratio [OR], 1.12 [95% CI, 0.94-1.35]; adjusted risk difference, 0.69% [95% CI, -0.39% to 1.77%]). Among 830 patients taking a VKA with an INR greater than 1.7, sICH risk was significantly higher than in those not taking a VKA (8.3% vs 6.4%; adjusted OR, 1.88 [95% CI, 1.33-2.65]; adjusted risk difference, 4.03% [95% CI, 1.53%-6.53%]), while those with an INR of 1.7 or lower (n = 1585) had no significant difference in the risk of sICH (6.7% vs 6.4%; adjusted OR, 1.24 [95% CI, 0.87-1.76]; adjusted risk difference, 1.13% [95% CI, -0.79% to 3.04%]). Of 5 prespecified secondary end points, none showed a significant difference across VKA-exposed vs VKA-unexposed groups. Conclusions and Relevance: Among patients with acute ischemic stroke selected to receive EVT, VKA use within the preceding 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with a presenting INR greater than 1.7 was associated with a significantly increased risk of sICH compared with no use of anticoagulants.

Comparison of intermittent versus continuous infusion antihypertensives in acute ischemic stroke.

BACKGROUND: The optimal approach to blood pressure (BP) management in acute ischemic stroke remains unclear. The purpose of this study was to determine if an intermittent (labetalol or hydralazine) or continuous infusion (nicardipine or clevidipine) antihypertensive strategy facilitated timelier alteplase administration. METHODS: Patients ≥18 years who presented to the emergency department (ED) between September 1, 2013 and August 31, 2020, received alteplase for acute ischemic stroke, and required BP management with an intravenous antihypertensive were included in this multicenter, retrospective cohort study. Exclusion criteria were initial administration of a non-study antihypertensive, initial study antihypertensive administration >2 hours prior to or any time following alteplase, or receipt of both an intermittent and continuous infusion antihypertensive prior to alteplase. The primary endpoint was the time from ED presentation to alteplase administration. RESULTS: During the study period, 122 patients received an intermittent antihypertensive and 57 patients received a continuous infusion antihypertensive. The median door-to-needle time was 53 minutes for patients who received an intermittent antihypertensive compared to 57 minutes for those who received a continuous infusion antihypertensive (p=0.17). Secondarily, the proportion of patients who achieved the BP target <185/110 mmHg within 15 minutes of initial antihypertensive administration and the incidence of adverse events were similar between treatment groups. In cost analysis, intermittent antihypertensives were less expensive than continuous infusion antihypertensives ($2.20 vs. $71.40). CONCLUSIONS: Among patients with acute ischemic stroke and uncontrolled BP, the initial use of an intermittent or continuous infusion antihypertensive did not significantly impact the time to alteplase administration.

Frequency, Characteristics, and Outcomes of Endovascular Thrombectomy in Patients With Stroke Beyond 6 Hours of Onset in US Clinical Practice.

BACKGROUND AND PURPOSE: In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines-Stroke clinical registry. METHODS: We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines-Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes. RESULTS: We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3-7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%-38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours. CONCLUSIONS: EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.

Outcomes of Endovascular Therapy in Patients With Prestroke Mobility Impairment.

Background and Purpose: Patients with prestroke mobility impairment (PSMI) were excluded from endovascular clinical trials. There are limited data regarding safety and outcomes of endovascular thrombectomy in this population. We used a large, national data set (Get With The Guidelines­Stroke) to evaluate the safety and outcomes of endovascular thrombectomy in patients with PSMI. Methods: We included patients who underwent endovascular thrombectomy in the Get With The Guidelines­Stroke registry between 2015 and 2019. PSMI was defined as the inability to ambulate independently. Generalized estimating equations for logistic regression models were used to evaluate the association between PSMI and outcomes. Results: Of 56 762 patients treated with endovascular thrombectomy, 2919 (5.14%) had PSMI. PSMI was not associated with symptomatic intracranial hemorrhage (6.0% versus 5.4%; P=0.979). In-hospital death or discharge to hospice occurred in 32.3% of patients with PSMI versus 17.5% without PSMI (adjusted odds ratio, 1.45 [1.32­1.58]). Conclusions: While procedural adverse outcomes were no higher in patients with PSMI, further study is necessary to determine clinical benefit in this population.

Oral Anticoagulation and Adverse Outcomes after Ischemic Stroke in Heart Failure Patients without Atrial Fibrillation.

BACKGROUND: The safety and effectiveness of oral anticoagulation (OAC) after an ischemic stroke in older patients with heart failure (HF) without atrial fibrillation remains uncertain. METHODS: Utilizing Get With The Guidelines Stroke national clinical registry data linked to Medicare claims from 2009-2014, we assessed the outcomes of eligible patients with a history of HF who were initiated on OAC during a hospitalization for an acute ischemic stroke. The cumulative incidences of adverse events were calculated using Kaplan-Meier curves and adjusted Cox proportional hazard ratios were compared between patients discharged on or off OAC. RESULTS: A total of 8,261 patients from 1,370 sites were discharged alive after an acute ischemic stroke and met eligibility criteria. Of those, 747 (9.0%) were initiated on OAC.  Patients on OAC were younger (77.2±8.0 vs. 80.5±8.9 years, p<0.01). After adjustment for clinical covariates, the likelihood of 1 year mortality was higher in those on OAC (aHR: 1.22, 95% CI 1.05-1.41, p<0.01), while no significant differences were noted for ICH (aHR: 1.34, 95% CI 0.69-2.59, p=0.38) and recurrent ischemic stroke (aHR: 0.78, 95% CI 0.54-1.15, p = 0.21).  The likelihood of all-cause bleeding (aHR: 1.59, 95% CI 1.29-1.96, p<0.01) and all-cause re-hospitalization (aHR: 1.14, 95% CI 1.02-1.27, p = 0.02) was higher for those on OAC. CONCLUSION: Initiation of OAC after an ischemic stroke in older patients with HF in the absence of atrial fibrillation is associated with death, bleeding and re-hospitalization without an associated reduction in recurrent ischemic stroke. If validated, these findings raise caution for prescribing OAC to such patients.

Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: According to evidence-based clinical practice guidelines, patients presenting with disabling stroke symptoms should be treated with intravenous tissue plasminogen activator (IV tPA) within 4.5 h of time last known well. However, 25% of strokes are detected upon awakening (i.e., wake-up stroke [WUS]), which renders patients ineligible for IV tPA administered via time-based treatment algorithms, because it is impossible to establish a reliable time of symptom onset. We performed a systematic review and meta-analysis of the efficacy and safety of IV tPA compared with normal saline, placebo, or no treatment in patients with WUS using imaging-based treatment algorithms. METHODS: We searched MEDLINE, Web of Science, and Scopus between January 1, 2006 and April 30, 2020. We included controlled trials (randomized or nonrandomized), observational cohort studies (prospective or retrospective), and single-arm studies in which adults with WUS were administered IV tPA after magnetic resonance imaging (MRI)- or computed tomography (CT)-based imaging. Our primary outcome was recovery at 90 days (defined as a modified Rankin Scale [mRS] score of 0-2), and our secondary outcomes were symptomatic intracranial hemorrhage (sICH) within 36 h, mortality, and other adverse effects. RESULTS: We included 16 studies that enrolled a total of 14,017 patients. Most studies were conducted in Europe (37.5%) or North America (37.5%), and 1757 patients (12.5%) received IV tPA. All studies used MRI-based (five studies) or CT-based (10 studies) imaging selection, and one study used a combination of modalities. Sixty-one percent of patients receiving IV tPA achieved an mRS score of 0 to 2 at 90 days (95% confidence interval [CI]: 51%-70%, 12 studies), with a relative risk (RR) of 1.21 compared with patients not receiving IV tPA (95% CI: 1.01-1.46, four studies). Three percent of patients receiving IV tPA experienced sICH within 36 h (95% CI: 2.5%-4.1%; 16 studies), which is an RR of 4.00 compared with patients not receiving IV tPA (95% CI: 2.85-5.61, seven studies). CONCLUSIONS: This systematic review and meta-analysis suggests that IV tPA is associated with a better functional outcome at 90 days despite the increased but acceptable risk of sICH. Based on these results, IV tPA should be offered as a treatment for WUS patients with favorable neuroimaging findings.

Socio-ecological perspective on factors influencing acute recovery of younger stroke survivors: A mixed methods study.

AIMS: Stroke is affecting an increasing number of young and middle-aged adults. Given the substantial diversion from anticipated life trajectories that younger stroke survivors experience as a result of their stroke deficits, their health-related quality of life (HRQOL) is likely to be negatively impacted during the immediate post-acute recovery period. The aim of this study was to generate a comprehensive understanding of the influences on HRQOL and acute recovery during the first three months following stroke for younger adults using a socio-ecological perspective. DESIGN: Longitudinal, convergent mixed methods design. METHODS: HRQOL survey data, assessed using the Patient Generated Index (N = 31), and qualitative interview data about survivors' recovery experiences (N = 20) were collected. Simple linear regression and effect size results were integrated with themes and sub-themes identified from conventional content analysis using joint data displays. RESULTS: Depression and fatigue negatively affected recovery at the individual level. At the family and societal level, family functioning, social support including being married, having insurance, working, adequate income and being unemployed post-stroke all positively impacted recovery. Qualitative findings revealed determination, coping, and accessing healthcare to positively affect recovery though a meta-inference could not be drawn as no quantitative data addressed these concepts. CONCLUSION: A variety of factors intersecting across socio-ecological levels were perceived by young stroke survivors to influence acute recovery experiences and outcomes. IMPACT: This study identified individual-, family- and societal-level factors in younger adults' environments that may affect the acute stroke recovery experience. Findings underscore the need for research and clinical approaches that consider environmental factors at multiple levels of influence when supporting stroke recovery for younger adults.

Use, Temporal Trends, and Outcomes of Endovascular Therapy After Interhospital Transfer in the United States.

BACKGROUND: The use of endovascular therapy (EVT) in patients with acute ischemic stroke who have large vessel occlusion has rapidly increased in the United States following pivotal trials demonstrating its benefit. Information about the contribution of interhospital transfer in improving access to EVT will help organize regional systems of stroke care. METHODS: We analyzed trends of transfer-in EVT from a cohort of 1 863 693 patients with ischemic stroke admitted to 2143 Get With The Guidelines-Stroke participating hospitals between January 2012 and December 2017. We further examined the association between arrival mode and in-hospital outcomes by using multivariable logistic regression models. RESULTS: Of the 37 260 patients who received EVT at 639 hospitals during the study period, 42.9% (15 975) arrived at the EVT-providing hospital after interhospital transfer. Transfer-in EVT cases increased from 256 in the first quarter 2012 to 1422 in the fourth quarter 2017, with sharply accelerated increases following the fourth quarter 2014 ( P<0.001 for change in linear trend). Transfer-in patients were younger and more likely to be of white race, to arrive during off-hours, and to be treated at comprehensive stroke centers. Transfer-in patients had significantly longer last-known-well-to-EVT initiation time (median, 289 minutes versus 213 minutes; absolute standardized difference, 67.33) but were more likely to have door-to-EVT initiation time of ≤90 minutes (65.6% versus 23.6%; absolute standardized difference, 93.18). In-hospital outcomes were worse for transfer-in patients undergoing EVT in unadjusted and in risk-adjusted models. Although the difference in in-hospital mortality disappeared after adjusting for delay in EVT initiation (14.7% versus 13.4%; adjusted odds ratio, 1.01; 95% CI, 0.92-1.11), transfer-in patients were still more likely to develop symptomatic intracranial hemorrhage (7.0% versus 5.7%; adjusted odds ratio, 1.15; 95% CI, 1.02-1.29) and less likely to have either independent ambulation at discharge (33.1% versus 37.1%; adjusted odds ratio, 0.87; 95% CI, 0.80-0.95) or to be discharged to home (24.3% versus 29.1%; adjusted odds ratio, 0.82; 95% CI, 0.76-0.88). CONCLUSIONS: Interhospital transfer for EVT is increasingly common and is associated with a significant delay in EVT initiation highlighting the need to develop more efficient stroke systems of care. Further evaluation to identify factors that impact EVT outcomes for transfer-in patients is warranted.

Selective Serotonin Reuptake Inhibitors and Intracerebral Hemorrhage Risk and Outcome.

Background and Purpose- Selective serotonin reuptake inhibitors (SSRIs) have a well-established association with bleeding complications and conflicting reports on outcome after stroke. We sought to evaluate whether pre-intracerebral hemorrhage (ICH) SSRI use increased ICH risk and post-ICH SSRI use improved ICH outcome. Methods- Through post hoc analysis of the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage), SSRI use was categorized into no use, pre-ICH only, pre- and post-ICH use (termed "continuous"), and post-ICH only (termed "new"). Using multivariable modeling, associations were sought between pre-ICH SSRI use and ICH risk in the case-control set, and associations between post-ICH SSRI use and 3-month outcome were analyzed in the ICH case set. Exploratory analyses sought to assess influence of race/ethnicity in models. Results- The final study cohort consisted of 2287 ICH cases and 2895 controls. Pre-ICH SSRI use was not associated with ICH risk (odds ratio, 0.824 [95% CI, 0.632-1.074]) nor potentiation of ICH risk with anticoagulant or antiplatelet use. New post-ICH SSRI use was associated with unfavorable modified Rankin Scale score at 3 months after ICH (odds ratio, 1.673 [95% CI, 1.162-2.408]; P=0.006) in multivariable analyses. Additional propensity score analysis indicated a similar trend but did not reach statistical significance (P=0.107). When stratified by race/ethnicity, multivariable modeling demonstrated reduced ICH risk with pre-ICH SSRI use in Hispanics (odds ratio, 0.513 [95% CI, 0.301-0.875]; P=0.014), but not non-Hispanic whites or blacks, and no associations between post-ICH SSRI use and 3-month outcome in any racial/ethnic group. Conclusions- In a large multiethnic cohort, pre-ICH SSRI use was not associated with increased ICH risk, but post-ICH SSRI use was associated with unfavorable 3-month neurological outcome after ICH. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01202864.

Implementation of Best Practices-Developing and Optimizing Regional Systems of Stroke Care: Design and Methodology.

The AHA Guidelines recommend developing multi-tiered systems for the care of patients with acute stroke.1 An ideal stroke system of care should ensure that all patients receive the most efficient and timely care, regardless of how they first enter or access the medical care system. Coordination among the components of a stroke system is the most challenging but most essential aspect of any system of care. The Implementation of Best Practices For Acute Stroke Care-Developing and Optimizing Regional Systems of Stroke Care (IMPROVE Stroke Care) project, is designed to implement existing guidelines and systematically improve the acute stroke system of care in the Southeastern United States. Project participation includes 9 hub hospitals, approximately 80 spoke hospitals, numerous pre-hospital agencies (911, fire, and emergency medical services) and communities within the region. The goal of the IMPROVE Stroke program is to develop a regional integrated stroke care system that identifies, classifies, and treats acute ischemic stroke patients more rapidly and effectively with reperfusion therapy. The project will identify gaps and barriers to implementation of stroke systems of care, leverage existing resources within the regions, aid in designing strategies to improve care processes, bring regional representatives together to agree on and implement best practices, protocols, and plans based on guidelines, and establish methods to monitor quality of care. The impact of implementation of stroke systems of care on mortality and long-term functional outcomes will be measured.

Disease Burden Following Non-Cardioembolic Minor Ischemic Stroke or High-Risk TIA: A GWTG-Stroke Study.

BACKGROUND: Limited real-world data are available on outcomes following non-cardioembolic minor ischemic stroke (IS) or high-risk transient ischemic attack (TIA), particularly in the United States (US). We examined outcomes and Medicare payments following any severity IS or TIA as well as the subgroup with minor IS or high-risk TIA. METHODS: Medicare beneficiaries >65 years were identified using US nationwide Get with the Guidelines (GWTG)-Stroke Registry linked to Medicare claims data. The cohort consisted of patients enrolled in Medicare fee-for-service plan, hospitalized with non-cardioembolic IS or TIA between 2011 and 2014, segmenting a subgroup with minor IS (National Institute of Health Stroke Scale [NIHSS] ≤5) or high-risk TIA (ABCD2-score ≥6) compatible with the THALES clinical trial population. Outcomes included functional status at discharge, clinical outcomes (all-cause mortality, ischemic stroke, and hemorrhagic stroke, individually and as a composite), hospitalizations, and population average inpatient Medicare payments following non-cardioembolic IS or TIA. RESULTS: The THALES-compatible cohort included 62,518 patients from 1471 hospitals. At discharge, 37.0% were unable to ambulate without assistance, and 96.2% were prescribed antiplatelet therapy. Cumulative incidences at 30 days, 90 days, and 1 year for the composite outcome were 3.7%, 7.6%, and 17.2% and 2.4%, 4.0%, and 7.3% for subsequent stroke. The mean Medicare payment for the index hospitalization was $7951. The cumulative all-cause inpatient Medicare spending per patient (with or without any subsequent admission) at 30 days and 1 year from discharge was $1451 and $8105, respectively. CONCLUSIONS: The burden of illness for minor IS/high-risk TIA patients indicates an important unmet need. Improved therapeutic options may offer a significant impact on both patient outcomes and Medicare spending.

Today's Approach to Treating Brain Swelling in the Neuro Intensive Care Unit.

Brain swelling is an urgent clinical problem that frequently accompanies ischemic stroke, brain hemorrhage, and traumatic brain injury; it increases morbidity and mortality associated with them. It occurs due to failure of membrane transporters and leakage of the blood-brain barrier (BBB), resulting in combination of cytotoxic, ionic, and vasogenic edema. Currently, decompressive craniectomy and osmotherapy are the mainstays of management, but these therapies do not halt the underlying molecular cascade leading to brain swelling. Recent advances in the molecular underpinnings of cerebral edema have opened up possibilities of newer targeted therapeutic options. Here the authors outline the current approach for rapid diagnosis and intervention to reduce mortality and morbidity associated with brain swelling.

Neurogenic Stunned Myocardium Following Acute Subarachnoid Hemorrhage: Pathophysiology and Practical Considerations.

Neurogenic stunned myocardium (NSM) is a triad of transient left ventricular dysfunction, electrocardiogram changes, and elevation in cardiac enzymes, often mimicking a myocardial infarction. It has been described following acute brain injury. The purported mechanism is catecholamine excess resulting in cardiac dysfunction. From the clinical standpoint, the most frequently encountered electrocardiographic changes are QTc prolongation and ST-T changes, with modest elevations in troponin levels. Basal and mid-ventricular segments of the left ventricle are most commonly involved. NSM poses therapeutic challenges when it occurs secondary to aneurysmal subarachnoid hemorrhage, particularly in the setting of coexisting vasospasm. Overall, NSM carries good prognosis if recognized early, with appropriate management of hemodynamic and cardiopulmonary parameters.

Thrombolysis for acute ischemic stroke in patients with cancer: a population study.

BACKGROUND AND PURPOSE: The safety of thrombolysis for acute stroke in patients with cancer is not well established. Our aim is to study the outcomes after thrombolysis in patients with stroke with cancer. METHODS: Patients with acute ischemic stroke who received thrombolysis were identified from the 2009 and 2010 Nationwide Inpatient Sample. Patients with cancer-associated strokes and noncancer strokes were compared based on demographics, comorbidities, and outcomes. RESULTS: Of the 32 576 strokes treated with thrombolysis, cancer-associated strokes had significantly higher comorbidity indices overall, but fewer vascular risk factors than noncancer strokes. There was no difference in the rates of home discharge and in-hospital mortality, after adjusting for confounders. Subgroup analysis showed that compared with liquid cancers, patients with solid tumors had worse home discharge (odds ratio, 0.178; 95% confidence interval, 0.109-0.290; P<0.001) and higher in-hospital mortality (odds ratio, 3.018; 95% confidence interval, 1.37-6.646; P=0.006) after thrombolysis. Metastatic cancers had poorest outcomes, but intracerebral hemorrhage rates were similar. CONCLUSIONS: Thrombolytic therapy for acute stroke in patients with cancer is not associated with increased risk of intracerebral hemorrhage or in-hospital mortality. However, careful consideration of the cancer subtype may help delineate the subset of patients with poor response to thrombolysis. Prospective confirmation is warranted.

Evaluation of commercially available point-of-care ultrasound for automated optic nerve sheath measurement.

BACKGROUND: Measurement of the optic nerve sheath diameter (ONSD) via ultrasonography has been proposed as a non-invasive metric of intracranial pressure that may be employed during in-field patient triage. However, first responders are not typically trained to conduct sonographic exams and/or do not have access to an expensive ultrasound device. Therefore, for successful deployment of ONSD measurement in-field, we believe that first responders must have access to low-cost, portable ultrasound and be assisted by artificial intelligence (AI) systems that can automatically interpret the optic nerve sheath ultrasound scan. We examine the suitability of five commercially available, low-cost, portable ultrasound devices that can be combined with future artificial intelligence algorithms to reduce the training required for and cost of in-field optic nerve sheath diameter measurement. This paper is focused on the quality of the images generated by these low-cost probes. We report results of a clinician preference survey and compare with a lab analysis of three quantitative image quality metrics across devices. We also examine the suitability of the devices in a hypothetical far-forward deployment using operators unskilled in ultrasound, with the assumption of a future onboard AI video interpreter. RESULTS: We find statistically significant differences in clinician ranking of the devices in the following categories: "Image Quality", "Ease of Acquisition", "Software", and "Overall ONSD". We show differences in signal-to-noise ratio, generalized contrast-to-noise ratio, point-spread function across the devices. These differences in image quality result in a statistically significant difference in manual ONSD measurement. Finally, we show that sufficiently wide transducers can capture the optic nerve sheath during blind (no visible B-mode) scans performed by operators unskilled in sonography. CONCLUSIONS: Ultrasound of the optic nerve sheath has the potential to be a convenient, non-invasive, point-of-injury or triage measure for elevated intracranial pressure in cases of traumatic brain injury. When transducer width is sufficient, briefly trained operators may obtain video sequences of the optic nerve sheath without guidance. This data suggest that unskilled operators are able to achieve the images needed for AI interpretation. However, we also show that image quality differences between ultrasound probes may influence manual ONSD measurements.

Revisiting Transcranial Light Stimulation as a Stroke Therapeutic-Hurdles and Opportunities.

Near-infrared laser therapy, a special form of transcranial light therapy, has been tested as an acute stroke therapy in three large clinical trials. While the NEST trials failed to show the efficacy of light therapy in human stroke patients, there are many lingering questions and lessons that can be learned. In this review, we summarize the putative mechanism of light stimulation in the setting of stroke, highlight barriers, and challenges during the translational process, and evaluate light stimulation parameters, dosages and safety issues, choice of outcomes, effect size, and patient selection criteria. In the end, we propose potential future opportunities with transcranial light stimulation as a cerebroprotective or restorative tool for future stroke treatment.