Telestroke in Catalonia: Increasing Thrombolysis Rate and Avoiding Interhospital Transfers.

OBJECTIVES: The study aimed to evaluate the impact of a telestroke network on acute stroke care in Catalonia, by measuring thrombolysis rates, access to endovascular treatment, and clinical outcome of telestroke patients in a population-based study. METHODS: Telestroke network was implemented on March 2013 and consists of 12 community hospitals and 1 expert stroke neurologist 24 h/7 day, covering a population of 1.3 million inhabitants. Rest of the population (6.2 million) of Catalonia is covered by 8 primary stroke centers (PSC) and 6 comprehensive stroke centers (CSC). After a 2-way videoconference and visualization of neuroimaging on a web platform, the stroke neurologist decides the therapeutic approach and/or to transfer the patient to another facility, entering these data in a mandatory registry. Simultaneously, all patients treated with reperfusion therapies in all centers of Catalonia are prospectively recorded in a mandatory and audited registry. RESULTS: From March 2013 to December 2015, 1,206 patients were assessed by telestroke videoconference, of whom 322 received intravenous thrombolysis (IVT; 33.8% of ischemic strokes). Baseline and 24 h NIHSS, rate of symptomatic hemorrhage, mortality, and good outcome at 3 months were similar compared to those who received IVT in PSC or CSC (2,897 patients in the same period). The door-to-needle time was longer in patients treated through telestroke, but was progressively reduced from 2013 to 2015. Percentage of patients receiving thrombectomy after IVT was similar in patients treated through telestroke circuit, compared to those treated in PSC or CSC (conventional circuit). Population rates of IVT*100,000 inhabitants in Catalonia increased from 2011 to 2015, especially in areas affected by the implementation of telestroke network, achieving rates as high as 16 per 100,000 inhabitants. Transfers to another facility were avoided after telestroke consultation in 46.8% of ischemic, 76.5% of transient ischemic attacks, and 23.5% of hemorrhages. CONCLUSIONS: Telestroke favors safe and effective thrombolysis, helps to increase the population rate of IVT, and avoids a large number of interhospital transfers.

Remote thalamic microstructural abnormalities related to cognitive function in ischemic stroke patients.

OBJECTIVE: Ischemic stroke can lead to a continuum of cognitive sequelae, ranging from mild vascular cognitive impairment to vascular dementia. These cognitive deficits can be influenced by the disruption of cortico-subcortical circuits. We sought to explore remote thalamic microstructural abnormalities and their association with cognitive function after ischemic stroke. METHOD: Seventeen patients with right hemispheric ischemic stroke and 17 controls matched for age, sex, and years of education were included. All participants underwent neurological, neuropsychological, and diffusion tensor image examination. Patients were assessed 3 months poststroke. Voxel-wise analysis was used to study thalamic diffusion differences between groups. Mean fractional anisotropy (FA) and mean diffusivity (MD) values in significant thalamic areas were calculated for each subject and correlated with cognitive performance. RESULTS: Stroke patients showed lower FA values and higher MD values in specific areas of both the left and right thalamus compared with controls. In patients, decreased FA values were associated with lower verbal fluency performance in the right thalamus (R(2) = 0.45, ß = 0.74) and the left thalamus (R(2) = 0.57, ß = 0.77) after adjusting for diabetes mellitus. Moreover, increased MD values were associated with lower verbal fluency performance in the right thalamus (R(2) = 0.27, ß = -0.54) after adjusting for diabetes mellitus. In controls, thalamic FA and MD values were not related to any cognitive function. CONCLUSION: Our findings support the hypothesis that ischemic stroke lesions are associated with remote thalamic diffusion abnormalities, and that these abnormalities can contribute to cognitive dysfunction 3 months after a cerebrovascular event.

Thalamic diffusion differences related to cognitive function in white matter lesions.

Cerebral white matter lesions (WMLs) are related to cognitive deficits, probably due to a disruption of frontal-subcortical circuits. We explored thalamic diffusion differences related to white matter lesions (WMLs) and their association with cognitive function in middle-aged individuals. Ninety-six participants from the Barcelona-AsIA Neuropsychology Study were included. Participants were classified into groups based on low grade and high grade of periventricular hyperintensities (PVHs) and deep white matter hyperintensities (DWMHs). Tract-Based Spatial Statistics was used to study thalamic diffusion differences between groups. Mean fractional anisotropy (FA) values in significant areas were calculated for each subject and correlated with cognitive performance. Participants with high-grade PVHs and DWMHs showed lower FA thalamic values compared to those with low-grade PVHs and DWMHs, respectively. Decreased FA thalamic values in high-grade DWMHs, but not high-grade PVH, were related to lower levels of performance in psychomotor speed, verbal fluency, and visuospatial skills. Thalamic diffusion differences are related to lower cognitive function only in participants with high-grade DWMHs. These results support the hypothesis that fronto-subcortical disruption is associated with cognitive function only in DWMHs.

Iron overload, measured as serum ferritin, increases brain damage induced by focal ischemia and early reperfusion.

High levels of iron, measured as serum ferritin, are associated to a worse outcome after stroke. However, it is not known whether ischemic damage might increase ferritin levels as an acute phase protein or whether iron overload affects stroke outcome. The objectives are to study the effect of stroke on serum ferritin and the contribution of iron overload to ischemic damage. Swiss mice were fed with a standard diet or with a diet supplemented with 2.5% carbonyl iron to produce iron overload. Mice were submitted to permanent (by ligature and by in situ thromboembolic models) or transient focal ischemia (by ligature for 1 or 3h). Treatment with iron diet produced an increase in the basal levels of ferritin in all the groups. However, serum ferritin did not change after ischemia. Animals submitted to permanent ischemia had the same infarct volume in the groups studied. However, in mice submitted to transient ischemia followed by early (1h) but not late reperfusion (3h), iron overload increased ischemic damage and haemorrhagic transformation. Iron worsens ischemic damage induced by transient ischemia and early reperfusion. In addition, ferritin is a good indicator of body iron levels but not an acute phase protein after ischemia.

Citicoline preclinical and clinical update 2009-2010.

Citicoline is a neuroprotectant and neurorestorative drug that is used in the treatment of acute ischemic stroke in some countries. The research with this compound continues. In this review, we focus on the latest publications or communications or both and on the major ongoing experimental and clinical projects involving citicoline in stroke recovery.

Tratamiento intravenoso con activador del plasminógeno tisular en la isquemia cerebral aguda / Intravenous tissue-type plasminogen activator for the treatment of acute cerebral ischemia

FUNDAMENTO Y OBJETIVO: Se desconoce si el riesgo de transformación hemorrágica sintomática (THS) del infarto cerebral por el uso de activador del plasminógeno tisular (t-PA) en la práctica clínica es superior al observado en los ensayos clínicos. El objetivo de este estudio fue analizar la seguridad y la evolución clínica de los pacientes con isquemia cerebral aguda que recibieron tratamiento abierto con t-PA en hospitales españoles. PACIENTES Y MÉTODO: Estudio observacional y prospectivo que incluyó a 155 pacientes consecutivos con isquemia cerebral de menos de 3 h de evolución, o de menos de 6 h en ausencia de signos tempranos de infarto cerebral extenso en la tomografía computarizada (TC) craneal. Se administraron 0,9 mg/kg de t-PA intravenoso, el 10 per cent en bolo y el resto en infusión continua durante 60 min. El deterioro neurológico se cuantificó con la escala del ictus del NIH (NIHSS). Se evaluaron la THS en la TC realizada a las 24-36 h, la mortalidad y la capacidad funcional a los 3 meses. Los pacientes fueron atendidos por neurólogos expertos, y controlados en unidades de ictus. RESULTADOS: La mediana de la NIHSS al ingreso fue de 16, y el tiempo medio desde el inicio de los síntomas hasta el tratamiento, de 163 min. Se observó THS en 12 pacientes (7,7 per cent; intervalo de confianza [IC] del 95 per cent, 4,0-13,1), que fue fatal en 7 (4,5 per cent; IC del 95 per cent, 1,8-9,1). La mortalidad global a los 90 días fue del 16,8 per cent (IC del 95 per cent, 11,2-23,6). A las 24 h, el 48 per cent (IC del 95 per cent, 39,7-55,9) de los pacientes había mejorado en 4 puntos o más en la NIHSS, y el 29 per cent (IC del 95 per cent, 22,0-36,8) había mejorado en 10 puntos o más o se había recuperado. En el día 90, el 56 per cent (IC del 95 per cent, 47,9-64,1) de los pacientes era independiente. CONCLUSIONES: Este estudio demuestra que en la práctica clínica la administración intravenosa de tPA por neurólogos con experiencia, en centros españoles con unidades o equipos de ictus, es segura y se asocia a una evolución clínica favorable, comparable a la observada en los ensayos clínicos (AU)