Effect of a diabetes-specific formula in non-diabetic inpatients with stroke: a randomized controlled trial.

BACKGROUND/OBJECTIVES: In patients with acute stroke, the presence of hyperglycaemia has been associated with higher morbidity and less neurological recovery. The aim of the study was to evaluate the impact of a diabetes specific enteral nutrition (EN) formula on glycaemia, comorbidities and mortality in patients admitted with a first episode of stroke who received complete EN. METHODS: This was a prospective randomised controlled trial. Patients with acute stroke did not have diagnosis of diabetes mellitus and required nasogastric tube feeding. This study has been registered with code NCT03422900. The patients were randomised into two arms: an isocaloric isoprotein formula (control group (CG), 27 patients) vs a diabetes-specific formula (low glycaemic index carbohydrates, fibre (80% soluble) and higher lipid content) (experimental group (EG), 25 patients). Pre-EN blood glucose, hyperglycaemia during EN treatment, HbA1c, insulin use, oral route recovery, length of stay (LOS) and mortality at 30 days were collected. The complications of enteral nutrition during admission were collected as well. RESULTS: 52 patients were included, 50% females, with an age of 77.44(11.48) years; 34 (65.4%) had ischaemic stroke, with a Rankin score of 0(0-2), and a National Institute of Health Stroke Scale (NIHSS) of 19 (15-22). In CG, there were more cases of hyperglycaemia on the 5th day post-NE (13(65%) vs7(35%), p < 0.01). CG showed an OR of 7.58(1.49-39.16) (p = 0.02) for the development of hyperglycaemia. There were no differences in LOS between groups (12(8.5) days vs 14(23) days, p = 0.19) or in the death rate (10(37%) vs 10(40%), p = 0.8), although differences were found in terms of oral route recovery (EG: 11(44%) patients vs CG: 5(18.5%) patients, p = 0.04) (OR (EG): 5.53(1.25-24.47); p = 0.02). CONCLUSIONS: The use of a diabetes-specific enteral formula in non-diabetic patients admitted with acute stroke reduced the risk of developing hyperglycaemia and improved the rate of oral route recovery. Registered under ClinicalTrials.gov Identifier no. NCT03422900.

Thrombectomy versus Medical Management for Isolated Anterior Cerebral Artery Stroke: An International Multicenter Registry Study.

Background Evidence supporting a potential benefit of thrombectomy for distal medium vessel occlusions (DMVOs) of the anterior cerebral artery (ACA) is, to the knowledge of the authors, unknown. Purpose To compare the clinical and safety outcomes between mechanical thrombectomy (MT) and best medical treatment (BMT) with or without intravenous thrombolysis for primary isolated ACA DMVOs. Materials and Methods Treatment for Primary Medium Vessel Occlusion Stroke, or TOPMOST, is an international, retrospective, multicenter, observational registry of patients treated for DMVO in daily practice. Patients treated with thrombectomy or BMT alone for primary ACA DMVO distal to the A1 segment between January 2013 and October 2021 were analyzed and compared by one-to-one propensity score matching (PSM). Early outcome was measured by the median improvement of National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours. Favorable functional outcome was defined as modified Rankin scale scores of 0-2 at 90 days. Safety was assessed by the occurrence of symptomatic intracerebral hemorrhage and mortality. Results Of 154 patients (median age, 77 years; quartile 1 [Q1] to quartile 3 [Q3], 66-84 years; 80 men; 94 patients with MT; 60 patients with BMT) who met the inclusion criteria, 110 patients (median age, 76 years; Q1-Q3, 67-83 years; 50 men; 55 patients with MT; 55 patients with BMT) were matched. DMVOs were in A2 (82 patients; 53%), A3 (69 patients; 45%), and A3 (three patients; 2%). After PSM, the median 24-hour NIHSS point decrease was -2 (Q1-Q3, -4 to 0) in the thrombectomy and -1 (Q1-Q3, -4 to 1.25) in the BMT cohort (P = .52). Favorable functional outcome (MT vs BMT, 18 of 37 [49%] vs 19 of 39 [49%], respectively; P = .99) and mortality (MT vs BMT, eight of 37 [22%] vs 12 of 39 [31%], respectively; P = .36) were similar in both groups. Symptomatic intracranial hemorrhage occurred in three (2%) of 154 patients. Conclusion Thrombectomy appears to be a safe and technically feasible treatment option for primary isolated anterior cerebral artery occlusions in the A2 and A3 segment with clinical outcomes similar to best medical treatment with and without intravenous thrombolysis. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Zhu and Wang in this issue.

Randomized Controlled Trial Evaluating the Benefit of a Novel Clinical Decision Support System for the Management of COVID-19 Patients in Home Quarantine: A Study Protocol.

(1) Background: We present the protocol of a randomized controlled trial designed to evaluate the benefit of a novel clinical decision support system for the management of patients with COVID-19. (2) Methods: The study will recruit up to 500 participants (250 cases and 250 controls). Both groups will receive the conventional telephone follow-up protocol by primary care and will also be provided with access to a mobile application, in which they will be able to report their symptoms three times a day. In addition, patients in the active group will receive a wearable smartwatch and a pulse oximeter at home for real-time monitoring. The measured data will be visualized by primary care and emergency health service professionals, allowing them to detect in real time the progression and complications of the disease in order to promote early therapeutic interventions based on their clinical judgement. (3) Results: Ethical approval for this study was obtained from the Drug Research Ethics Committee of the Valladolid East Health Area (CASVE-NM-21-516). The results obtained from this study will form part of the thesis of two PhD students and will be disseminated through publication in a peer-reviewed journal. (4) Conclusions: The implementation of this telemonitoring system can be extrapolated to patients with other similar diseases, such as chronic diseases, with a high prevalence and need for close monitoring.

Influence of Hyperglycemia Associated with Enteral Nutrition on Mortality in Patients with Stroke.

Objectives: To evaluate in patients admitted for stroke: (1) The frequency of hyperglycaemia associated with enteral nutrition (EN). (2) The risk of morbidity and mortality associated with the development of this type of hyperglycaemia. METHODS: A longitudinal observational study was conducted in 115 non-diabetic patients admitted for stroke with EN. Age, functional capacity (Rankin scale), and blood plasma glucose (BPG) were recorded. Hyperglycaemia was considered as: a value higher than 126 mg/dL before the EN and/or a value higher than 150 mg/dL after a week of enteral nutrition. According to this, three groups were differentiated: HyperES: Those who had hyperglycemia before the beginning of the EN (33% patients); NoHyper: those who did not have hyperglycemia before or after (47.8% patients); and HyperEN: Those who did not have hyperglycemia before but suffered it after the beginning of the EN (19.1% patients). RESULTS: The age was 72.72 (15.32) years. A higher rate of mortality was observed in the HyperEN group 45.50%, than HyperES 15.80% or NoHyper: 10.90%). A lower recovery of the oral feeding was observed in those patients of the HyperEN group 27.30%, than HyperES: 42.10% or NoHyper: 61.80%). In the multivariate analysis adjusting for age, sex, and Rankin scale the development of hyperglycemia in those who did not have it at the beginning (HyperEN) was an independent risk factor for non-recovery of the oral feeding (OR: 4.21 (1.20-14.79), p = 0.02); and mortality adjusted for age, sex and Rankin scale (OR: 6.83 (1.76-26.47), p < 0.01). CONCLUSIONS: In non-diabetic patients admitted for stroke with EN, the development of hyperglycaemia in relation to enteral nutrition supposes an independent risk factor for mortality and for the non-recovery of the oral feeding.

Influence of a multidisciplinary protocol on nutritional status at diagnosis in amyotrophic lateral sclerosis.

OBJECTIVE: The aim of this study were to understand the influence of a multidisciplinary care protocol in amyotrophic lateral sclerosis (ALS) on the change in the delay of remission to the nutrition specialist and the initial nutritional status. METHODS: A cohort study was performed in 43 patients with ALS who were referred to the Nutrition Unit between April 2015 and April 2017. Anthropometric parameters and diagnostic times were collected, and the nutritional status was studied through subjective global assessment (SGA). Patients who were included before (control cohort [NoP]) and after (protocol cohort [P]) a multidisciplinary protocol were compared. The mean age of the participants was 66.79 y (10.86 y). Of the patients, 62.8% belonged to the protocol cohort. RESULTS: Patients who started the protocol had a lower delay in initial assessment by a nutrition specialist (P:2 [1-6] mo/NoP:12 [10-29] mo; P = 0.03). When the nutritional status was analyzed according to the SGA, more patients who did not initiate protocol were in the state of severe malnutrition (C) (P 22.2% versus NoP 60%; P = 0.01). Entry into the protocol was an independent protective factor of the presence of severe malnutrition at the beginning of the nutritional follow-up (odds ratio, 0.20; 95% confidence interval, 0.03-0.73; P = 0.02). CONCLUSIONS: The implementation of a multidisciplinary protocol in ALS allowed patients to present a lower percentage of severe malnutrition in an initial assessment by the nutrition specialist. This protocol is a protective factor for the presence of malnutrition at the beginning of support.

[Endovascular treatment of critical basilar stenosis with a Solitaire® stent device: a first experience in our centre]. / Tratamiento endovascular de una estenosis crítica basilar con dispositivo stent Solitaire®: primera experiencia en nuestro centro.

INTRODUCTION: Although intracranial arteriosclerosis is an important cause of stroke, the therapeutic attitude has still not been clearly established. Hence, the SAMMPRIS study compared intensive medical treatment with angioplasty and stent placement, with outcomes favouring the pharmacological treatment. These results could be partly due to the device used (Wingspan® stent). CASE REPORT: A 71-year-old male with a severe stenosis of the basilar artery, who suffered repeated episodes of transient neurological focus despite being treated with antiplatelet therapy and statins. Given the circumstances, the decision was made to perform a therapeutic arteriography with angioplasty and placement of a Solitaire® stent in order to optimise results, a residual stenosis of 40% being achieved. Subsequent progress was favourable and the control tests carried out showed a minimum progression. CONCLUSIONS: As far as we know, this is the first case of critical stenosis of the basilar artery being treated by placement of a Solitaire® stent to be reported in the literature.

TITLE: Tratamiento endovascular de una estenosis critica basilar con dispositivo stent Solitaire ®: primera experiencia en nuestro centro.Introduccion. Aunque la arterioesclerosis intracraneal es una causa importante de ictus, la actitud terapeutica no esta claramente establecida. En este sentido, el estudio SAMMPRIS comparo el tratamiento medico intensivo con la angioplastia y colocacion de stent, con resultados favorables al tratamiento farmacologico. Estos resultados podrian, en parte, deberse al dispositivo utilizado (stent Wingspan ®). Caso clinico. Varon de 71 años con una estenosis grave de la arteria basilar, en quien se repetian episodios de focalidad neurologica transitoria a pesar del tratamiento con doble antiagregacion y estatinas. En estas circunstancias se decidio realizar una arteriografia terapeutica con angioplastia y colocacion de un stent Solitaire ® para optimizar resultados y se logro una estenosis residual del 40%. La evolucion fue favorable y los controles posteriores muestran una minima progresion. Conclusion. Segun nuestro conocimiento, este es el primer caso publicado de tratamiento de una estenosis critica de la arteria basilar mediante la colocacion de un stent Solitaire ®.

[Spontaneous resolution of a type IV dural arteriovenous fistula]. / Resolución espontánea de una fístula dural arteriovenosa tipo IV.

TITLE: Resolucion espontanea de una fistula dural arteriovenosa tipo IV.

[High performance of an implantable Holter monitor in the detection of concealed paroxysmal atrial fibrillation in patients with cryptogenic stroke and a suspected embolic mechanism]. / Altorendimiento del holter implantable en la detecciónde fibrilación auricular paroxística oculta en pacientescon ictus criptogénico y sospecha de mecanismo embólico.

INTRODUCTION: Implantable loop recorders (ILR) may allow detection of occult paroxysmal atrial fibrillation (PAF) in patients with cryptogenic ischemic stroke. However, optimal selection algorithm and ideal duration of monitoring remain unclear. AIM. To determine the incidence and time-profile of PAF in patients with cryptogenic ischemic stroke studied with Reveal XT ILR, who were selected based on a high suspicion of cerebral embolism. SELECTION CRITERIA: absence of stroke etiology after complete study including vascular imaging, transesophageal echocardiography and at least 24 hours of cardiac rhythm monitoring, and confirmation of acute embolic occlusion of intracranial artery by transcranial duplex or characteristics of acute ischemic lesion on neuroimaging suggesting embolic mechanism of ischemia. After implanting Reveal XT ILR, patients were trained to perform transmissions monthly or when symptoms occurred. We reviewed the information online each month and patients underwent clinical visits at 3rd and 6th month and then every six months. RESULTS: We included 101 patients with cryptogenic ischemic stroke and at least one month of follow-up after ILR implant. Mean age was 67 years, 54 women (53.5%). Mean follow-up after implantation was 281 ± 212 days. Occult PAF was detected in 34 patients (33.7%). Frequency of false positives: 22.8%. Median time from implant to arrhythmia detection was 102 days (range: 26-240 days). 24 (70%) patients with PAF had several arrhythmic episodes detected with ILR. The majority of events (75%) were detected during the first six months of monitoring. CONCLUSIONS: In our patients with probably embolic cryptogenic ischemic stroke, PAF was detected by Reveal XT ILR in 33.7%. One in four events occurred after the first six months of monitoring.

TITLE: Alto rendimiento del holter implantable en la deteccion de fibrilacion auricular paroxistica oculta en pacientes con ictus criptogenico y sospecha de mecanismo embolico.Introduccion. El holter implantable permite detectar fibrilacion auricular paroxistica (FAP) oculta en pacientes con ictus criptogenico, pero se desconoce que algoritmo de seleccion tiene un mayor rendimiento y la duracion optima de monitorizacion. Objetivo. Conocer la frecuencia y el tiempo hasta detectar la FAP mediante un holter implantable Reveal XT ® en pacientes con ictus criptogenico seleccionados por sospecha elevada de embolismo cerebral. Pacientes y metodos. Criterios de seleccion: ausencia de etiologia del ictus tras el estudio completo incluyendo un ecocardiograma transesofagico, monitorizacion ECG y holter de 24 horas, asi como confirmacion de oclusion aguda embolica de la arteria intracraneal por duplex transcraneal o bien alta sospecha de embolismo por caracteristicas de neuroimagen. Tras implantar el holter Reveal XT se formo a los pacientes para que emprendieran transmisiones todos los meses o ante sintomas. Se reviso la informacion online mensualmente y se realizaron visitas clinicas en las unidades de Neurologia y Cardiologia. Resultados. Se incluyeron 101 pacientes con ictus criptogenico y al menos un mes de seguimiento: edad media de 67 años, 54 mujeres (53,5%). Tiempo medio de seguimiento: 281 ± 212 dias. Se detecto FAP oculta en 34 pacientes (33,7%) y falsos positivos en 23 (22,8%). Mediana desde el implante hasta la deteccion de la arritmia: 102 dias (rango: 26-240 dias). En un 70% de los pacientes se registraron multiples episodios de FAP. El 75% de los eventos se detectaron durante los primeros seis meses de monitorizacion. Conclusiones. El algoritmo de seleccion de pacientes con ictus criptogenico segun sospecha de embolismo cerebral se asocio a una elevada frecuencia (33,7%) de FAP oculta con holter implantable. Uno de cada cuatro eventos sucedio tras los primeros seis meses de monitorizacion.