Dysphagia and Obstructive Sleep Apnea in Acute, First-Ever, Ischemic Stroke.

BACKGROUND: Obstructive sleep apnea (OSA) and dysphagia are common in acute stroke and are both associated with increased risk of complications and worse prognosis. The aims of the present study were (1) to evaluate the prevalence of OSA and dysphagia in patients with acute, first-ever, ischemic stroke; (2) to investigate their clinical correlates; and (3) to verify if these conditions are associated in acute ischemic stroke. METHODS: We enrolled a cohort of 140 consecutive patients with acute-onset (<48 hours), first-ever ischemic stroke. Computed tomography (CT) and magnetic resonance imaging scans confirmed the diagnosis. Neurological deficit was measured using the National Institutes of Health Stroke Scale (NIHSS) by examiners trained and certified in the use of this scale. Patients underwent a clinical evaluation of dysphagia (Gugging Swallowing Screen) and a cardiorespiratory sleep study to evaluate the presence of OSA. RESULTS: There are 72 patients (51.4%) with obstructive sleep apnea (OSA+), and there are 81 patients (57.8%) with dysphagia (Dys+). OSA+ patients were significantly older (P = .046) and had greater body mass index (BMI) (P = .002), neck circumference (P = .001), presence of diabetes (P = .013), and hypertension (P < .001). Dys+ patients had greater NIHSS (P < .001), lower Alberta Stroke Programme Early CT Score (P < .001), with greater BMI (P = .030). The association of OSA and dysphagia was greater than that expected based on the prevalence of each condition in acute stroke (P < .001). CONCLUSIONS: OSA and dysphagia are associated in first-ever, acute ischemic stroke.

Relevance of prehospital stroke code activation for acute treatment measures in stroke care: a review.

BACKGROUND: The use of emergency services with prehospital stroke assessment and early notification to the treatment hospital (stroke code) is a crucial determinant of delay time for acute stroke treatment. We reviewed and summarized the literature on prehospital stroke code system implementation. METHODS: Two databases were explored (last update June 20, 2011) with 3 key words (stroke code, stroke prehospital management and stroke prehospital services). Inclusion criteria were: randomized and quasirandomized controlled trials, cohort and case-control studies, and hospital- and emergency-based registers, with no year or language restrictions. We examined the reference lists of all included articles. All potentially relevant reports and abstracts were transcribed into a specifically designed data abstraction form. RESULTS: Only 19 of the 680 studies which were initially retrieved, published from 1999 to 2011, fulfilled our inclusion criteria. One clinical trial was identified. Large differences in stroke code procedures and study designs within and across countries prohibited the pooling of the data. Most studies were carried out in urban areas. Assuming the rate of tissue-plasminogen activator treatment as the performance measure, most studies report a significant increase in the rate of treatment (increase between 3.2 and 16%) with only 1 study not reporting any increase. CONCLUSIONS: Despite its limitations, this review suggests that the use of prehospital stroke code is an important intervention to improve the accessibility of the benefits of thrombolysis, especially when implemented together with educational campaigns to optimize the awareness and behavior of patients and bystanders.

An emergency clinical pathway for stroke patients--results of a cluster randomised trial (isrctn41456865).

BACKGROUND: Emergency Clinical Pathways (ECP) for stroke have never been tested in randomized controlled trials (RCTs). OBJECTIVE: To evaluate the effectiveness of an ECP for stroke patients in Latium (Italy) emergency system. METHODS: cluster-RCT designed to compare stroke patient referrals by Emergency Medical Service (EMS) and Emergency Room (ER) health professionals trained in the ECP, with those of non-trained EMS and ER controls. Primary outcome measure was the proportion of eligible (aged

Cognitive Training in Patients with Alzheimer's Disease: Findings of a 12-month Randomized Controlled Trial.

BACKGROUND: Cognitive training (CT) is a non-pharmacological intervention based on a set of tasks that reflect specific cognitive functions. CT is aimed at improving cognition in patients with cognitive impairment, though no definitive conclusions have yet been drawn on its efficacy in Alzheimer's disease (AD). OBJECTIVE: To assess the effectiveness of a CT program designed to improve cognition in AD patients. METHOD: This is a randomized, controlled, single-blind, longitudinal trial with a no-treatment control condition in mild-to-moderate AD. Treated patients received in-group CT twice a week for six months, whereas controls did not. CT consisted of tasks ranging from paper-and-pencil to verbal-learning exercises. Participants' cognitive levels were assessed at baseline, post-intervention and 6 months later by means of a complete neuropsychological test battery. Repeated measures ANOVA was used to analyze the effect of time on the outcome measures, as well as to compare treated and untreated patients over time, with demographic data considered as covariates. RESULTS: Of the 140 patients enrolled, 45 in the treated group and 85 controls concluded the study. The CT significantly improved treated subjects' cognitive functions immediately after the CT. Six months later, some test scores remained stable when compared with those obtained at baseline. The control group performed significantly worse than the treated group at each time-point, displaying a progressive cognitive decline over time. CONCLUSION: Our results suggest that CT may improve cognitive functions in patients with AD and may help to temporarily slow their cognitive decline.

Determinants of plasma levels of brain natriuretic peptide after acute ischemic stroke or TIA.

Plasma levels of brain natriuretic peptide (BNP) are frequently elevated after an acute stroke and have been shown to be an independent predictor of mortality. However, the relationships between stroke and BNP concentrations have not yet been systematically investigated. Plasma BNP assay and echocardiography were performed in 48 patients with ischemic stroke or TIA with a mean delay of 12.7 h after onset. Median BNP concentration was 88.6 pg/mL (range 5-1270). Older age, chronic heart failure, atrial fibrillation, stroke severity, lower hemoglobin levels, lower left ventricular ejection fraction, and abnormalities of left atrium or appendage (LA/LAA) were univariately associated with increased BNP levels. At multivariable analysis, the presence of at least one LA/LAA abnormality (atrial dilatation, low flow velocity, spontaneous echocontrast or thrombus) had the strongest association with BNP, explaining 38.9% of the variance in the whole sample and 28.5% in patients without atrial fibrillation. In acute ischemic stroke patients, elevated plasma BNP levels have multiple determinants, among which left atrial disease appears to be the stronger, even in patients without atrial fibrillation. These results encourage further investigation of plasma BNP concentration as a potential marker of the presence of left atrial sources of emboli.

Which model of stroke unit is better for stroke patient management?

The increasing prevalence of cerebrovascular diseases has made urgent the need to develop timely and effective treatment strategies to tackle this health problem. Stroke units (SUs) appear to be the ideal setting where the management of acute stroke patients, including specific treatments as thrombolysis, may be optimized. Which model of SU gives the best results is still an unsettled issue. The more intensive and timely multidisciplinary approach to the acute phase of stroke, the management of medical complications, and the earlier and more focused rehabilitation, are likely the most qualifying aspects of our Neurovascular treatment unit.