Keeping prior anticoagulation treatment in the acute phase of ischaemic stroke: the REKOALA study.

INTRODUCTION: A consensus on the management of anticoagulated patients in the acute phase of ischaemic stroke has not yet been established. We aimed to evaluate clinical outcomes in such patients based on the continuation or discontinuation of anticoagulation. METHODS: Retrospective study of patients with acute ischaemic stroke and cardioembolic source receiving anticoagulant therapy is done. Patients were classified based on the continuation or discontinuation of anticoagulation at admission. Clinical outcomes, haemorrhagic and ischaemic events were assessed. Multivariate logistic regression analysis, propensity score matching (PSM) analysis and a sub-analysis of patients with severe ischaemic stroke at admission (NIHSS score ≥ 15) were performed. RESULTS: Anticoagulation was continued in 147 (78.8%) of 186 patients. Patients continuing anticoagulant had lower NIHSS (median 5 vs 18, p < 0.001). There were no differences in haemorrhagic or ischaemic events. In the multivariate analysis, good functional outcome at discharge was higher in the continuation group, OR (CI95%) 3.77 (1.2-11.2). PSM analysis adjusted for potential confounders such as NIHSS had higher rates of good functional outcomes at discharge (80% vs 36%, p = 0.004) and at 90 days (76% vs 44%, p = 0.042) in the continuation group. Patients with severe stroke in this group had lower 90-day mortality (34.6% vs 62.5%, p = 0.045) and higher rates of good clinical outcome at discharge (33.3% vs 8.3%, p = 0.032). No differences were observed in 90-day haemorrhagic or ischaemic events. CONCLUSION: Continuation of anticoagulation in patients with acute ischaemic stroke and cardioembolic source did not increase the risk of intracranial haemorrhage and may be associated with better functional outcomes.

Neck CT angiography in acute stroke: An open window for fast detection of COVID-19 lung involvement? Applicability in telemedicine.

BACKGROUND: Chest CT has been proposed as a screening test to rule out SARS-CoV-2 lung infection in acute stroke. Our objectives are to analyze the predictive value of neck CT angiography (CTA) source images compared with conventional chest CT, the interobserver concordance and the reliability of the diagnosis using a mobile app. METHODS: A retrospective observational study that included acute stroke patients admitted to a stroke center. Two raters blinded to the clinical data evaluated and classified the pulmonary findings in chest CT and neck CTA source images according to the COVID-19 Reporting and Data System (CO-RADS). CTA findings were evaluated using a conventional workstation and the JOIN mobile app. Scores of 3-5 were grouped as appearing typical or indeterminate for COVID-19 lung involvement and 0-2 as appearing atypical or negative for pneumonia. SARS-CoV-2 infection was confirmed by polymerase chain reaction (PCR). RESULTS: A total of 242 patients were included (42 with PCR-confirmed COVID-19). In the cohort of 43 patients with both neck CTA and chest CT, the predictive value for COVID-19 was equivalent (sensitivity, 53.8%; specificity, 92.9%). The interobserver agreement in the classification into CO-RADS 3-5 or 1-2 in CTA was good (K = 0.694; standard error, 0.107). In the cohort of 242 patients with neck CTA, the intraobserver agreement between the workstation and the JOIN app was perfect (K = 1.000; standard error 0.000). CONCLUSIONS: Neck CTA enables the accurate identification of COVID-19-associated lung abnormalities in acute stroke. CO-RADS evaluations through mobile applications have a predictive value similar to the usual platforms.

Circulating Extracellular Vesicle Proteins and MicroRNA Profiles in Subcortical and Cortical-Subcortical Ischaemic Stroke.

In order to investigate the role of circulating extracellular vesicles (EVs), proteins, and microRNAs as damage and repair markers in ischaemic stroke depending on its topography, subcortical (SC), and cortical-subcortical (CSC) involvement, we quantified the total amount of EVs using an enzyme-linked immunosorbent assay technique and analysed their global protein content using proteomics. We also employed a polymerase chain reaction to evaluate the circulating microRNA profile. The study included 81 patients with ischaemic stroke (26 SC and 55 CSC) and 22 healthy controls (HCs). No differences were found in circulating EV levels between the SC, CSC, and HC groups. We detected the specific expression of C1QA and Casp14 in the EVs of patients with CSC ischaemic stroke and the specific expression of ANXA2 in the EVs of patients with SC involvement. Patients with CSC ischaemic stroke showed a lower expression of miR-15a, miR-424, miR-100, and miR-339 compared with those with SC ischaemic stroke, and the levels of miR-339, miR-100, miR-199a, miR-369a, miR-424, and miR-15a were lower than those of the HCs. Circulating EV proteins and microRNAs from patients with CSC ischaemic stroke could be considered markers of neurite outgrowth, neurogenesis, inflammation process, and atherosclerosis. On the other hand, EV proteins and microRNAs from patients with SC ischaemic stroke might be markers of an anti-inflammatory process and blood-brain barrier disruption reduction.

Simulation training programs for acute stroke care: Objectives and standards of methodology.

The European Stroke Organisation (ESO) Simulation Committee was established in 2017 with the intent to promote simulation education and training in the stroke field. The application of simulation methodology in education and training improves healthcare professional performances in real clinical practice and patient outcomes. We evaluated the implementation of simulation training in stroke medicine, how it can significantly affect stroke pathways and quality of care. We herewith describe simulation techniques in the acute stroke setting. Simulation programs place the trainees in a safe environment, allowing both role-playings for decision making training and procedural simulation for technical skills improvement. This paper includes the position of the Committee on the key points, principles, and steps in order to set up and promote simulation programs in European stroke centers. Stroke is an emergency, and hyperacute phase management requires knowledge, expertise, optimal multidisciplinary team working, and timely actions in a very narrow time window. The ESO Simulation Committee promotes the implementation of simulation training in stroke care according to a specific and validated methodology.

Infartos cerebrales intrahospitalarios: datos del registro multicéntrico de pacientes con infarto cerebral ingresados en Cardiología y Cirugía Cardiaca / In-hospital ischemic strokes in patients admitted to Cardiology and Cardiac Surgery departments. Multi-centre registry

Fundamento y objetivo: Los pacientes ingresados en Cardiología y Cirugía Cardiaca tienen un riesgo importante de sufrir un infarto cerebral (IC). Analizamos las características clínicas, calidad de la atención neurológica y la evolución de los ictus intrahospitalarios (IIH) en estos servicios. Pacientes y método:Registro prospectivo de IC en pacientes ingresados en Cardiología y Cirugía Cardiaca en 13 hospitales españoles durante 2008. Recogemos datos demográficos, clínicos, terapéuticos, evolutivos y de mortalidad. Resultados: Registramos 73 casos. La edad media (DE) fue de 72 (11,6) años. El 75,4% de los IC fueron cardioembólicos. Como factores de riesgo para ictus destacaron: presencia de cardiopatías embolígenas (86,3%), suspensión del tratamiento antitrombótico previo (22%) y procedimientos invasivos (65,7%). La evaluación neurológica se hizo en menos de 3 horas en el 49,5% y pasadas 24 horas del IC en el 20,5%. Diez pacientes fueron tratados con trombólisis intravenosa, 8 no pudieron ser tratados por el retraso en avisar a Neurología. Entre las contraindicaciones para trombólisis destacaron la anticoagulación en rango (38%) y la cirugía reciente (33,3%). A los 3 meses, la mortalidad fue del 15% y solamente el 53,7% eran independientes. Los pacientes tratados con trombólisis tuvieron mejor evolución (87,5% de pacientes independientes, p=0,04).Conclusiones: Los IC intrahospitalarios en Cardiología y Cirugía Cardiaca son fundamentalmente cardioembólicos y producen una gran proporción de pacientes dependientes. Los pacientes tratados con trombólisis tuvieron mejor evolución clínica. El retraso en la llamada a Neurología impidió que una proporción relevante de pacientes fueran tratados con trombólisis intravenosa (AU)

Background and objective: Patients admitted to Cardiology and Cardiac Surgery Departments have an increased risk of ischemic stroke (IS). We analyzed clinical characteristics, quality of neurological care and mortality of in-hospital strokes (IHS) in these departments. Patients and method:Prospective registry of in-hospital ISs in Cardiology and Cardiac Surgery in 13 Spanish hospitals during 2008. Demographic, clinical and therapeutic data as well as mortality and functional evolution were recorded. Results: 73 patients were included. Mean age was 72±11.6 years. 75.4% of IS were cardioembolic. Special risk factors were presence of cardiac sources of embolism (86.3%), prior withdrawal of antithrombotic treatment (22%) and invasive procedures (65.7%). First neurological assessment was done in the first 3hours in 49.5% and beyond 24hours from IS onset in 20.5%. Ten patients were treated with intravenous thrombolysis, which was not possible in 8 patients because of the delay in calling the neurologist. Most frequent reasons for exclusion from thrombolytic therapy were recent major surgical procedures (33.3%) and anticoagulant therapy (38%). Three-month mortality was 15% and only 53.7% were functionally independent. Patients treated with thrombolysis had a better evolution (87.5% of independent patients, p=0.04). Conclusions: IS in Cardiology and Cardiac Surgery are mostly cardioembolic strokes and produce a high proportion of dependent patients. Patients treated with thrombolysis had a better evolution. Delays in contacting the neurologist led to exclusion from treatment an important proportion of patients who met thrombolysis criteria (AU)