Transient ischaemic attacks clinics provide equivalent and more efficient care than early in-hospital assessment.

BACKGROUND AND PURPOSE: Clinics for early management of transient ischaemic attacks (TIAs) have been developed in some stroke centres, resulting in reduced recurrence rates compared to appointment-based outpatient management, thus saving on hospitalization. We analysed the care process, recurrence rates and economic impact of the first year of work in our early-management TIA clinic and compared these with our previous in-hospital study protocols for low- and moderate-risk TIA patients. METHODS: This was a prospective evaluation of the management of low- to moderate-risk TIA patients, comparing a new TIA clinic model (2010) with a previous hospitalization model (2009). Demographic data, vascular risk factor profiles, diagnostic test performance, secondary prevention measures, final aetiological diagnoses and cerebrovascular recurrences at 7 and 90 days were compared between in-hospital and TIA clinic assessed patients. We also carried out an economic comparison of the costs of each model's process. RESULTS: Two hundred and eleven low- to moderate-risk TIA patients were included, of whom 40.8% were hospitalized. There were no differences between the TIA clinic assessed and in-hospital assessed patients in terms of risk factor diagnosis and secondary prevention measures. The stroke recurrence rate (2.4% vs. 1.2%; P = 0.65) was low and similar for both groups (CI 95%, 0.214-20.436; P = 0.52). Cost per patient was €393.28 for clinic versus €1931.18 for in-hospital management. Outpatient management resulted in a 77.8% reduction in hospitalizations. CONCLUSION: Transient ischaemic attacks clinics are efficient for the early management of low- to moderate-risk TIA patients compared to in-hospital assessment, with no higher recurrence rates and at almost one-fifth the cost.

Angioplastia carotídea y trombectomía intracraneal simultánea en un ictus agudo / Simultaneous carotid angioplasty and intracraneal thrombectomy in acute stroke

No disponible

Off-hour effects on stroke care and outcome in stroke centres.

BACKGROUND AND PURPOSE: Poorer stroke care processes and outcomes have been reported for acute stroke patients arriving at centres during off hours and weekends. OBJECTIVE: To compare each step of the continuous specialized care that Stroke Centres (SC) provide according to time of admission and final outcome. METHODS: Observational study of consecutive stroke patients admitted to SC during 2008 and 2009. Patients were classified into two groups according to their arrival time: Work Hours (WH) and Off Hour (OH) (weekends and any time other than 8:00 am to 3:00 pm on weekdays). Differences in time to diagnostic procedures, tPA administration, stroke outcome [modified Rankin Scale, (mRS)] and in-hospital fatality rates were analysed. RESULTS: A total of 912 patients were admitted. Data from 674 patients fulfilling study criteria were analysed. A total of 434 (64.4%) patients arrived during OH. No differences in stroke severity were found when comparing OH and WH. Time to blood test results was higher for WH (median 67 min vs. 47 min; P < 0.01), but time to cranial CT scan was similar. Intravenous tPA was administered to 58 (16.4%) OH vs. 26 (13.1%) WH patients (P = 0.33). OH arrival was not associated with poorer outcome (mRS ≥ 3) at discharge (32.8% vs. 37%; P = 0.27), or at the 3-month follow-up (30.6% vs. 27.6%, P = 0.52). No differences were found for in-hospital fatality rates (5.8% vs. 5.4%, P = 1.00). CONCLUSIONS: The care provided by SC with neurologists on call 24/7 prevents differences in outcomes associated with time of admission and guarantees equal attention to stroke patients.

Bajo rendimiento del ecocardiograma, comparado con el Doppler transcraneal, en la detección de la comunicación derecha-izquierda / Low sensitivity of the echocardiograph compared with contrast transcranial doppler in right-to-left shunt

Introducción: El Doppler transcraneal con contraste (DTC-c) tiene una alta sensibilidad para la detección de comunicación derecha-izquierda (CDI), probablemente mayor que la del ecocardiograma transtorácico (ETT) y comparable con la del transesofágico (ETE). Objetivo: Evaluar la precisión del ecocardiograma (ETT y ETE) para detectar CDI, comparándolo con DTC-c. Material y métodos: Estudio observacional de pacientes <55 años con isquemia cerebral de origen indeterminado (2007-2009) a los que se les realizó una monitorización con DTC-c para detectar CDI, en reposo y tras maniobra de Valsalva (MV). El ETT y ETE se realizaron cuando estaba indicado según el protocolo de estudio cerebrovascular de nuestro centro. La precisión del ETT y ETE para detectar CDI fue calculada comparándolos con DTC-c. Resultados: Se incluyeron 115 pacientes a los que se les realizó monitorización con DTC-c. Edad media 43,3 (DE 10,3) años, 51,3% hombres. El ETT se realizó en 102 y el ETE en 81 pacientes. La detección de CDI fue mayor con DTC-c que con ETT (67,6 vs. 22,5%, p=0,001) o con ETE (77,8 vs. 53,1%, p=0,001). El ETT, comparado con DTC-c tras MV, mostró: sensibilidad 31,8%, especificidad 96,9%, valor predictivo positivo (VPP) 95,6%, valor predictivo negativo (VPN) 40,5% y precisión 52.9% para detectar CDI. El ETE, comparado con DTC-c tras MV, mostró: sensibilidad 63,4%, especificidad 83,3%, VPP 93%, VPN 39,4% y precisión 67,9%. La precisión del ETT y ETE se incrementó cuando se compararon con el DTC-c en reposo. Conclusiones: El ETT y ETE presentan un número elevado de falsos negativos para detección de CDI, cuando se comparan con el DTC-c. Los estudios clínicos deberían considerar al DTC-c como mejor técnica para diagnosticar CDI cuando se sospecha embolia paradójica (AU)

Background: Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE).Objective: To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD.Material and methods: Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD. Results: A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest. Conclusions: TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected (AU)

[Low sensitivity of the echocardiograph compared with contrast transcranial Doppler in right-to-left shunt]. / Bajo rendimiento del ecocardiograma, comparado con el Doppler transcraneal, en la detección de la comunicación derecha-izquierda.

BACKGROUND: Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE). OBJECTIVE: To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD. MATERIAL AND METHODS: Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD. RESULTS: A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest. CONCLUSIONS: TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected.

Tratamiento previo con estatinas y riesgo de complicaciones infecciosas tras un infarto cerebral agudo / Previous statins treatment and risk of post-stroke infections

Introducción y objetivo: Diversos estudios clínicos y experimentales atribuyen un efecto inmunosupresor a las estatinas y la administración de simvastatina en la fase aguda del ictus se ha asociado a mayor frecuencia de infecciones durante el ingreso. Nuestro objetivo es comprobar si el consumo previo de estatinas influye en la aparición de complicaciones infecciosas intrahospitalarias tras un infarto cerebral (IC). Pacientes y métodos: Estudio observacional incluyendo pacientes con IC ingresados en la Unidad de Ictus. Se analizan: datos demográficos, factores de riesgo vascular, gravedad al ingreso, subtipo etiológico de infarto cerebral y consumo previo de estatinas. Se ha estudiado la aparición de las siguientes complicaciones infecciosas durante la hospitalización: neumonía, infección urinaria, colitis pseudomembranosa y sepsis de cualquier origen agrupando a los enfermos en dos grupos: pacientes que previamente tomaban o no estatinas. Resultados: Se incluyeron 2.045 pacientes (1.162 varones) con edad media de 69,05 años (DE 12,5). El 15% (306 pacientes) tomaba estatinas previamente al IC. Dichos pacientes presentaban con mayor frecuencia que los que no lo hacían (p<0,0001) antecedente de HTA, DM, arteriopatía periférica e hipercolesterolemia. La frecuencia de infección intrahospitalaria fue similar en ambos grupos, tanto evaluada de manera global (11,8% vs 13%, p=0,643) como al analizar cada una de las infecciones separadamente. En el subgrupo de IC aterotrombótico, las estatinas se asociaron con una menor frecuencia de sepsis (OR no ajustado 0,949, IC 95% [0,928 – 0,971]). Conclusiones: El tratamiento previo con estatinas parece no influir en la frecuencia de complicaciones infecciosas intrahospitalarias tras un IC agudo (AU)

Introduction: Clinical and laboratory studies have attributed an inmuno-supressor effect to the statins. Furthermore, the administration of simvastatin in the acute onset of stroke has been associated with an increased infection frequency. Our objective is to assess the influence of statins previous treatment on infection after ischemic stroke. Patients and methods: Observational study of patients with ischaemic stroke hospitalised in a Stroke Unit. Demographic data, vascular risk factors, stroke severity, stroke subtype and previous statins treatment were evaluated. The following infections were registered: pneumonia, urinary tract infection, pseudomembranous colitis and sepsis. The patients were classified into two groups, depending on previous statin treatment. Results: A total of 2045 patients were included (1165 were male, aged 69.05±12.5 years). Of these, 306 (15%) patients were receiving statins prior to stroke. These patients had more frequently arterial hypertension, DM, peripheral arterial disease and hypercholesterolaemia than the patients who were not treated with statins (P < 0001). There was no statistically significant difference between overall in-hospital infection frequency between patients treated with statins and those with no statins treatment, (11.8% vs. 13%), nor in individual infection type: pneumonia (7.8% vs. 10.2%), urinary tract infection (4.2% vs. 2.8%), pseudomembranous colitis (0.3% vs. 0.7%) and sepsis (2.6% vs. 4.4%). In the atherothrombotic stroke subtype, statins were associated with a lower frequency of sepsis (unadjusted OR, 0.949; 95% CI; 0.928-0.971). Conclusions: Previous treatment with statins does not appear to influence the frequency of in-hospital infections in patients with ischaemic stroke (AU)

Previous statins treatment and risk of post-stroke infections.

INTRODUCTION: Clinical and laboratory studies have attributed an inmuno-supressor effect to the statins. Furthermore, the administration of simvastatin in the acute onset of stroke has been associated with an increased infection frequency. Our objective is to assess the influence of statins previous treatment on infection after ischemic stroke. PATIENTS AND METHODS: Observational study of patients with ischaemic stroke hospitalised in a Stroke Unit. Demographic data, vascular risk factors, stroke severity, stroke subtype and previous statins treatment were evaluated. The following infections were registered: pneumonia, urinary tract infection, pseudomembranous colitis and sepsis. The patients were classified into two groups, depending on previous statin treatment. RESULTS: A total of 2045 patients were included (1165 were male, aged 69.05±12.5 years). Of these, 306 (15%) patients were receiving statins prior to stroke. These patients had more frequently arterial hypertension, DM, peripheral arterial disease and hypercholesterolaemia than the patients who were not treated with statins (P<0001). There was no statistically significant difference between overall in-hospital infection frequency between patients treated with statins and those with no statins treatment, (11.8% vs. 13%), nor in individual infection type: pneumonia (7.8% vs. 10.2%), urinary tract infection (4.2% vs. 2.8%), pseudomembranous colitis (0.3% vs. 0.7%) and sepsis (2.6% vs. 4.4%). In the atherothrombotic stroke subtype, statins were associated with a lower frequency of sepsis (unadjusted OR, 0.949; 95% CI; 0.928-0.971). CONCLUSIONS: Previous treatment with statins does not appear to influence the frequency of in-hospital infections in patients with ischaemic stroke.

[Hypercoagulability and ischemic stroke in young patients]. / Estados de hipercoagulabilidad e ictus isquémico en pacientes jóvenes.

INTRODUCTION: Hypercoagulable states have been reported as an established risk factor for cerebral venous thrombosis, but they have also been proposed as a predisposing factor for cerebral ischemia of arterial origin, especially among young patients. This may have implications on therapeutic management and secondary prevention. We have studied the frequency of prothrombotic abnormalities in young patients with ischaemic stroke, as other classic risk factors are less common in this group. MATERIALS AND METHODS: Observational study with sequential inclusion of patients under 55 with stroke or transient ischaemic attack (TIA) admitted to the Stroke Unit from January 2005 through December 2007. We analysed demographic data, severity and subtype of stroke, risk factors, including the presence of hypercoagulable states, and outcome. RESULTS: We included 100 patients, of whom 65 were men. The mean age was 42.6 ± 8.9 years, 46% with a hypercoagulable state, and no sex differences. Acquired hyperhomocysteinemia was the most common abnormality (18%), followed by protein C or S deficiency (8%), factor V Leiden mutation (5%) and methyl-tetrahydro-folate-reductase (MTHFR) C677T mutation (5%). Other findings included anticardiolipin antibodies (3%), presence of lupus anticoagulant (2%), thrombocytosis (3%) and G20210A prothrombin gene mutation (3%). No association was found between these states and the presence of other vascular risk factors, or more severe stroke or worse outcomes. There was an increased presence of these abnormalities in patients who were classified as atherothrombotic stroke (p = 0.04). CONCLUSIONS: The hypercoagulable states are common in young patients with ischaemic stroke, being present in up to 46% of them.

Estados de hipercoagulabilidad e ictus isquémico en pacientes jóvenes / Hypercoagulability and ischemic stroke in young patients

Introducción: Los estados de hipercoagulabilidad se han estudiado como una de las posibles etiologías de la trombosis venosa cerebral y, desde hace unos años, también como factor predisponente de isquemia cerebral de origen arterial, especialmente en pacientes jóvenes. Esto podría tener implicaciones en el manejo terapéutico y la prevención secundaria, por lo que nos proponemos estudiar la frecuencia de anomalías protrombóticas en pacientes jóvenes con ictus isquémico, subgrupo en que otros factores de riesgo clásicos son menos habituales. Material y métodos: Estudio observacional con inclusión secuencial de los pacientes menores de 55 an ̃os con infarto cerebral o ataque isquémico transitorio ingresados en la unidad de ictus desde enero de 2005 hasta diciembre de 2007. Se analizaron datos demográficos, gravedad y subtipo de ictus, factores de riesgo, incluidos los estados de hipercoagulabilidad, y evolución. Resultados: Se incluyó a 100 pacientes, de los que 65 eran varones, con una media ± desviación estándar de edad de 42,6 ± 8,9 años. El 46% presentó estado de hipercoagulabilidad, sin diferencia por sexo. La hiperhomocisteinemia adquirida fue la alteración más frecuente (18%), seguida del déficit de proteína C o S (8%), la mutación para el factor V de Leiden (5%) y la mutación C677T del gen de la metiltetrahidrofolato reductasa (MTHFR) (5%). Otras alteraciones procoagulantes fueron síndrome antifosfolípido (3%), anticoagulante lúpico (2%), trombocitosis (3%) y mutación 20210A del gen de la protrombina (3%). No se encontró relación de estas alteraciones con otros factores de riesgo vascular, como tampoco se relacionó la hipercoagulabilidad con el ictus de mayor gravedad o peor evolución. Se observó una mayor presencia de estas alteraciones en los pacientes catalogados de ictus de origen aterotrombótico (p = 0,04). Conclusiones: Los estados de hipercoagulabilidad son frecuentes en los pacientes menores de 55 años con ictus isquémico, encontrándose hasta en el 46% de ellos (AU)

Introduction: Hypercoagulable states have been reported as an established risk factor for cerebral venous thrombosis, but they have also been proposed as a predisposing factor for cerebral ischemia of arterial origin, especially among young patients. This may have implications on therapeutic management and secondary prevention. We have studied the frequency of prothrombotic abnormalities in young patients with ischaemic stroke, as other classic risk factors are less common in this group. Materials and methods: Observational study with sequential inclusion of patients under 55 with stroke or transient ischaemic attack (TIA) admitted to the Stroke Unit from January 2005 through December 2007. We analysed demographic data, severity and subtype of stroke, risk factors, including the presence of hypercoagulable states, and outcome. Results: We included 100 patients, of whom 65 were men. The mean age was 42.6 ± 8.9 years, 46% with a hypercoagulable state, and no sex differences. Acquired hyperhomocysteinemia was the most common abnormality (18%), followed by protein C or S deficiency (8%), factor V Leiden mutation (5%) and methyl-tetrahydro-folate-reductase (MTHFR) C677T mutation (5%). Other findings included anticardiolipin antibodies (3%), presence of lupus anticoagulant (2%), thrombocytosis (3%) and G20210A prothrombin gene mutation (3%). No association was found between these states and the presence of other vascular risk factors, or more severe stroke or worse outcomes. There was an increased presence of these abnormalities in patients who were classified as atherothrombotic stroke (p = 0.04). Conclusions: The hypercoagulable states are common in young patients with ischaemic stroke, being present in up to 46% of them (AU)