Beyond hyperglycemia: glycaemic variability as a prognostic factor after acute ischemic stroke.

INTRODUCTION: Glycaemic variability (GV) refers to variations in blood glucose levels, and may affect stroke outcomes. This study aims to assess the effect of GV on acute ischaemic stroke progression. METHODS: We performed an exploratory analysis of the multicentre, prospective, observational GLIAS-II study. Capillary glucose levels were measured every 4 hours during the first 48 hours after stroke, and GV was defined as the standard deviation of the mean glucose values. The primary outcomes were mortality and death or dependency at 3 months. Secondary outcomes were in-hospital complications, stroke recurrence, and the impact of the route of insulin administration on GV. RESULTS: A total of 213 patients were included. Higher GV values were observed in patients who died (n = 16; 7.8%; 30.9 mg/dL vs 23.3 mg/dL; p = 0.05). In a logistic regression analysis adjusted for age and comorbidity, both GV (OR = 1.03; 95% CI, 1.003-1.06; p = 0.03) and stroke severity (OR = 1.12; 95% CI, 1.04-1.2; p = 0.004) were independently associated with mortality at 3 months. No association was found between GV and the other outcomes. Patients receiving subcutaneous insulin showed higher GV than those treated with intravenous insulin (38.95 mg/dL vs 21.34 mg/dL; p < 0.001). CONCLUSIONS: High GV values during the first 48 hours after ischaemic stroke were independently associated with mortality. Subcutaneous insulin may be associated with higher VG levels than intravenous administration.

Más allá de la hiperglucemia: la variabilidad glucémica como factor pronóstico en el infarto cerebral agudo / Beyond hyperglycemia: glycaemic variability as a prognostic factor after acute ischemic stroke

Introducción: La variabilidad glucémica (VG) hace referencia a las oscilaciones en los niveles de glucosa en sangre y podría influir en el pronóstico del ictus. Objetivo: Analizar el efecto de la VG en la evolución del infarto cerebral agudo (IC).MétodosAnálisis exploratorio del estudio GLIAS-II (multicéntrico, prospectivo y observacional). Se midieron los niveles de glucemia capilar cada cuatro horas durante las primeras 48 horas y la VG se definió como la desviación estándar de los valores medios. Variables principales: mortalidad y muerte o dependencia a los tres meses. Variables secundarias: porcentaje de complicaciones intrahospitalarias y de recurrencia de ictus, e influencia de la vía de administración de insulina sobre la VG.ResultadosSe incluyeron 213 pacientes. Los pacientes que fallecieron (N = 16;7,8%) presentaron mayores valores de VG (30,9 mg/dL vs. 23,3 mg/dL; p = 0,05). En el análisis de regresión logística ajustado por edad y comorbilidad, tanto la VG (OR = 1,03; IC del 95%: 1,003-1,06: p = 0,03) como la gravedad del IC (OR = 1,12; IC del 95%: 1,04-1,2; p = 0,004) se asociaron de forma independiente con la mortalidad a los tres meses. No se encontró asociación entre la VG y las demás variables de estudio. Los pacientes que recibieron tratamiento con insulina subcutánea mostraron una mayor VG que los tratados con insulina intravenosa (38,9 mg/dL vs. 21,3 mg/dL; p < 0,001).ConclusionesValores elevados de VG durante las primeras 48 horas tras el IC se asociaron de forma independiente con la mortalidad. La administración subcutánea de insulina podría condicionar una mayor VG que la vía intravenosa. (AU)

Introduction: Glycaemic variability (GV) refers to variations in blood glucose levels, and may affect stroke outcomes. This study aims to assess the effect of GV on acute ischaemic stroke progression.MethodsWe performed an exploratory analysis of the multicentre, prospective, observational GLIAS-II study. Capillary glucose levels were measured every 4 hours during the first 48 hours after stroke, and GV was defined as the standard deviation of the mean glucose values. The primary outcomes were mortality and death or dependency at 3 months. Secondary outcomes were in-hospital complications, stroke recurrence, and the impact of the route of insulin administration on GV.ResultsA total of 213 patients were included. Higher GV values were observed in patients who died (n = 16; 7.8%; 30.9 mg/dL vs 23.3 mg/dL; p = 0.05). In a logistic regression analysis adjusted for age and comorbidity, both GV (OR = 1.03; 95% CI, 1.003-1.06; p = 0.03) and stroke severity (OR = 1.12; 95% CI, 1.04-1.2; p = 0.004) were independently associated with mortality at 3 months. No association was found between GV and the other outcomes. Patients receiving subcutaneous insulin showed higher GV than those treated with intravenous insulin (38.95 mg/dL vs 21.34 mg/dL; p < 0.001).ConclusionsHigh GV values during the first 48 hours after ischaemic stroke were independently associated with mortality. Subcutaneous insulin may be associated with higher VG levels than intravenous administration. (AU)

Beyond hyperglycemia: glycaemic variability as a prognostic factor after acute ischemic stroke. / Más allá de la hiperglucemia: la variabilidad glucémica como factor pronóstico en el infarto cerebral agudo.

INTRODUCTION: Glycaemic variability (GV) refers to variations in blood glucose levels, and may affect stroke outcomes. This study aims to assess the effect of GV on acute ischaemic stroke progression. METHODS: We performed an exploratory analysis of the multicentre, prospective, observational GLIAS-II study. Capillary glucose levels were measured every 4 hours during the first 48 hours after stroke, and GV was defined as the standard deviation of the mean glucose values. The primary outcomes were mortality and death or dependency at 3 months. Secondary outcomes were in-hospital complications, stroke recurrence, and the impact of the route of insulin administration on GV. RESULTS: A total of 213 patients were included. Higher GV values were observed in patients who died (n = 16; 7.8%; 30.9 mg/dL vs 23.3 mg/dL; p = 0.05). In a logistic regression analysis adjusted for age and comorbidity, both GV (OR = 1.03; 95% CI, 1.003-1.06; p = 0.03) and stroke severity (OR = 1.12; 95% CI, 1.04-1.2; p = 0.004) were independently associated with mortality at 3 months. No association was found between GV and the other outcomes. Patients receiving subcutaneous insulin showed higher GV than those treated with intravenous insulin (38.95 mg/dL vs 21.34 mg/dL; p < 0.001). CONCLUSIONS: High GV values during the first 48 hours after ischaemic stroke were independently associated with mortality. Subcutaneous insulin may be associated with higher VG levels than intravenous administration.

Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid Pandemia COVID-19. Impacto en la asistencia del ictus. Plan Ictus Madrid / Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan

INTRODUCCIÓN: La sobrecarga asistencial y los cambios organizativos frente a la pandemia de COVID-19 podrían estar repercutiendo en la atención al ictus agudo en la Comunidad de Madrid. MÉTODOS: Encuesta estructurada en bloques: características del hospital, cambios en infraestructura y recursos, circuitos de código ictus, pruebas diagnósticas, rehabilitación y atención ambulatoria. Análisis descriptivo según el nivel de complejidad en la atención del ictus (disponibilidad o no de unidad de ictus y de trombectomía mecánica). RESULTADOS: De los 26 hospitales del SERMAS que atienden urgencias en adultos, 22 cumplimentaron la encuesta entre el 16 y 27 de abril. El 95% han cedido neurólogos para atender a pacientes afectados por la COVID-19. Se han reducido camas de neurología en el 89,4%, modificado los circuitos en urgencias para ictus en el 81%, con circuitos específicos para sospecha de infección por SARS-CoV2 en el 50%, y en el 42% de los hospitales los pacientes con ictus agudo positivos para SARS-CoV2 no ingresan en camas de neurología. Ha mejorado el acceso al tratamiento, con trombectomía mecánica las 24 h en el propio hospital en 10 hospitales, y se han reducido los traslados interhospitalarios secundarios. Se ha evitado el ingreso de pacientes con ataque isquémico transitorio o ictus leve (45%) y se han incorporado consultas telefónicas para seguimiento en el 100%. CONCLUSIONES: Los cambios organizativos de los hospitales de la Comunidad de Madrid frente a la pandemia por SARS-Co2 han modificado la dedicación de recursos humanos e infraestructuras de las unidades de neurología y los circuitos de atención del ictus, realización de pruebas diagnósticas, ingreso de los pacientes y seguimiento

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up

Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates.

BACKGROUND AND PURPOSE: The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS: This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS: The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS: Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.

Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan. / Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid.

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.

Will neurological care change over the next 5 years due to the COVID-19 pandemic? Key informant consensus survey. / ¿Va a cambiar la neurología tras la pandemia de COVID-19 en los próximos 5 años? Estudio de enfoque mediante informadores clave.

INTRODUCTION: The COVID-19 pandemic will give rise to long-term changes in neurological care, which are not easily predictable. MATERIAL AND METHODS: A key informant survey was used to enquire about the changes expected in the specialty over the next 5 years. The survey was completed by heads of neurology departments with broad knowledge of the situation, having been active during the pandemic. RESULTS: Despite a low level of consensus between participants, there was strong (85%) and moderate consensus (70%) about certain subjects, mainly the increase in precautions to be taken, the use of telemedicine and teleconsultations, the reduction of care provided in in-person consultations to avoid the presence of large numbers of people in waiting rooms, the development of remote training solutions, and the changes in monitoring visits during clinical trials. There was consensus that there would be no changes to the indication of complementary testing or neurological examination. CONCLUSION: The key informant survey identified the foreseeable changes in neurological care after the pandemic.

Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. / Atención al ictus agudo durante la pandemia por COVID-19. Recomendaciones Plan Ictus Madrid.

INTRODUCTION: The COVID-19 pandemic has resulted in complete saturation of healthcare capacities, making it necessary to reorganise healthcare systems. In this context, we must guarantee the provision of acute stroke care and optimise code stroke protocols to reduce the risk of SARS-CoV-2 infection and rationalise the use of hospital resources. The Madrid Stroke multidisciplinary group presents a series of recommendations to achieve these goals. METHODS: We conducted a non-systematic literature search using the keywords "stroke" and "COVID-19" or "coronavirus" or "SARS-CoV-2." Our literature review also included other relevant studies known to the authors. Based on this literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee. RESULTS: These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home). CONCLUSIONS: The recommendations presented here may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals.

Influence of oral anticoagulation on stroke severity and outcomes: A propensity score matching case-control study.

BACKGROUND: Oral anticoagulants (OAC) such as vitamin K antagonists (VKA) and direct-acting OACs (DOAC) remain the mainstay for prevention of cardioembolic stroke. The influence of previous OAC treatment on stroke severity and outcomes is not well stablished. We compared patients with incident cardioembolic strokes according to pre-stroke treatment. METHODS: Retrospective observational study of patients with cardioembolic stroke. Demographic data, vascular risk factors, pre-stroke treatments, reperfusion therapies and outcomes were analyzed. Propensity score matching of baseline characteristics was used to compare case-control samples across different treatment groups: adequate OAC vs no OAC; inadequate VKA vs no OAC; adequate VKA vs inadequate VKA; adequate VKA vs DOAC. RESULTS: 462 patients (76 ±â€¯11.6 years) included. 255 (55%) had a known major cardioembolic source, but only 151 (59%) of them were under OAC upon admission (127 VKA, 24 DOAC). Four patients received VKA for other reasons. Of those taking VKA, 91 (69%) had an inadequate anticoagulation. After propensity score matching, we found no significant differences in stroke severity across the different groups. Patients receiving DOAC had lower mortality at 3 months (8% vs 33%, p = .033) and higher successful recanalization rates after thrombectomy (100% vs 25%, p = .033) compared with adequate VKA anticoagulation. CONCLUSIONS: DOAC treatment significantly reduced mortality at three months compared with adequate VKA anticoagulation. Further studies are needed to confirm its influence on endovascular thrombectomy outcomes.

The effect of post-stroke hyperglycaemia on the levels of brain damage and repair-related circulating biomarkers: the Glycaemia in Acute Stroke Study II.

BACKGROUND AND PURPOSE: The aim was to identify whether post-stroke hyperglycaemia (PSH) influences the levels of circulating biomarkers of brain damage and repair, and to explore whether these biomarkers mediate the effect of PSH on the ischaemic stroke (IS) outcome. METHODS: This was a secondary analysis of the Glycaemia in Acute Stroke II study. Biomarkers of inflammation, prothrombotic activity, endothelial dysfunction, blood-brain barrier rupture, cell death and brain repair processes were analysed at 24-48 h (baseline) and 72-96 h (follow-up) after IS. The associations of the biomarkers and stroke outcome (modified Rankin Scale score at 3 months) based on the presence of PSH were compared. RESULTS: A total of 174 patients participated in this sub-study. Brain-derived neurotrophic factor (BDNF) at admission was negatively correlated with glucose levels. PSH was associated with a trend toward higher levels of endothelial progenitor cells (EPCs) at baseline. The EPCs in the PSH group then decreased in the follow-up samples (-8.5 ± 10.3) compared with the non-PSH group (4.7 ± 7.33; P = 0.024). However, neither BDNF nor EPC values had correlation with the 3-month outcome. Higher interleukin-6 at follow-up was associated with poor outcomes (modified Rankin Scale > 2) independently of PSH. CONCLUSION: Post-stroke hyperglycaemia appears to be associated with a negative regulation of BDNF and a different reaction in EPC levels. However, neither BDNF nor EPCs showed significant mediation of the PSH association with IS outcome, and only higher interleukin-6 in the follow-up samples (72-96 h) was related to poor outcomes, independently of PSH status. Further studies are needed to achieve definite conclusions.

Enfermedad cerebral, conectividad, plasticidad y terapia cognitiva. Una visión neurológica del trastorno mental / Brain disease, connectivity, plasticity and cognitive therapy: A neurological view of mental disorders

INTRODUCCIÓN: La relación entre mente y cerebro ha evolucionado desde el clásico dualismo hasta los conocimientos actuales que ponen de manifiesto que las funciones mentales son el resultado de la actividad cerebral. Este cambio de paradigma, junto con los recientes avances en diferentes técnicas de neuroimagen, ha dado lugar a una novedosa concepción del funcionamiento cerebral en términos de conectividad estructural y funcional. El objetivo del presente trabajo es describir la relación entre conectividad, lesión cerebral, plasticidad cerebral y recuperación funcional. DESARROLLO: Si la función cerebral surge de la organización en red del cerebro como un todo, la disfunción cerebral se puede producir por una alteración en la conexión de estas redes. Así, a partir del modelo conectivista, los trastornos cognitivos y del comportamiento que aparecen tras una afección cerebral se describen como consecuencia de una alteración en la organización funcional de las redes cerebrales. Sin embargo, la pérdida de funciones puede ser recuperada gracias a la capacidad de los circuitos de ser dinámicos y versátiles. La plasticidad cerebral permite una reorganización funcional que llevará a una recuperación, espontánea o potenciada con terapia cognitiva, después de algún tipo de enfermedad cerebral. CONCLUSIONES: El conocimiento de la conectividad y la plasticidad cerebrales proporciona una nueva perspectiva desde la que entender el funcionamiento cerebral en condiciones normales, los mecanismos del daño cerebral y los de la recuperación funcional, constituyendo las bases para el desarrollo de la terapia cognitiva

INTRODUCTION: Our conception of the mind-brain relationship has evolved from the traditional idea of dualism to current evidence that mental functions result from brain activity. This paradigm shift, combined with recent advances in neuroimaging, has led to a novel definition of brain functioning in terms of structural and functional connectivity. The purpose of this literature review is to describe the relationship between connectivity, brain lesions, cerebral plasticity, and functional recovery. DEVELOPMENT: Assuming that brain function results from the organisation of the entire brain in networks, brain dysfunction would be a consequence of altered brain network connectivity. According to this approach, cognitive and behavioural impairment following brain damage result from disrupted functional organisation of brain networks. However, the dynamic and versatile nature of these circuits makes recovering brain function possible. Cerebral plasticity allows for functional reorganisation leading to recovery, whether spontaneous or resulting from cognitive therapy, after brain disease. CONCLUSIONS: Current knowledge of brain connectivity and cerebral plasticity provides new insights into normal brain functioning, the mechanisms of brain damage, and functional recovery, which in turn serve as the foundations of cognitive therapy

Brain disease, connectivity, plasticity and cognitive therapy: A neurological view of mental disorders. / Enfermedad cerebral, conectividad, plasticidad y terapia cognitiva. Una visión neurológica del trastorno mental.

INTRODUCTION: Our conception of the mind-brain relationship has evolved from the traditional idea of dualism to current evidence that mental functions result from brain activity. This paradigm shift, combined with recent advances in neuroimaging, has led to a novel definition of brain functioning in terms of structural and functional connectivity. The purpose of this literature review is to describe the relationship between connectivity, brain lesions, cerebral plasticity, and functional recovery. DEVELOPMENT: Assuming that brain function results from the organisation of the entire brain in networks, brain dysfunction would be a consequence of altered brain network connectivity. According to this approach, cognitive and behavioural impairment following brain damage result from disrupted functional organisation of brain networks. However, the dynamic and versatile nature of these circuits makes recovering brain function possible. Cerebral plasticity allows for functional reorganisation leading to recovery, whether spontaneous or resulting from cognitive therapy, after brain disease. CONCLUSIONS: Current knowledge of brain connectivity and cerebral plasticity provides new insights into normal brain functioning, the mechanisms of brain damage, and functional recovery, which in turn serve as the foundations of cognitive therapy.

Glycemia in Acute Stroke II study: a call to improve post-stroke hyperglycemia management in clinical practice.

BACKGROUND AND PURPOSE: The aim of the study was to analyze the effect of conventional glucose management, which aimed to maintain glucose levels <155 mg/dL (8.5 mmol/L), on glucose control and the outcomes of patients with acute ischaemic stroke (IS) in a clinical practice setting. METHODS: This was a multicenter, prospective cohort study of patients with acute IS. Patients were classified into four groups based on their initial 48-h capillary glucose levels and the administration of and response to corrective treatment: (i) untreated and maximum glucose levels <155 mg/dL (8.5 mmol/L) within the first 48 h; (ii) treated and good responders [glucose levels persistently <155 mg/dL (8.5 mmol/L)]; (iii) treated and non-responders [any glucose values ≥155 mg/dL (8.5 mmol/L) during the 24 h after the start of corrective treatment]; and (iv) untreated with any glucose value ≥155 mg/dL (8.5 mmol/L). The primary outcome was death or dependence at 3 months (blinded rater). RESULTS: A total of 213 patients were included. Ninety-seven (45.5%) patients developed glucose levels ≥155 mg/dL (8.5 mmol/L), 69 (71.1%) underwent corrective treatment and 31 patients underwent no corrective treatment at the physician's discretion [28 of whom had isolated values ≥155 mg/dL (8.5 mmol/L)]. Only 11 (16%) patients responded to conventional treatment, whereas 58 (84%) patients were non-responsive. Non-responders showed a twofold higher risk of death or dependence at 3 months (odds ratio, 2.472; 95% confidence interval, 1.096-5.576; P = 0.029). CONCLUSIONS: Lack of response to conventional treatment for glucose management in acute IS is frequent and associated with poor outcomes.

The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.

BACKGROUND AND PURPOSE: For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. METHODS: The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. RESULTS: Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. CONCLUSIONS: The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT.

Réplica a la carta «Algunas consideraciones sobre el infarto cerebral desde otra óptica» / Reply to letter "Remarks on cerebral infarct from anotherpoint of view"

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A collaborative system for endovascular treatment of acute ischaemic stroke: the Madrid Stroke Network experience.

BACKGROUND AND PURPOSE: The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round-the-clock access to EVT for AIS. METHODS: A weekly schedule was established to ensure that at least one SC was 'on-call' to provide EVT for all those with moderate to severe AIS due to large vessel occlusion, >4.5 h from symptom onset, or within this time-window but with contraindication to, or failure of, systemic thrombolysis. The time-window for treatment was 8 h for anterior circulation stroke and <24 h in posterior stroke. Outcomes measured were re-canalization rates, modified Rankin Scale (mRS) score at 3 months, mortality and symptomatic intra-cranial haemorrhage (SICH). RESULTS: Over a 2-year period (2012-2013), 303 candidate patients with AIS were considered for EVT as per protocol, and 196 (65%) received treatment. Reasons for non-treatment were significant improvement (14%), spontaneous re-canalization (26%), clinical worsening (9%) or radiological criteria of established infarction (31%). Re-canalization rate amongst treated patients was 80%. Median delay from symptom onset to re-canalization was 323 min (p25; p75 percentiles 255; 430). Mortality was 11%; independence (mRS 0-2) was 58%; SICH was 3%. CONCLUSIONS: Implementation of a collaborative network to provide EVT for AIS is feasible and effective. Results are good in terms of re-canalization rates and clinical outcomes.

Reflexiones sobre el tratamiento endovascular en el ictus isquémico agudo. Plan de atención al ictus en la Comunidad de Madrid / Reflections on endovascular treatment for ischaemic stroke. A stroke care plan for the Region of Madrid

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Preventing diarrhoea in enteral nutrition: the impact of the delivery set hang time.

BACKGROUND: To meet the current recommendations for enteral tube feeding (ETF), we updated our previous practice in 2011 and began to use a 24-h delivery set hang time (DSHT). We evaluated the impact of this update on the risk of diarrhoea and in diarrhoea-free survival. METHODS: Observational, retrospective study with historical controls on ischaemic and haemorrhagic stroke patients undergoing ETF. Diarrhoea occurrence (≥ 3 liquid stools in 24 h) was compared between patients with a 24 h DSHT (2011-2014) and a 72/96 h DSHT (2010-2011). The analysis was conducted using Kaplan-Meier curves and a Cox regression model. RESULTS: A total of 175 patients were included [median age 81 years (IQR = 12), 46.9% males], 103 in the group with a 24 h DSHT and 72 in the group with a 72/96 h DSHT. The group with a 24 h DSHT had a lower diarrhoea frequency (13.6% vs. 34.7%, risk ratio: 0.39, 95% CI: 0.22-0.70, p = 0.001) and a lower diarrhoea incidence rate (0.87 vs. 2.32 cases of diarrhoea/100 patient*day, rate ratio: 0.37, 95% CI: 0.19-0.72, p = 0.004). The Kaplan-Meier curves showed a longer diarrhoea-free survival for this group (p = 0.003, log-rank test). A 24 h DSHT was associated with a lower risk of diarrhoea (HR = 0.27, 95% CI: 0.12-0.61, p = 0.002), adjusted by albumin, stroke severity, intravenous thrombolysis, the administration of clindamycin and cefotaxime, and the administration of an enteral formula for diabetic patients. CONCLUSIONS: The 24 h DSHT was independently associated with a lower risk of diarrhoea and longer diarrhoea-free survival in hospitalised patients with acute stroke under ETF, compared with a 72/96 h DSHT.

Recurrence of stroke amongst women of reproductive age: impact of and on subsequent pregnancies.

BACKGROUND AND PURPOSE: The risk of recurrence of stroke after pregnancy is poorly known. METHODS: This was an observational study of women younger than 45 years of age with transient ischaemic attack (TIA), cerebral infarction (CI), cerebral venous thrombosis (CVT) or intracerebral hemorrhage (ICH) treated in a stroke unit (January 1996-2011). The clinical data were prospectively collected in a database. Information on reproductive history after stroke was obtained using telephone surveys (2011). The variables were demographic data, vascular risk factors, stroke type, outcomes, medical advice concerning pregnancies after stroke, number of pregnancies after stroke, neurological assessment during pregnancy, antithrombotic treatments during pregnancy/puerperium, fertility treatments administered and information about hemorrhagic/ischaemic stroke recurrence. RESULTS: Overall, 102 women were included: 24 TIA, 64 CI (four large vessel disease, 14 cardioembolic, 12 small vessel disease, 17 undetermined etiology, 17 uncommon etiology), 12 CVT and two ICH. Mean age at the time of first stroke was 35 (±7.5) years. Median follow-up was 7.4 years (range 1-17). Thirty-two pregnancies occurred in 27 patients (previous diagnosis: four TIA, 17 CI, five CVT and one ICH). One woman became pregnant using in vitro fertilization. Only eight pregnancies were followed up by a neurologist. Of 26 pregnancies without previous history of ICH, 18 (62%) underwent preventive antithrombotic treatment. No recurrence of stroke was observed during pregnancy/puerperium. Of the women without pregnancies after the first cerebrovascular event, four CIs and three TIAs were observed. CONCLUSION: The recurrence of stroke after pregnancy is very low, which should be considered when counseling these patients.