Transcranial Doppler 6 h after Successful Reperfusion as a Predictor of Infarct Volume.

OBJECTIVES: The aim of the study is to analyze the hemodynamic changes in the middle cerebral artery (MCA) after endovascular revascularization in acute ischemic stroke (AIS) due to large vessel occlusion and its association with the infarct volume size in the control head CT. MATERIALS AND METHODS: Prospective study of patients with AIS due to internal carotid artery terminus or M1 segment of the MCA occlusion, who underwent endovascular treatment with a final TICI 2b-3 score, without concomitant stenosis ≥50% in both cervical carotid arteries. Transcranial Doppler ultrasound (TCD) of both MCAs was carried out at 6 h after the endovascular procedure. Mean flow velocities (MFV) after arterial reperfusion and its association with the infarct volume size in 24-36 h control head CT were determined. RESULTS: 91 patients (51 women) were included with a median age of 78 years and National institute of Health Stroke Scale of 18. The MCA was occluded in 76.92%, and intravenous thrombolysis was administered in 40.7%. The incidence of symptomatic intracranial hemorrhage was 5.5%. At three months, mortality was 19.8% and a 52.7% of patients achieved functional independence (modified Rankin Scale 0-2). After a multivariable logistic regression analysis, an increase in the MFV greater than 50% at 6 h in the treated MCA compared to contralateral MCA, was an independent predictor of large infarct volume in the control head CT with an OR 9.615 (95%CI: 1.908-47.620), p=0.006 CONCLUSIONS: Increased MFV assessed by TCD examination following endovascular recanalization is independently associated with larger infarct volume.

Stroke Etiology and Outcomes after Endovascular Thrombectomy: Results from the SITS Registry and a Meta-Analysis.

BACKGROUND AND PURPOSE: The influence of stroke etiology on outcomes after endovascular thrombectomy (EVT) is not well understood. We aimed to investigate whether stroke etiology subgrouped as large artery atherosclerosis (LAA) and cardiac embolism (CE) influences outcomes in large artery occlusion (LAO) treated by EVT. METHODS: We included EVT treated LAO stroke patients registered in the Safe Implementation of Treatment in Stroke (SITS) thrombectomy register between January 1, 2014 and September 3, 2019. Primary outcome was successful reperfusion (modified Treatment in Cerebral Infarction 2b-3). Secondary outcomes were symptomatic intracranial hemorrhage (SICH), 3-month functional independence (modified Ranking Scale 0-2) and death. Multivariable logistic regression models were used for comparisons. In addition, a meta-analysis of aggregate data from the current literature was conducted (PROSPERO, ID 167447). RESULTS: Of 7,543 patients, 1,903 (25.2%) had LAA, 3,214 (42.6%) CE, and 2,426 (32.2%) unknown, other, or multiple etiologies. LAA patients were younger (66 vs. 74, P<0.001) and had lower National Institutes of Health Stroke Scale score at baseline (15 vs. 16, P<0.001) than CE patients. Multivariable analyses showed that LAA patients had lower odds of successful reperfusion (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.57 to 0.86) and functional independence (OR, 0.74; 95% CI, 0.63 to 0.85), higher risk of death (OR, 1.44; 95% CI, 1.21 to 1.71), but no difference in SICH (OR, 1.09; 95% CI, 0.71 to 1.66) compared to CE patients. The systematic review found 25 studies matching the criteria. The meta-analysis did not find any difference between etiologies. CONCLUSIONS: From the SITS thrombectomy register, we observed a lower chance of reperfusion and worse outcomes after thrombectomy in patients with LAA compared to CE etiology, despite more favorable baseline characteristics. In contrast, the meta-analysis did not find any difference between etiologies with aggregate data.

Mechanical Thrombectomy in Medium Vessel Occlusions: Blind Exchange With Mini-Pinning Technique Versus Mini Stent Retriever Alone.

BACKGROUND AND PURPOSE: Mechanical thrombectomy techniques for intracranial medium vessel occlusions (MeVOs) have evolved in recent years, although the optimal approach is still unclear. The aim of this study was to investigate the effectiveness and safety of mechanical thrombectomy in MeVOs using mini (0.017 inches microcatheter compatible) stent retrievers combined with low-profile (0.035 inches distal inner diameter) distal aspiration catheters through the blind exchange/mini-pinning (BEMP) technique compared with mini stent retrievers alone. METHODS: Retrospective review of a prospectively maintained database of patients treated with the BEMP technique or mini stent retriever alone for intracranial MeVOs from 2017 to 2020 in a comprehensive stroke center. Both groups were compared about baseline characteristics, occlusion site, clinical presentation, clot cause, procedural outcomes (MeVO first-pass and final expanded Thrombolysis in Cerebral Ischemia score, the mini stent retriever used, number of passes with the front-line approach, and need of rescue therapy), safety outcomes (emboli to unwanted territories and hemorrhagic complications), and clinical outcomes at 90 days. Multivariable logistic regression analysis was performed with potential predictors of vessel recanalization to find independent variables associated with MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization. RESULTS: We reviewed 102 patients/106 MeVOs treated with the BEMP technique (n=56) or mini stent retriever (n=50). There was a higher rate of MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization (57% versus 34%, P=0.017), lower need of rescue therapy (7.1% versus 22%, P=0.028), and lower rate of emboli to new territory (1.8% versus 12%, P=0.035) and symptomatic intracranial hemorrhage (1.9% versus 12.8%, P=0.038) with the BEMP technique. After multivariable analysis, the sole independent factor associated to MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization was the BEMP technique (odds ratio, 2.72 [95% CI, 1.19-6.22]; P=0.018). CONCLUSIONS: In the setting of MeVOs, the BEMP technique may lead to higher rates of the first-pass recanalization and a lower incidence of symptomatic intracranial hemorrhage than mini stent retrievers alone.

Management of Large Vessel Occlusion Stroke Related to Infective Endocarditis: Is Mechanical Thrombectomy a Safe Option?

INTRODUCTION: Acute ischemic stroke is the most common neurological complication of infective endocarditis. Intravenous thrombolysis is contraindicated in these patients due to a higher risk of hemorrhagic complications. Whether mechanical thrombectomy has some benefit in these patients remains unanswered although some favorable results can be found in literature. METHODS: We report twelve cases of acute ischemic stroke due to septic emboli treated with mechanical thrombectomy in two comprehensive stroke centers. RESULTS: Median age was 63 years (IQR 58.8-77.5 years). Diagnosis of infective endocarditis was previous to the diagnosis of stroke in three of the patients. There were five cases of prosthetic-valve endocarditis and eight cases of native-valve endocarditis. Two patients were treated with intravenous thrombolysis with an extensive subarachnoid hemorrhage in 24 h follow-up CT in one of them. Another patient suffered an arterial perforation during the endovascular procedure without successful recanalization. 6 of the patients (50%) developed some type of hemorrhagic complications with three cases of symptomatic intracerebral hemorrhage. Early neurological recovery was achieved in 3 (25%) patients. Functional independence at 3 months in patients with successful revascularization was reached in 50% of the cases. CONCLUSIONS: In patients with large vessel acute ischemic stroke related to infective endocarditis, mechanical thrombectomy might be considered with some potential benefit reported. There may be a high risk of hemorrhagic complications, as known for intravenous thrombolysis in this condition, suggesting that this procedure should be carefully evaluated in these patients.

La autonomía del paciente en el ictus: pérdida aguda de la competencia y consentimiento informado / Autonomy in stroke patients: acute loss of competence and informed consent

El paciente con ictus, por su carácter de urgencia y por la frecuente afectación de funciones neurológicas esenciales para otorgar libremente consentimiento informado, plantea algunos problemas específicos en cuanto a los límites de la autonomía del paciente. Revisamos aspectos de la legislación española a este respecto, las recomendaciones internacionales, y proponemos un test rápido a pie de cama para evaluar la pérdida aguda de la competencia (AU)

Stroke patients, because of their emergency qualities and the frequent involvement of neurological functions essential to freely give informed consent, pose some specific problems regarding the limits of patient autonomy. We review aspects of the Spanish legislation in this respect, the international recommendations, and we propose a fast bedside test to evaluate the acute loss of competence (AU)

Guía de actuación clínica en la hemorragia subaracnoidea. Sistemática diagnóstica y tratamiento / Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJETIVO: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. MATERIAL Y MÉTODOS: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. RESULTADOS: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. CONCLUSIONES: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes

Guía para el tratamiento preventivo del ictus isquémico y AIT (II). Recomendaciones según subtipo etiológico / Guidelines for the preventive treatment of ischaemic stroke and TIA (II). Recommendations according to aetiological sub-type

FUNDAMENTO Y OBJETIVO: Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). MÉTODOS: Revisión de evidencias disponibles sobre la prevención del ictus isquémico y AIT en función del subtipo etiológico. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. RESULTADOS: En el II de origen aterotrombótico reducen el riesgo de recurrencias el tratamiento antiagregante y los procedimientos revascularizadores en casos seleccionados de estenosis carotidea ipsilateral (70-99%). La prevención de II de origen cardioembólico (fibrilación auricular, valvulopatías, prótesis valvulares y en infarto de miocardio con trombo mural) se basa en el uso de anticoagulantes orales. En el II de origen inhabitual, las terapias preventivas dependerán de la etiología; en la trombosis venosa cerebral la anticoagulación oral es eficaz. CONCLUSIONES: Se concluye con recomendaciones de práctica clínica en prevención de ictus isquémico y AIT adaptadas al subtipo etiológico de II que ha presentado el paciente

BACKGROUND AND OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA). METHODS: We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective. CONCLUSIONS: We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient

Recurrent transient ischaemic attack and early risk of stroke: data from the PROMAPA study.

BACKGROUND: Many guidelines recommend urgent intervention for patients with two or more transient ischaemic attacks (TIAs) within 7 days (multiple TIAs) to reduce the early risk of stroke. OBJECTIVE: To determine whether all patients with multiple TIAs have the same high early risk of stroke. METHODS: Between April 2008 and December 2009, we included 1255 consecutive patients with a TIA from 30 Spanish stroke centres (PROMAPA study). We prospectively recorded clinical characteristics. We also determined the short-term risk of stroke (at 7 and 90 days). Aetiology was categorised using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. RESULTS: Clinical variables and extracranial vascular imaging were available and assessed in 1137/1255 (90.6%) patients. 7-Day and 90-day stroke risk were 2.6% and 3.8%, respectively. Large-artery atherosclerosis (LAA) was confirmed in 190 (16.7%) patients. Multiple TIAs were seen in 274 (24.1%) patients. Duration <1 h (OR=2.97, 95% CI 2.20 to 4.01, p<0.001), LAA (OR=1.92, 95% CI 1.35 to 2.72, p<0.001) and motor weakness (OR=1.37, 95% CI 1.03 to 1.81, p=0.031) were independent predictors of multiple TIAs. The subsequent risk of stroke in these patients at 7 and 90 days was significantly higher than the risk after a single TIA (5.9% vs 1.5%, p<0.001 and 6.8% vs 3.0%, respectively). In the logistic regression model, among patients with multiple TIAs, no variables remained as independent predictors of stroke recurrence. CONCLUSIONS: According to our results, multiple TIAs within 7 days are associated with a greater subsequent risk of stroke than after a single TIA. Nevertheless, we found no independent predictor of stroke recurrence among these patients.

Viral encephalitis and atherothrombotic stroke.

The clinical hallmark of viral encephalitis is an acute febrile illness, but stroke-like presentations have been rarely described. We report a patient who arrived at A&E with an acute right middle cerebral artery syndrome, without fever. Following thrombolytic treatment, clinical deficit almost disappeared and a critical ipsilateral carotid stenosis was identified. Stenting was implemented and 7 days later the patient started with high fever and reappearance of the initial deficit. Hyperperfusion syndrome and pneumonia were initially considered as the diagnosis but herpetic encephalitis (HE) was the final diagnosis. A very good response to antiviral treatment was achieved. We discuss whether the patient suffered from an unusual sudden stroke-like onset HE without encephalitic features or whether a stroke led to delayed HE.

Intravenous thrombolytic treatment in the oldest old.

Background and Purpose. Intravenous thrombolysis using tissue plasminogen activator is safe and probably effective in patients >80 years old. Nevertheless, its safety has not been specifically addressed for the oldest old patients (≥85 years old, OO). We assessed the safety and effectiveness of thrombolysis in this group of age. Methods. A prospective registry of patients treated with intravenous thrombolysis. Patients were divided in two groups (<85 years and the OO). Demographic data, stroke aetiology and baseline National Institute Health Stroke Scale (NIHSS) score were recorded. The primary outcome measures were the percentage of symptomatic intracranial haemorrhage (SICH) and functional outcome at 3 months (modified Rankin Scale, mRS). Results. A total of 1,505 patients were registered. 106 patients were OO [median 88, range 85-101]. Female sex, hypertension, elevated blood pressure at admission, cardioembolic strokes and higher basal NIHSS score were more frequent in the OO. SICH transformation rates were similar (3.1% versus 3.7%, P = 1.00). The probability of independence at 3 months (mRS 0-2) was lower in the OO (40.2% versus 58.7%, P = 0.001) but not after adjustment for confounding factors (adjusted OR, 0.82; 95% CI, 0.50 to 1.37; P = 0.455). Three-month mortality was higher in the OO (28.0% versus 11.5%, P < 0.001). Conclusion. Intravenous thrombolysis for stroke in OO patients did not increase the risk of SICH although mortality was higher in this group.

Is psycho-physical stress a risk factor for stroke? A case-control study.

BACKGROUND: Chronic stress is associated with cardiovascular diseases, but the link with stroke has not been well established. Stress is influenced by life-style habits, personality type and anxiety levels. We sought to evaluate psycho-physical stress as a risk factor for stroke, while assessing gender influences. METHODS: Case-control study. cases: patients (n=150) aged 18-65, admitted consecutively to our Stroke Unit with the diagnosis of incident stroke. CONTROLS: (n=300) neighbours (paired with case ±5 years) recruited from the census registry. STUDY VARIABLES: socio-demographic characteristics, vascular risk factors, psychophysical scales of H&R (Holmes & Rahe questionnaire of life events), ERCTA (recall scale of type A behaviour), SF12 (QoL scale), GHQ28 (general health questionnaire). Statistical analyses included conditional multiple logistic regression models. RESULTS: Mean age was 53.8 years (SD: 9.3). Compared with controls, and following adjustment for confounding variables, significant associations between stroke and stress were: H&R values >150 OR=3.84 (95% CI 1.91 to 7.70, p<0.001); ERCTA (values >24) OR=2.23 (95% CI 1.19 to 4.18, p=0.012); mental SF12 (values >50) OR=0.73 (95% CI 0.39 to 1.37, p=0.330); psychological SF12 (values >50) OR=0.66 (95% CI 0.33 to 1.30, p=0.229), male gender OR=9.33 (95% CI 4.53 to 19.22, p<0.001), high consumption of energy-providing beverages OR=2.63 (95% CI 1.30 to 5.31, p=0.007), current smoker OR=2.08 (95% CI 1.01 to 4.27, p=0.046), ex-smoker OR=2.35 (95% CI 1.07 to 5.12, p=0.032), cardiac arrhythmia OR=3.18 (95% CI 1.19 to 8.51, p=0.022) and Epworth scale (≥9) OR=2.83 (95% CI 1.03 to 7.78, p=0.044). CONCLUSIONS: Compared with healthy age-matched individuals, stressful habits and type A behaviour are associated with high risk of stroke. This association is not modified by gender.

Stroke preceding autoimmune encephalitis with neuronal potassium channel antibody.

Autoimmune encephalitis related to voltage-gated potassium channel (VGKC) antibodies can occur as a complication of cancer but, more frequently, as a non-paraneoplastic disorder. The prompt recognition and treatment could mitigate the morbidity associated with this entity, but the broad-spectrum of neurological manifestations often makes the diagnosis a challenge. The authors describe, here, a unique case of autoimmune encephalitis related to VGKC antibodies preceded by an ischaemic stroke. Conditions associated with the stroke (infection, seizures, metabolic disturbances) had delayed the diagnosis. The authors suggest that autoimmune encephalitis needs to be taken into consideration as part of a differential diagnosis in patients with prolonged encephalopathy following an ischaemic stroke. Infection may trigger an inflammatory response. In addition, the rupture of blood brain barrier that occurs in stroke may have a pathogenic role by allowing antibodies to gain access to the central nervous system.

Safety and outcomes following thrombolytic treatment in stroke patients who had received prior treatment with anticoagulants.

BACKGROUND: Information is scare regarding the safety of intravenous thrombolysis in patients under anticoagulant treatment, given that this is an exclusion criterion in clinical trials. We analyzed the risk of hemorrhagic complications following thrombolysis in patients under treatment with low-molecular-weight heparins (LMWH) and oral anticoagulants (OA). METHODS: In a multicentered prospective study of consecutive acute stroke patients treated with intravenous alteplase we recorded age, gender, baseline NIHSS score, treatment delay, risk factors, etiology and previous therapy. The neurological progress (National Institutes of Health Stroke Scale at 7 days) and functional evolution at 3 months (modified Rankin Scale score), mortality and symptomatic intracerebral hemorrhage (SICH) were compared between patients with LMWH or OA and those without prior anticoagulant therapy. RESULTS: Of the 1,482 patients, 21 (1.4%) had received LMWH and 70 (4.7%) OA (international normalized ratio, INR, 0.9-2.0). Patients on OA were older, presented higher basal glucose levels, had been treated later and had a higher prevalence of hypertension, dyslipidemia, prior stroke, atrial fibrillation and cardioembolic pathologies. The severity of stroke on admission was similar in the different groups. The percentages of patients achieving independence (mRS 0-2) at 3 months were 33, 44 and 58 (LMWH, OA and no prior anticoagulant treatment, respectively; p = 0.02 for both comparisons of LMWH vs. no treatment and OA vs. no treatment); the mortality rates were 30, 25 and 12% (p = 0.010, p = 0.001, respectively) and the SICH were 14, 3 and 2% (p < 0.0001 for comparison of LMWH vs. no treatment). In the case of treatment with OA, the outcomes were independent of the INR value. Following adjustment for confounding variables, the prior use of OA was associated with higher mortality (OR: 2.15, 95% CI: 1.1-4.2; p = 0.026) but not with SICH transformation or lower probability of independence. The use of LMWH was associated with higher mortality (OR: 5.3, 95% CI: 1.8-15.5; p = 0.002), risk of SICH (OR: 8.4, 95% CI: 2.2-32.2; p = 0.002) and lower probability of achieving independence (OR: 0.3, 95% CI: 0.1-0.97; p = 0.043). CONCLUSIONS: The use of intravenous thrombolysis appears to be safe in patients previously treated with OA with INR levels <2 since there is no increase in SICH. The prior use of LMWH appears to increase the risk of SICH, death and dependence and, as such, the decision for systemic treatment with thrombolytic agents needs to be taken with caution in these cases. Larger case series are necessary to confirm these findings.

Thrombolytic therapy for acute ischemic stroke after recent transient ischemic attack.

BACKGROUND AND AIM: Safety and efficacy of intravenous thrombolysis in stroke patients with recent transient ischemic attack are hotly debated. Patients suffering transient ischemic attack may present with diffusion-weighted imaging lesions, and although normal computed tomography would not preclude thrombolysis, the concern is that they may be at higher risk for hemorrhage post-thrombolysis treatment. Prior ipsilateral transient ischemic attack might provide protection due to ischemic preconditioning. We assessed post-thrombolysis outcomes in stroke patients who had prior transient ischemic attack. METHODS: Multicentered prospective study of consecutive acute stroke patients treated with intravenous tissue plasminogen activator (tPA). Ipsilateral transient ischemic attack, baseline characteristics, risk factors, etiology, and time-lapse to treatment were recorded. National Institutes of Health Stroke Scale at seven-days and modified Rankin Scale at three-months, symptomatic intracranial hemorrhage, and mortality were compared in patients with and without transient ischemic attack. RESULTS: There were 877 patients included, 60 (6·84%) had previous ipsilateral transient ischemic attack within one-month prior to the current stroke (65% in the previous 24 h). Transient ischemic attack patients were more frequently men (70% vs. 53%; P = 0·011), younger (63 vs. 71 years of age; P = 0·011), smokers (37% vs. 25%; P = 0·043), and with large vessel disease (40% vs. 25%; P = 0·011). Severity of stroke at onset was similar to those with and without prior transient ischemic attack (median National Institutes of Health Stroke Scale score 12 vs. 14 P = 0·134). Those with previous transient ischemic attack were treated earlier (117 ± 52 vs. 144 ± 38 mins; P < 0·005). After adjustment for confounding variables, regression analysis showed that previous transient ischemic attack was not associated with differences in stroke outcome such as independence (modified Rankin Scale 0-2) (odds ratios: 1·035 (0·57-1·93) P = 0·91), mortality (odds ratios: 0·99 (0·37-2·67) P = 0·99), or symptomatic intracranial hemorrhage (odds ratios: 2·04 (0·45-9·32) P = 0·36). CONCLUSIONS: Transient ischemic attack preceding ischemic stroke does not appear to have a major influence on outcomes following thrombolysis. Patients with prior ipsilateral transient ischemic attack appear not to be at higher risk of bleeding complications.

Quality of life after stroke: the importance of a good recovery.

BACKGROUND: Health-related quality of life (HRQoL) is a recognized and important outcome after stroke. An increased survival and the presence of moderate impairment in long-term stroke survivors impact their HRQoL. METHODS: HRQoL measures and HRQoL determinants in stroke survivors are reviewed. RESULTS: Stroke is the leading cause of long-term disability in western countries. Specific HRQoL scales have been developed in the last years, such as the Stroke Impact Scale, the Stroke Specific Quality of Life Scale, the Stroke and Aphasia HRQoL Scale, and the Burden of Stroke Scale. Disability and poststroke depression are consistent determinants of HRQoL. Other determinants include female sex, coping strategies, and social support. Poststroke depression affects HRQoL, functional recovery, cognitive function and healthcare use in stroke survivors. Stroke caregivers have lower HRQoL, greater prevalence of stress and depression, economical burden, and changes in social relationships. Advancing age and anxiety in patients and caregivers, high dependency and poor family support identify caregivers at risk of adverse outcomes. CONCLUSIONS: Physical and psychosocial well-being is greatly affected in stroke survivors and their caregivers.

In-hospital stroke treated with intravenous tissue plasminogen activator.

BACKGROUND AND PURPOSE: In-hospital strokes (IHSs) are potential candidates for thrombolysis. We analyzed the treatment procedures, safety, and efficacy of intravenous tissue plasminogen activator (IV-tPA) in IHSs compared with out-of-hospital strokes (OHSs). METHODS: This study was based on a multicenter prospective registry of patients treated with IV-tPA divided into IHSs and OHSs. We recorded intrahospital delays and stroke outcomes. RESULTS: Among 367 patients treated with IV-tPA, 30 were IHSs. Baseline characteristics were similar except for a greater proportion of diabetes (36.7% vs 17.5%, P=0.01), cardiac failure (16.7% vs 5.3%, P=0.014), and atrial fibrillation (33.3% vs 17.5%, P=0.034) in IHSs than OHSs. In-hospital delays were significantly longer in IHSs for door-to-computed tomography time (39.5+/-18.7 vs 22.6+/-19.7 minutes, P<0.0001) and computed tomography-to-treatment time (92.0+/-26.1 vs 65.4+/-25.8 minutes, P<0.0001). No differences were observed in safety or efficacy. CONCLUSIONS: In-hospital procedures for thrombolysis proceed more slowly in IHSs than in OHSs. Thrombolysis is safe and efficient in IHS.

Peculiarities of stroke risk in women.

Stroke constitutes a serious socioeconomic and health care problem in women because it is the principal cause of incapacity and the first cause of death in this section of the population in several countries. The incidence of cerebral infarction and myocardial infarction is lower in females than in males, but only up to menopause, when, especially after >65 years of age, the differences disappear. This is attributable to the protective role of the natural estrogens during the fertile part of the woman's life. The estrogens have antiatherogenic and neuroprotective effects and, before menopause, account for a risk profile that is less atherogenic. The risk factors that have higher importance in young women are migraine and oral contraceptive use as well as etiologies specifically associated with pregnancy, birth and puerperium, or even diseases that present more commonly in women (systemic lupus erythematosus, fibromuscular dysplasia). These entities lose their relevance after menopause, when the classical vascular-disease risk factors take on their role, and also include others such as hormone replacement therapy. Due to the specific epidemiology of stroke, females are underrepresented in the clinical trials of primary and secondary prevention, the result being that the outcomes measured in these trials are less consistent and do not show as clear a benefit for women as for men.

Estrogens as neuroprotectants against ischemic stroke.

Estrogens have proven vasoprotective properties against atherosclerosis that depend on the direct effect on vascular smooth muscle and endothelium and on systemic actions that imply serum lipids, coagulation and fibrinolytic cascades, vasoactive proteins and antioxidant systems. They also have neuroprotective effects against cerebral ischemia that include antioxidant and anti-inflammatory effects, modulation of protein synthesis, inhibition of apoptosis and trophic effects and preservation of microvascular blood flow in the ischemic area. Estrogenic actions depend on activation of specific estrogen receptors that modulate gene expression and produce long-term effects on vascular endothelial and smooth muscle cells, neurons and glia, on interaction with plasma membrane sites that produce rapid non-genomic actions and also on receptor-independent mechanisms. This paper reviews what it is known about the mechanisms underlying the vaso- and neuroprotective effects of estrogens. Experimental and clinical evidences of such protective effects are also discussed. Therapeutical implications for stroke prevention and treatment derived from the available evidence are considered.