Statistical analysis plan for the multicenter, open, randomized controlled clinical trial to assess the efficacy and safety of intravenous tirofiban vs aspirin in acute ischemic stroke due to tandem lesion, undergoing recanalization therapy by endovascular treatment (ATILA trial).

RATIONALE: In-stent reocclusion after endovascular therapy has a negative impact on outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Optimal antiplatelet therapy approach in these patients to avoid in-stent reocclusion is yet to be elucidated. AIMS: To assess efficacy and safety of intravenous tirofiban versus intravenous aspirin in patients undergoing MT plus carotid stenting in the setting of AIS due to TL. SAMPLE SIZE ESTIMATES: Two hundred forty patients will be enrolled, 120 in every treatment arm. METHODS AND DESIGN: A multicenter, prospective, randomized, controlled (aspirin group), assessor-blinded clinical trial will be conducted. Patients fulfilling the inclusion criteria will be randomized at MT onset to the experimental or control group (1:1). Intravenous aspirin will be administered at a 500-mg single dose and tirofiban at a 500-mcg bolus followed by a 200-mcg/h infusion during the first 24 h. All patients will be followed for up to 3 months. STUDY OUTCOMES: Primary efficacy outcome will be the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. Primary safety outcome will be the rate of symptomatic intracranial hemorrhage. DISCUSSION: This will be the first clinical trial to assess the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL. TRIAL REGISTRATION: The trial is registered as NCT05225961. February, 7th, 2022.

Atención urgente al ictus en hospitales con unidad de ictus. Proyecto Quick / Urgent stroke care in hospitals with a stroke unit. Quick Project

Introducción. El ictus es una emergencia médica dependiente del tiempo. La rapidez en su reconocimiento y en la atención que reciben los pacientes es clave en el pronóstico. Objetivos. Analizar los tiempos de actuación médica, evaluar posibles áreas de mejora y estudiar la dotación de recursos de los centros. Pacientes y métodos. Registro prospectivo de pacientes atendidos en ocho unidades de ictus experimentadas españolas con sospecha de ictus y activación del código ictus. Se recogieron los tiempos inicio-puerta, puerta-tomografía computarizada (TC), puerta-aguja, TC-aguja e inicio-aguja. También se recogieron el método de trasporte al hospital, el tipo de ictus y las terapias de reperfusión. En cuanto a la dotación estructural de los centros, se recogieron la ratio de enfermería, la monitorización de camas, la disponibilidad de TC multimodal y resonancia magnética, y la realización de cursos de información o formación. Resultados. Se incluyeron 197 pacientes, de los cuales fueron válidos 181 (151 infartos y 30 hemorragias cerebrales). Las medianas (p25-p75) en minutos fueron: inicio-puerta, 104 (70-188); puerta-TC, 27 (19-41); TC-aguja, 30 (21-43); puertaaguja, 64 (49-83); e inicio-aguja, 156 (129-202). Se aplicaron terapias de reperfusión en 68 pacientes (el 45% de los infartos cerebrales), de los cuales el 81% fueron trombólisis intravenosas; el 7%, tratamientos endovasculares; y el 12%, una combinación de ambos. Los recursos de los centros estuvieron de acuerdo con lo recomendado por las guías clínicas. Hubo un bajo porcentaje de pacientes estudiados con resonancia magnética. Conclusión. El porcentaje de pacientes tratados con trombólisis fue muy elevado y los tiempos de los circuitos intrahospitalarios, aunque buenos, tienen margen de mejora (AU)

Introduction. A stroke is a time-dependent medical emergency. Swiftness in its recognition and in the care received by the patients plays a key role in the prognosis. Aims. To analyse the medical intervention times, to evaluate possible areas where improvements can be made and to examine the allocation of resources in the centres. Patients and methods. The study was based on a prospective register of patients with suspected stroke and stroke code activation treated in eight experienced Spanish stroke units. Onset-to-door, door-to-computed tomography (CT), door-toneedle, CT-to-needle and onset-to-needle times were collected. Information about the means of transport used to get to the hospital, the type of stroke and reperfusion therapies was also collected. With regard to the structural resources of the centres, data were gathered about the nurse-to-patient ratio, bed monitoring, availability of multimodal CT and magnetic resonance, and doing information or training courses. Results. Altogether 197 patients were included, of whom 181 (151 infarctions and 30 brain haemorrhages) were valid. The medians (p25-p75) in minutes were: onset-to-door, 104 (70-188); door-to-CT, 27 (19-41); CT-to-needle, 30 (21-43); doorto-needle, 64 (49-83); and onset-to-needle, 156 (129-202). Reperfusion therapies were applied in 68 patients (45% of the cerebral infarctions), of which 81% were intravenous thrombolyses; 7%, endovascular treatments; and 12%, a combination of the two. The resources available in the centres were in accordance with those recommended by the clinical guidelines. There was a low percentage of patients who were studied by means of magnetic resonance. Conclusion. The percentage of patients treated with thrombolysis was very high and although the times of the in-hospital circuits were good, there is still room for further improvement (AU)

[Urgent stroke care in hospitals with a stroke unit. Quick Project]. / Atención urgente al ictus en hospitales con unidad de ictus. Proyecto Quick.

INTRODUCTION: A stroke is a time-dependent medical emergency. Swiftness in its recognition and in the care received by the patients plays a key role in the prognosis. AIMS: To analyse the medical intervention times, to evaluate possible areas where improvements can be made and to examine the allocation of resources in the centres. PATIENTS AND METHODS: The study was based on a prospective register of patients with suspected stroke and stroke code activation treated in eight experienced Spanish stroke units. Onset-to-door, door-to-computed tomography (CT), door-to-needle, CT-to-needle and onset-to-needle times were collected. Information about the means of transport used to get to the hospital, the type of stroke and reperfusion therapies was also collected. With regard to the structural resources of the centres, data were gathered about the nurse-to-patient ratio, bed monitoring, availability of multimodal CT and magnetic resonance, and doing information or training courses. RESULTS: Altogether 197 patients were included, of whom 181 (151 infarctions and 30 brain haemorrhages) were valid. The medians (p25-p75) in minutes were: onset-to-door, 104 (70-188); door-to-CT, 27 (19-41); CT-to-needle, 30 (21-43); door-to-needle, 64 (49-83); and onset-to-needle, 156 (129-202). Reperfusion therapies were applied in 68 patients (45% of the cerebral infarctions), of which 81% were intravenous thrombolyses; 7%, endovascular treatments; and 12%, a combination of the two. The resources available in the centres were in accordance with those recommended by the clinical guidelines. There was a low percentage of patients who were studied by means of magnetic resonance. CONCLUSION: The percentage of patients treated with thrombolysis was very high and although the times of the in-hospital circuits were good, there is still room for further improvement.

TITLE: Atencion urgente al ictus en hospitales con unidad de ictus. Proyecto Quick.Introduccion. El ictus es una emergencia medica dependiente del tiempo. La rapidez en su reconocimiento y en la atencion que reciben los pacientes es clave en el pronostico. Objetivos. Analizar los tiempos de actuacion medica, evaluar posibles areas de mejora y estudiar la dotacion de recursos de los centros. Pacientes y metodos. Registro prospectivo de pacientes atendidos en ocho unidades de ictus experimentadas españolas con sospecha de ictus y activacion del codigo ictus. Se recogieron los tiempos inicio-puerta, puerta-tomografia computarizada (TC), puerta-aguja, TC-aguja e inicio-aguja. Tambien se recogieron el metodo de trasporte al hospital, el tipo de ictus y las terapias de reperfusion. En cuanto a la dotacion estructural de los centros, se recogieron la ratio de enfermeria, la monitorizacion de camas, la disponibilidad de TC multimodal y resonancia magnetica, y la realizacion de cursos de informacion o formacion. Resultados. Se incluyeron 197 pacientes, de los cuales fueron validos 181 (151 infartos y 30 hemorragias cerebrales). Las medianas (p25-p75) en minutos fueron: inicio-puerta, 104 (70-188); puerta-TC, 27 (19-41); TC-aguja, 30 (21-43); puerta-aguja, 64 (49-83); e inicio-aguja, 156 (129-202). Se aplicaron terapias de reperfusion en 68 pacientes (el 45% de los infartos cerebrales), de los cuales el 81% fueron trombolisis intravenosas; el 7%, tratamientos endovasculares; y el 12%, una combinacion de ambos. Los recursos de los centros estuvieron de acuerdo con lo recomendado por las guias clinicas. Hubo un bajo porcentaje de pacientes estudiados con resonancia magnetica. Conclusion. El porcentaje de pacientes tratados con trombolisis fue muy elevado y los tiempos de los circuitos intrahospitalarios, aunque buenos, tienen margen de mejora.

[SPECT/CT with 99mTc-HMPAO in progressive encephalitis mediated by anti-GAD antibodies]. / SPECT/TC con 99mTc-HMPAO en la encefalitis progresiva mediada por anticuerpos anti-GAD.

TITLE: SPECT/TC con 99mTc-HMPAO en la encefalitis progresiva mediada por anticuerpos anti-GAD.

SPECT/TC con 99mTc-HMPAO en la encefalitis progresiva mediada por anticuerpos anti-GAD / SPECT/TC with 99mTc-HMPAO in progressive encephalitis mediated by anti-GAD antibodies

No disponible

Etanercept: ¿constituye un factor de riesgo para el desarrollo de trombosis venosa cerebral? / Etanercept: does it constitute a risk factor for development of cerebral venous thrombosis?

No disponible

[Etanercept: does it constitute a risk factor for development of cerebral venous thrombosis?]. / Etanercept: constituye un factor de riesgo para el desarrollo de trombosis venosa cerebral?

TITLE: Etanercept: constituye un factor de riesgo para el desarrollo de trombosis venosa cerebral?

Reoclusión arterial recurrente tras recanalización endovascular en un paciente con déficit de proteína S / Recurring arterial reocclusion following endovascular recanalisation in a patient with protein S deficiency

No disponible

[Recurring arterial reocclusion following endovascular recanalisation in a patient with protein S deficiency]. / Reoclusion arterial recurrente tras recanalizacion endovascular en un paciente con deficit de proteina S.

TITLE: Reoclusion arterial recurrente tras recanalizacion endovascular en un paciente con deficit de proteina S.

Development, Implementation, and Evaluation of a Telemedicine Service for the Treatment of Acute Stroke Patients: TeleStroke.

BACKGROUND: Health care service based on telemedicine can reduce both physical and time barriers in stroke treatments. Moreover, this service connects centers specializing in stroke treatment with other centers and practitioners, thereby increasing accessibility to neurological specialist care and fibrinolytic treatment. OBJECTIVE: Development, implementation, and evaluation of a care service for the treatment of acute stroke patients based on telemedicine (TeleStroke) at Virgen del Rocío University Hospital. METHODS: The evaluation phase, conducted from October 2008 to January 2011, involved patients who presented acute stroke symptoms confirmed by the emergency physician; they were examined using TeleStroke in two hospitals, at a distance of 16 and 110 kilometers from Virgen del Rocío University Hospital. We analyzed the number of interconsultation sheets, the percentage of patients treated with fibrinolysis, and the number of times they were treated. To evaluate medical professionals' acceptance of the TeleStroke system, we developed a web-based questionnaire using a Technology Acceptance Model. RESULTS: A total of 28 patients were evaluated through the interconsultation sheet. Out of 28 patients, 19 (68%) received fibrinolytic treatment. The most common reasons for not treating with fibrinolysis included: clinical criteria in six out of nine patients (66%) and beyond the time window in three out of nine patients (33%). The mean "onset-to-hospital" time was 69 minutes, the mean time from admission to CT image was 33 minutes, the mean "door-to-needle" time was 82 minutes, and the mean "onset-to-needle" time was 150 minutes. Out of 61 medical professionals, 34 (56%) completed a questionnaire to evaluate the acceptability of the TeleStroke system. The mean values for each item were over 6.50, indicating that respondents positively evaluated each item. This survey was assessed using the Cronbach alpha test to determine the reliability of the questionnaire and the results obtained, giving a value of 0.97. CONCLUSIONS: The implementation of TeleStroke has made it possible for patients in the acute phase of stroke to receive effective treatment, something that was previously impossible because of the time required to transfer them to referral hospitals.

[Factors that affect time delays to fibrinolytic treatment in ischaemic stroke]. / Factores que influyen en la demora del tratamiento fibrinolitico en el ictus isquémico.

INTRODUCTION: Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. AIM: To analyse the factors that delay treatment. PATIENTS AND METHODS: After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. RESULTS: Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. CONCLUSIONS: The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times.

Factores que influyen en la demora del tratamiento fibrinolítico en el ictus isquémico / Factors that affect time delays to fibrinolytic treatment in ischaemic stroke

Introducción. Ampliar la ventana terapéutica trombolítica del ictus isquémico hasta las 4,5 horas se ha demostrado útil y seguro, pero la celeridad en la respuesta sigue siendo determinante. Objetivo. Analizar los factores que demoran el tratamiento. Pacientes y métodos. Tras activar el dispositivo Código Ictus, se registraron los casos consecutivos de ictus atendidos en urgencias durante el año 2006, sus características clínicas, epidemiológicas, procedencia, modo de traslado y demoras del proceso. Resultados. Del total de pacientes con ictus isquémico, el 10,1% concluyó el estudio de urgencias con una mediana de 1 hora para decidir tratar en las 3 horas y el 13,1%, entre las 3 y 4,5 horas con una mediana de 2 horas y 6 minutos. Para el análisis de todas las variables se seleccionó a 498 pacientes; el 39% ingresó en las primeras 3 horas y el 11,2% entre las 3 y 4,5 horas del inicio de los síntomas. El uso del sistema telefónico de emergencias, el traslado en UCI móvil o ambulancia y el déficit en el nivel de conciencia, visual o, en menor grado, del lenguaje o habla incidieron en una demora menor. Conclusiones. Los factores dependientes del propio paciente, en general, no disminuyeron la demora. La gravedad clínica, la presencia de informadores y la activación del sistema de emergencias acortaron los tiempos en las actuaciones (AU)

Introduction. Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. Aim. To analyse the factors that delay treatment. Patients and methods. After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. Results. Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. Conclusions. The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times (AU)

[False diagnoses of strokes in emergency departments]. / Falsos diagnósticos de ictus en los servicios de urgencias.

INTRODUCTION: Diagnosing a stroke can sometimes be difficult. There are a number of mimic conditions that can lead to false diagnoses. AIM: To examine false diagnoses of acute stroke. PATIENTS AND METHODS: We reviewed the medical histories with diagnoses of acute stroke -i.e. ischaemic or haemorrhagic stroke and transient ischaemic attack (TIA)- for a three-month period. Alternative diagnoses were established in doubtful stroke cases (without meeting the World Health Organisation stroke criteria). RESULTS: Altogether there were 358 patients: 110 TIA, 191 ischaemics and 57 haemorrhagics. In all, 65 false diagnoses were selected, which represented 18.2% of the total number (41.8% of the cases of TIA) and 31.8% of the strokes admitted in the emergency department. The subtypes of false diagnoses were: 46 TIA (70.8%), 18 ischaemics (27.7%) and one haemorrhagic (1.5%). The alternative diagnoses were the following: syncope/pre-syncope in 10.8% of cases (n = 7); confusional syndrome/disorientation in 21.5% (n = 14); lowered level of consciousness in 27.7% (n = 18); generalised weakness in 6.2% (n = 4); dizziness/vertigo in 3.1% (n = 2); isolated dysarthria in 10.8% (n = 7); epileptic seizure in 6.2% (n = 4); and others in 13.8% (n = 9). A total of 71.7% could be attributed to systemic causes. The mean age was 79 years and 64.6% were females (n = 42). Computerised tomography of the head was performed in 70.8% of the cases (n = 46). A neurologist assessed 7.7% of them (n = 5). The destination on being discharged was: primary care (53.3%), visit to neurology department (31.7%), visit internal medicine department (6.7%), hospitalisation in neurology department (1.7%), hospitalisation in other specialties (1.7%), transfer (1.7%) and death (3.3%). CONCLUSIONS: False diagnoses of cerebrovascular diseases are common. In emergency departments almost half of the diagnoses of TIA may be wrong. Most false diagnoses refer to TIA (70%) and occur in elderly patients, can be attributed to systemic causes, have not been assessed by a neurologist and are referred to primary care. Hospital stroke registries that include emergency patients may be overestimated, especially in the number of cases of TIA.

Falsos diagnósticos de ictus en los servicios de urgencias / False diagnoses of strokes in emergency departments

Introducción. El diagnóstico de ictus en ocasiones puede ser difícil. Existen numerosas condiciones simuladoras que pueden dar lugar a falsos diagnósticos. Objetivo. Estudiar falsos diagnósticos de ictus agudo. Pacientes y métodos. Revisamos las historias con diagnóstico de ictus agudo –isquémico, hemorrágico y accidente isquémico transitorio (AIT)– durante tres meses. Ante ictus dudosos (sin criterios de ictus según la Organización Mundial de la Salud) se establecieron diagnósticos alternativos. Resultados. El total fue de 358 pacientes: 110 AIT, 191 isquémicos y 57 hemorrágicos. Se seleccionaron 65 falsos diagnósticos, correspondientes al 18,2% del total (el 41,8% de los AIT) y al 31,8% de los ictus de alta en urgencias (el 46,4% de los AIT). Los subtipos de falsos diagnósticos fueron: 46 AIT (70,8%), 18 isquémicos (27,7%) y uno hemorrágico (1,5%). Los diagnósticos alternativos fueron: síncope/presíncope en el 10,8% de los casos (n = 7); síndrome confusional/desorientación en el 21,5% (n = 14); disminución del nivel de conciencia en el 27,7% (n = 18); debilidad generalizada en el 6,2% (n = 4); mareo/ vértigo en el 3,1% (n = 2); disartria aislada en el 10,8% (n = 7); crisis epiléptica en el 6,2% (n = 4); y otros en el 13,8% (n = 9). Fue atribuible a causas sistémicas el 71,7%. La edad media fue de 79 años y el 64,6% eran mujeres (n = 42). Se realizó tomografía computarizada craneal al 70,8% (n = 46). El 7,7% fue valorado por el neurólogo (n = 5). El destino en el momento del alta fue: atención primaria (53,3%), consultas de neurología (31,7%), consultas de medicina interna (6,7%), hospitalización en neurología (1,7%), hospitalización en otras especialidades (1,7%), traslado (1,7%) y fallecimiento (3,3%). Conclusiones. Los falsos diagnósticos de enfermedades cerebrovasculares son frecuentes. En los servicios de urgencias casi la mitad de diagnósticos de AIT pueden ser erróneos. La mayoría de los falsos diagnósticos corresponden a AIT (70%), son pacientes ancianos, atribuibles a causas sistémicas, no valorados por neurología y remitidos a atención primaria. Los registros hospitalarios de ictus que incluyen pacientes de urgencias pueden estar sobreestimados, principalmente los AIT (AU)

Introduction. Diagnosing a stroke can sometimes be difficult. There are a number of mimic conditions that can lead to false diagnoses. Aim. To examine false diagnoses of acute stroke. Patients and methods. We reviewed the medical histories with diagnoses of acute stroke –i.e. ischaemic or haemorrhagic stroke and transient ischaemic attack (TIA)– for a three-month period. Alternative diagnoses were established in doubtful stroke cases (without meeting the World Health Organisation stroke criteria). Results. Altogether there were 358 patients: 110 TIA, 191 ischaemics and 57 haemorrhagics. In all, 65 false diagnoses were selected, which represented 18.2% of the total number (41.8% of the cases of TIA) and 31.8% of the strokes admitted in the emergency department. The subtypes of false diagnoses were: 46 TIA (70.8%), 18 ischaemics (27.7%) and one haemorrhagic (1.5%). The alternative diagnoses were the following: syncope/pre-syncope in 10.8% of cases (n = 7); confusional syndrome/disorientation in 21.5% (n = 14); lowered level of consciousness in 27.7% (n = 18); generalised weakness in 6.2% (n = 4); dizziness/vertigo in 3.1% (n = 2); isolated dysarthria in 10.8% (n = 7); epileptic seizure in 6.2% (n = 4); and others in 13.8% (n = 9). A total of 71.7% could be attributed to systemic causes. The mean age was 79 years and 64.6% were females (n = 42). Computerised tomography of the head was performed in 70.8% of the cases (n = 46). A neurologist assessed 7.7% of them (n = 5). The destination on being discharged was: primary care (53.3%), visit to neurology department (31.7%), visit internal medicine department (6.7%), hospitalisation in neurology department (1.7%), hospitalisation in other specialties (1.7%), transfer (1.7%) and death (3.3%). Conclusions. False diagnoses of cerebrovascular diseases are common. In emergency departments almost half of the diagnoses of TIA may be wrong. Most false diagnoses refer to TIA (70%) and occur in elderly patients, can be attributed to systemic causes, have not been assessed by a neurologist and are referred to primary care. Hospital stroke registries that include emergency patients may be overestimated, especially in the number of cases of TIA (AU)