Potential effects of a mobile stroke unit on time to treatment and outcome in patients treated with thrombectomy or thrombolysis: A Danish-German cross-border analysis.

BACKGROUND AND PURPOSE: A mobile stroke unit (MSU) reduces delays in stroke treatment by allowing thrombolysis on board and avoiding secondary transports. Due to the beneficial effect in comparison to conventional emergency medical services, current guidelines recommend regional evaluation of MSU implementation. METHODS: In a descriptive study, current pathways of patients requiring a secondary transport for mechanical thrombectomy were reconstructed from individual patient records within a Danish (n = 122) and an adjacent German region (n = 80). Relevant timestamps included arrival times (on site, primary hospital, thrombectomy centre) as well as the initiation of acute therapy. An optimal MSU location for each region was determined. The resulting time saving was translated into averted disability-adjusted life years (DALYs). RESULTS: For each region, the optimal MSU location required a median driving time of 35 min to a stroke patient. Time savings in the German region (median [Q1; Q3]) were 7 min (-15; 31) for thrombolysis and 35 min (15; 61) for thrombectomy. In the Danish region, the corresponding time savings were 20 min (8; 30) and 43 min (25; 66). Assuming 28 thrombectomy cases and 52 thrombolysis cases this would translate to 9.4 averted DALYs per year justifying an annual net MSU budget of $0.8M purchasing power parity dollars (PPP-$) in the German region. In the Danish region, the MSU would avert 17.7 DALYs, justifying an annual net budget of PPP-$1.7M. CONCLUSION: The effects of an MSU can be calculated from individual patient pathways and reflect differences in the hospital infrastructure between Denmark and Germany.

COVID-19 did not result in increased hospitalization for stroke and transient ischemic attack: A nationwide study.

BACKGROUND: The risk of thrombosis increases in infectious diseases, yet observational studies from single centers have shown a decrease in admission of acute ischemic stroke patients during the COVID-19 pandemic. To investigate unselected stroke admission rates we performed a nationwide study in Denmark. METHODS: We extracted information from Danish national health registries. The following mutually exclusive time periods were compared to the year before the lockdown: (1) first national lockdown, (2) gradual reopening, (3) few restrictions, (4) regional lockdown, and (5) second national lockdown. RESULTS: Generally, admission rates were unchanged during the pandemic. In the unadjusted data, we observed a small decrease in the admission rate for all strokes under the first lockdown (incidence rate ratio: 0.93, confidence interval [CI]: 0.87-0.99) and a slight increase during the periods with gradual reopening, few restrictions, and the regional lockdown driven by ischemic strokes. We found no change in the rate of severe strokes, mild strokes, or 30-day mortality. An exception was the higher mortality for all strokes during the first lockdown (risk ratio: crude 1.30 [CI: 1.03-1.59]; adjusted 1.17 [CI: 0.93-1.47]). The quality of care remained unchanged. CONCLUSION: Stroke admission rates remained largely unchanged during the pandemic, while an increased short-term mortality rate in patients admitted with stroke observed during the first lockdown was seen, probably reflecting that the more frail patients constituted a higher proportion of admitted patients at the beginning of the pandemic.

Stroke admissions and revascularization treatments in Denmark during COVID-19.

OBJECTIVE: The aim of this study was to assess the number of stroke-related admissions and acute treatments during the first two waves of COVID-19 and lockdowns in the Capital Region of Denmark and the Region of Zealand. MATERIALS & METHODS: The weekly numbers of admitted patients with stroke were retrieved from electronic patient records from January 2019 to February 2021 and analysed to reveal potential fluctuations in patient volumes during the pandemic. RESULTS: A total of 23,688 patients were included, of whom 2049 patients were treated with tissue-type plasminogen activators (tPA) and 552 underwent endovascular thrombectomy (EVT). We found a transient decrease in the number of weekly admitted patients (pts/week) with all strokes (-9.8 pts/week, 95% CI: -19.4; -0.2, p = .046) and stroke mimics (-30.1 pts/week, 95% CI: -39.9; -20.3, p < .001) during the first lockdown compared to pre-COVID-19. The number of subarachnoid haemorrhage, intracerebral haemorrhage, and ischaemic stroke admissions showed insignificant declines. Analysing all COVID-19 periods collectively revealed increased volumes of ischaemic stroke (+6.2 pts/week, 95% CI: +1.6; +10.7, p = .009) compared to pre-COVID levels, while numbers of stroke mimics remained lower than pre-COVID. Weekly tPA and EVT treatments remained constant throughout the study period. CONCLUSIONS: Our results are comparable with other studies in finding reductions in stroke-related admissions early in the pandemic. This is the first study to report increased stroke volumes following the first wave of the pandemic. The mechanisms behind the observed drop and subsequent rise in strokes are unclear and warrant further investigation.

Myeloproliferative blood cancers as a human neuroinflammation model for development of Alzheimer's disease: evidences and perspectives.

Chronic inflammation and involvement of myeloid blood cells are associated with the development of Alzheimer's disease (AD). Chronic inflammation is a highly important driving force for the development and progression of the chronic myeloproliferative blood cancers (MPNs), which are characterized by repeated thrombotic episodes years before MPN-diagnosis, being elicited by elevated erythrocytes, leukocytes, and platelets. Mutations in blood cells, the JAK2V617F and TET2-mutations, contribute to the inflammatory and thrombogenic state. Herein, we discuss the MPNs as a human neuroinflammation model for AD development, taking into account the many shared cellular mechanisms for reduction in cerebral blood, including capillary stalling with plugging of blood cells in the cerebral microcirculation. The therapeutic consequences of an association between MPNs and AD are immense, including reduction in elevated cell counts by interferon-alpha2 or hydroxyurea and targeting the chronic inflammatory state by JAK1-2 inhibitors, e.g., ruxolitinib, in the future treatment of AD.

Prehospital continuous ECG is valuable for very early detection of atrial fibrillation in patients with acute stroke.

INTRODUCTION: Early detection of atrial fibrillation (AF) after stroke is essential to achieve timely initiation of appropriate prophylactic treatment. We aimed to assess the diagnostic value of using prehospital continuous ECG (cECG) for AF detection after acute stroke. PATIENTS AND METHODS: In this retrospective cohort study, we included AF naïve ischemic stroke patients of 50 years or older. Medical records and corresponding digital prehospital cECGs were systematically reviewed. The proportion of AF detectable by prehospital cECG, in-hospital 12-lead ECG, telemetry and outpatient cECG was determined. McNemar's chi-squared test was used to compare probability of AF on prehospital cECG vs. in-hospital 12-lead ECG. RESULTS: In 500 included patients, a new onset AF was detectable by prehospital cECG in 27 patients (5.4% [95% CI 3.6-7.8]). In-hospital 12-lead ECG detected AF in 28 of 458 patients (6.1% [95% CI 4.1-8.7). Sixty-two (12.4% [95% CI 9.6-15.6]) were diagnosed with new onset AF by either prehospital cECG, in-hospital 12-lead ECG, in-hospital telemetry or outpatient cECG. Thus, 43.5% of all AF cases were detectable during prehospital transport. The probability of AF did not differ between prehospital cECG and in-hospital 12-lead ECG. Nevertheless, a lack in overlapping diagnoses meant number needed to screening with prehospital cECG was 16 for diagnosing one AF case not detected by in-hospital 12-lead ECG. CONCLUSION: Using prehospital cECG as an addition to very early AF evaluation after acute stroke had diagnostic value and could represent a low cost and easily accessible opportunity for very early AF detection. This may improve post-stroke care and save resources for further unnecessary AF screening. Conducting routine prehospital cECG after acute stroke and ensuring this is available to clinicians is encouraged.

Computed Tomography Perfusion Showing Cerebral Hypoperfusion in a Patient with Acute Cerebral Venous Sinus Thrombosis-A Case Report.

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke. We report the case of a patient with acute CVST, showing perfusion abnormalities on computed tomography perfusion with perfusion defect in the relevant hemisphere. The defect was found in a region adjacent to the occluded sinus and was not corresponding to an arterial territory. To the best of our knowledge this is the first ever report on CT perfusion abnormalities few hours after acute symptom onset in CVST.

Electrical Stimulation in Lower Limb During Exercise to Improve Gait Speed and Functional Motor Ability 6 Months Poststroke. A Review with Meta-Analysis.

INTRODUCTION: Stroke is the third most common cause of disability in adults over 65 years of age and there are 30.7 million survivors after stroke worldwide. Stroke survivors have the highest odds of reporting severe disability and the greatest variety of individual domains of disability compared to a range of other conditions. Electrical stimulation of peripheral sensory-motor systems increases voluntary movement and muscle strength and thereby raises the activities of daily living (ADL). Little is known about electrical stimulation during physical activity in rehabilitation; the objective of this review is therefore to investigate whether external electrical stimulation combined with activity improves functional motor ability and gait speed in patients who have experienced a stroke within the last 6 months. METHODS: A review and random effects meta-analysis of randomized controlled clinical trials on gait speed and functional motor ability measured with Barthel Index (BI) and Bergs Balance Scale (BBS). RESULTS: Eight trials were included (n = 191). Explorative meta-analysis was performed on gait speed (5 trials, n = 120), BI (3 trials, n = 74), and BBS (3 trial n = 79). A small, significant difference on gait speed 0.15 (95% confidence interval [CI]: 0.08-0.21) m/s, but no difference in BI 2.88 (95 % CI: -3.3 to 9.07) and BBS 1.73 (95% CI: -2.8 to 6.27). CONCLUSIONS: Sparse, low-quality evidence indicates that electrical stimulation combined with activity is a relevant intervention to improve ADL within 6 months poststroke.

Treatment of medication overuse headache-A review.

Medication overuse headache (MOH) is the most prevalent chronic headache disorder with a prevalence between 1% and 2% worldwide. The disease has been acknowledged for almost 30 years, yet experts still disagree on how best to treat MOH. By performing a search in PubMed on the terms "medication overuse headache," "analgesics abuse headache," "rebound headache," "drug induced headache," and "headache AND drug misuse" limited to human studies published in English between January 1, 2004, and November 1, 2017, we aimed to evaluate current literature concerning predictors of treatment outcome, inpatient and outpatient treatment programs, initial versus latent administration of prophylactic medications, and to review the effect of prophylactic medications. Selection criteria were prospective, comparative, or controlled trials on treatment of MOH in persons of at least 18 years of age. Several studies evaluated risk factors to predict the outcome of MOH treatment, but many studies were underpowered. Psychiatric comorbidity, high dependence score, and overuse of barbiturates, benzodiazepines, and opioids predicted a poorer outcome of withdrawal therapy. Patients with these risk factors benefit from inpatient treatment, whereas patients without risk factors benefit equally from inpatient and outpatient treatment. Some medications for migraine prophylactics have shown better effect on MOH compared with placebo, but not when combined with withdrawal. We conclude that detoxification programs are of great importance in MOH treatment. Latent administration of prophylactic medications reduces the number of patients needing prophylactic medication. Individualizing treatment according to the predictors of outcome may improve treatment outcome and thus reduce work-related and treatment-related costs.

Modulation of task-related cortical connectivity in the acute and subacute phase after stroke.

The functional relevance of cortical reorganization post-stroke is still not well understood. In this study, we investigated task-specific modulation of cortical connectivity between neural oscillations in key motor regions during the early phase after stroke. EEG and EMG recordings were examined from 15 patients and 18 controls during a precision grip task using the affected hand. Each patient attended two sessions in the acute and subacute phase (median of 3 and 34 days) post-stroke. Dynamic causal modelling (DCM) for induced responses was used to investigate task-specific modulations of oscillatory couplings in a bilateral network comprising supplementary motor area (SMA), dorsal premotor cortex (PMd) and primary motor cortex (M1). Fourteen models were constructed for each subject, and the input induced by the experimental manipulation (task) was set to inferior parietal lobule (IPL). Bayesian model selection favoured a fully connected model. A reduced coupling from SMA and intact M1 in the γ-band (31-48 Hz) to lesioned M1 in the ß-band (15-30 Hz) was observed in patients in the acute phase compared to controls. Behavioural performance improved significantly in the subacute phase, while an increased positive coupling from intact PMd to lesioned M1 and a less negative modulation from lesioned M1 to intact M1 were observed for patients compared to controls both from the γ-band to the ß-band. We infer that the observed differences in cross-frequency cortical interactions are important for functional recovery.

Optimizing Residents' Performance of Lumbar Puncture: An RCT Comparing the Effect of Preparatory Interventions on Performance and Self-Confidence.

BACKGROUND: Lumbar puncture is often associated with uncertainty and limited experience on the part of residents; therefore, preparatory interventions can be essential. There is growing interest in the potential benefit of videos over written text. However, little attention has been given to whether the design of the videos impacts on subsequent performance. OBJECTIVE: To investigate the effect of different preparatory interventions on learner performance and self-confidence regarding lumbar puncture (LP). DESIGN: Randomized controlled trial in which participants were randomly assigned to one of three interventions as preparation for performing lumbar puncture: 1) goal- and learner-centered video (GLV) presenting procedure-specific process goals and learner-centered information; 2) traditional video (TV) providing expert-driven content, but no process goals; and 3) written text (WT) with illustrations. PARTICIPANTS AND MAIN MEASURES: Participants were PGY-1 doctors without LP experience. After the preparatory intervention, participants performed an LP in a simulated setting with a standardized patient and an assistant. Two content experts, blinded to participant group allocation, assessed video recordings of the performance using the Lumbar Puncture Assessment Tool (LumPAT) and an overall global rating. Participants rated their self-confidence immediately prior to performing the procedure. The primary outcome was the difference in LumPAT scores among groups. KEY RESULTS: A total of 110 PGY-1 doctors were included. Results demonstrated significant differences in LumPAT mean scores among the three groups: GLV, 42.8; TV, 40.6; WT, 38.1 (p = 0.01). The global rating scores were highest in the GLV group (p = 0.026). Self-confidence scores differed significantly among the three groups (p = 0.003), with the TV group scoring the highest. There were no significant correlations between self-confidence scores and performance scores in any of the groups. CONCLUSION: A video designed with procedure-specific process goals and learner-centered information resulted in better subsequent LP performance than a traditionally designed video or written text. Participants' self-confidence was not predictive of their actual performance.

Secondary Stroke Prophylaxis with Clopidogrel Produces Sufficient Antiplatelet Response.

BACKGROUND: Antiplatelet therapy is a cornerstone prevention strategy for secondary ischemic stroke (IS) and transient ischemic attack (TIA). Yet, a proportion of patients who receive antiplatelet therapy experience recurrent ischemic cerebrovascular events. A recent meta-analysis found an increased risk of recurrent stroke in clopidogrel- or aspirin-treated patients with ischemic stroke who had high on-treatment platelet reactivity (HTPR). Few studies have focused specifically on clopidogrel HTPR. Therefore, the aim of this study was to examine the relationship between clopidogrel HTPR and recurrent ischemic events in a population of Danish patients with IS. METHODS: We performed a prospective observational study to evaluate the relationship between HTPR defined as platelet reaction units >208 and a composite primary endpoint of recurrent stroke, TIA, acute myocardial infarction (AMI), or vascular death over a 2-year follow-up period. RESULTS: A total of 142 patients were included in the final statistical analysis, but only 3 patients (2.1%) demonstrated clopidogrel HTPR. The median time of on-treatment platelet testing was 75 days. Recurrent IS, TIA, AMI, or vascular death occurred in 14 patients (10%). Of these, 1 new ischemic event (AMI) occurred in a HTPR patient. There was no difference in the frequency of new ischemic events between the HTPR and non-HTPR groups (P = .27); moreover, the number of patients with HTPR was too small for statistical analysis. CONCLUSIONS: Clopidogrel HTPR does not seem to be a major contributor to recurrent ischemic events in Danish ischemic stroke patients.

Assessment of Residents Readiness to Perform Lumbar Puncture: A Validation Study.

BACKGROUND: Lumbar puncture is a common procedure in many specialties. The procedure serves to diagnose life-threatening conditions, often requiring rapid performance. However, junior doctors possess uncertainties regarding performing the procedure and frequently perform below expectations. Hence, proper training and assessment of performance is crucial before entering clinical practice. OBJECTIVE: To develop and collect validity evidence for an assessment tool for lumbar puncture performance, including a standard to determine when trainees are ready for clinical practice. DESIGN: Development of a new tool, based on clinician interviews and a literature review, was followed by an explorative study to gather validity evidence. PARTICIPANTS AND MAIN MEASURES: We interviewed 12 clinicians from different specialties. The assessment tool was used to assess 11 doctors at the advanced beginners' level and 18 novices performing the procedure in a simulated, ward-like setting with a standardized patient. Procedural performance was assessed by three content experts. We used generalizability theory to explore reliability. The discriminative ability of the tool was explored by comparing performance scores between the two groups. The contrasting groups method was used to set a pass/fail standard and the consequences of this was explored. KEY RESULTS: The interviews identified that in addition to the technical aspects of the procedure, non-technical elements involving planning and conducting the procedure are important. Cronbach's alpha = 0.92, Generalizability-coefficient was 0.88 and a Decision-study found one rater was sufficient for low-stakes assessments (G-coefficient 0.71). The discriminative ability was confirmed by a significant difference between the mean scores of novices, 40.9 (SD 6.1) and of advanced beginners, 47.8 (SD 4.0), p = 0.004. A standard of 44.0 was established which was consistent with the raters' global judgments of pass/fail. CONCLUSION: We developed and demonstrated strong validity evidence for the lumbar puncture assessment tool. The tool can be used to assess readiness for practice.

Systemic Thrombolysis in Acute Ischemic Stroke after Dabigatran Etexilate Reversal with Idarucizumab-A Case Report.

INTRODUCTION: Idarucizumab is a reversal agent for dabigatran etexilate. By reversing the anticoagulating effect of dabigatran etexilate with idarucizumab (Praxbind), patients presenting with an acute ischemic stroke can now be eligible for thrombolysis. PATIENT: We describe our experience with idarucizumab in a 71-year-old male patient pretreated with dabigatran etexilate. The patient arrived with a hemiparesis, central facial palsy, and dysarthria. METHOD: Dabigatran etexilate was antagonized with idarucizumab, approximately 2.5 hours after the patient's last dose. Immediately after the infusion of idarucizumab, the patient received thrombolytic therapy. RESULTS: The hemiparesis and the central facial palsy were fully remitted 3 days after the onset of symptoms, and the dysarthria was remitted 2 days afterwards. DISCUSSION: Non-vitamin K oral anticoagulants (NOACs) are widely used for the prevention of embolic stroke in patients with atrial fibrillation. Dabigatran etexilate is an oral thrombin inhibitor that can be reversed by idarucizumab. Idarucizumab, a monoclonal antibody fragment, directly binds dabigatran etexilate and neutralizes its activity. CONCLUSION: Reversal of dabigatran etexilate using idarucizumab was safe and successful with no recombinant tissue plasminogen activator interactions.

Neutrophil-to-lymphocyte ratio and all-cause mortality with and without myeloproliferative neoplasms-a Danish longitudinal study.

The neutrophil-to-lymphocyte ratio(NLR) is increased in chronic inflammation and myeloproliferative neoplasms (MPN). We hypothesize that NLR is associated with all-cause mortality and mortality by comorbidity burden in the general population and individuals with MPN. We included 835,430 individuals from The Danish General Suburban Population Study, general practitioners, and outpatient clinics. We investigated NLR on mortality stratified by prevalent and incident MPN, essential thrombocythemia (ET), polycythemia vera (PV), myelofibrosis (MF), comorbidity burden (CCI-score), and the Triple-A risk score using hazard ratio (HR) and 95% confidence interval (95%CI). NLR 1-1.9 was the reference level. During a median follow-up of 11.2 years, 197,802 deaths were recorded. All-cause mortality increased for a stepwise increasing NLR with a HR (95%CI) for NLR ≥ 6 of 2.06(2.03-2.09) for the whole population and 2.93(2.44-3.50) in prevalent MPN. ET, PV, and MF had a HR (95%CI) for NLR ≥ 2 of 2.14(1.71-2.69), 2.19(1.89-2.54), and 2.31(1.91-2.80). Results were similar for incident MPN. Mortality was higher for stepwise increasing NLR and CCI-score(pinteraction < 2×10-16), with a HR for NLR ≥ 6 of 2.23(2.17-2.29), 4.10(4.01-4.20), and 7.69(7.50-7.89), for CCI-score 0, 1-2, or ≥3. The Triple-A risk score demonstrated alignment with NLR. Increasing NLR and comorbidity burden were associated with lower survival in individuals without MPN but were even worse in prevalent and incident MPN, ET, PV, and MF.

Prostaglandins in migraine: update.

PURPOSE OF REVIEW: This review presents recent findings on the role of prostaglandins in migraine pathophysiology. RECENT FINDINGS: Experimental studies have shown that prostaglandins are distributed in the trigeminal-vascular system and its receptors are localized in the trigeminal ganglion and the trigeminal nucleus caudalis. Prostaglandins were found in smooth muscles of cranial arteries, and functional studies in vivo showed that prostaglandins induced dilatation of cranial vessels. Human studies showed that intravenous infusion of vasodilating prostaglandins such as prostaglandin E2 (PGE2), prostaglandin I2 (PGI2) and prostaglandin D2 (PGD2) induced headache and dilatation of intra-cranial and extra-cranial arteries in healthy volunteers. In contrast, infusion of non-dilating prostaglandin F2α (PGF2α) caused no headache or any vascular responses in cranial arteries. PGE2 and PGI2 triggered migraine-like attacks in migraine patients without aura, accompanied by dilatation of the intra-cerebral and extra-cerebral arteries. A novel EP4 receptor antagonist could not prevent PGE2-induced headache in healthy volunteers. SUMMARY: Recent in-vitro/in-vivo data demonstrated presence and action of prostaglandins within the trigeminal pain pathways. Migraine induction after intravenous administration of PGE2 and PGI2 suggests a specific blockade of their receptors, EP and IP respectively, as a new potential drug target for the acute treatment of migraine.

Randomised trial on episodic cluster headache with an angiotensin II receptor blocker.

OBJECTIVES: The aim of this study was to evaluate the angiotensin II receptor antagonist candesartan as prophylactic medication in patients with episodic cluster headache. METHODS: This study comprised a prospective, placebo-controlled, double-blind, parallel-designed trial performed in seven centres in Scandinavia. Forty (40) patients with episodic cluster headache (ICHD-2) were recruited and randomised over a five-year period to placebo or 16 mg candesartan in the first week, and placebo or 32 mg candesartan in the second and third week. RESULTS: The number of cluster headache attacks (primary efficacy variable) during the three-week treatment period was reduced from 14.3 ± 9.2 attacks in week 1 to 5.6 ± 7.0 attacks in week 3 (-61%) in the candesartan group and from 16.8 ± 14.1 attacks in week 1 to 10.5 ± 11.3 attacks in week 3 (-38%) in the placebo group. The difference between the candesartan and placebo group was not significant with the pre-planned non-parametric ranking test, but a post-hoc exact Poisson test, which takes into account the temporal properties of the data, revealed a significant result ( P < 0.0001). CONCLUSIONS: This was a negative trial. Post-hoc statistics suitable to describe the temporal changes in cluster headache indicate that conduction of future larger studies may be justified.

Development of a tailored intervention targeting sedentary behavior and physical activity in people with stroke and diabetes: A qualitative study using a co-creation framework.

Purpose: Type 2 diabetes and sedentary behavior pose serious health risks in stroke survivors. Using a co-creation framework, this study aimed to develop an intervention in collaboration with stroke survivors with type 2 diabetes, relatives, and cross-sectoral health care professionals to reduce sedentary behavior and increase physical activity. Materials and methods: This qualitative explorative study used a co-creation framework consisting of a workshop and focus group interviews with stroke survivors with type 2 diabetes (n = 3), relative (n = 1), and health care professionals (n = 10) to develop the intervention. A content analysis was used to analyze data. Results: The developed "Everyday Life is Rehabilitation" (ELiR) intervention consisted of a tailored 12-week home-based behavior change intervention with two consultations of action planning, goal setting, motivational interviewing, and fatigue management including education on sedentary behavior, physical activity, and fatigue. The intervention has a minimalistic setup using a double-page paper "Everyday Life is Rehabilitation" (ELiR) instrument making it implementable and tangible. Conclusions: In this study, a theoretical framework was used to develop a tailored 12-week home-based behavior change intervention. Strategies to reduce sedentary behavior and increase physical activity through activities of daily living along with fatigue management in stroke survivors with type 2 diabetes were identified.

Elevated white blood cell counts in ischemic stroke patients are associated with increased mortality and new vascular events.

Background and purpose: High levels of white blood cells (WBC) in ischemic stroke have been shown to increase the risk of new vascular events and mortality in short and intermediate follow-up studies, but long-term effects remain unknown. We studied whether elevated levels of WBC in ischemic stroke patients are associated with new vascular events and mortality in a 10-year follow-up period. Methods: We included ischemic stroke patients hospitalized between 2011 and 2012, categorizing their WBC counts within 48 h of stroke onset as high or normal (3.5-8.8 × 109 mmol/L; >8.8 × 109 mmol/L). Using Aahlen Johansen and Cox proportional hazard models with competing risk, we analyzed the association between WBC levels and new vascular events. Kaplan-Meier and standard Cox proportional hazard models were used to assess the risk of all-cause mortality. Results: Among 395 patients (median age 69, [IQR: 63, 78], female patients 38,0%), 38.5% had elevated WBC at admission. During the 10-year follow-up, 113 vascular events occurred, with 46% in patients with elevated WBC and 54% in patients with normal WBC. After adjusting for relevant factors, elevated WBC levels were independently associated with increased risk of new vascular events (HR: 1.61, CI: 1.09-2.39 p < 0.05) and death (HR: 1.55, CI: 1.15-2.09, p < 0.05). Conclusion: Elevated WBC levels in ischemic stroke patients are linked to a higher risk of new vascular events and mortality. Thus, ischemic stroke patients with elevated WBC without clinical infection need special attention to investigate possible underlying conditions to prevent future vascular events and reduce mortality. The interpretation of our results is limited by the absence of adjustment to premorbid functional status, stroke severity, and stroke treatment.

Inter-rater reliability and agreement of 6 Minute Walk Test and 10 Meter Walk Test at comfortable walk speed in patients with acute stroke.

PURPOSE: Remediation of gait problems is a key feature of neurological physiotherapy We aimed to investigate the inter-rater reliability and agreement of the Six Minute Walk Test (6MWT) and Ten Meter Walk Test (10MWT), at comfortable walking speed, in hospitalized acute ischemic stroke patients. METHOD: Forty acute first-time patients with brain stem or hemispheric ischemic stroke aged 67.4 ± 12.5 (SD), able to walk with or without an assistive device, were tested by one of three physiotherapists. Test-retest reliability was evaluated using a one-way random effects single measures model (1,1) absolute agreement-type Interclass Correlation Coefficient (ICC). Agreement was evaluated using the Standard Error of Measurement (SEM) and Smallest Detectable Change (SDC). RESULTS: Both tests demonstrated good reliability; ICC1,1 0.83 (CI 95% 0.70-0.90) (6MWT) and 0.76 (CI 95% 0.59-0.87) (10MWT). The 6MWT-SEM was 27.2 m (m) and the SDC was 75.4 m. The 10MWT-SEM was 0.36 meters per second (m/s) and the SDC was 1.0 m/s. CONCLUSION: Both tests demonstrated good inter-rater reliability, confirming their discriminative ability on a group of hospitalized first-time acute ischemic stroke patients. However, the measurement error was large for both tests, which is likely due to spontaneous neurological recovery and stress in the acute phase severely affecting the individual-level agreement estimate.

JAK2V617F mutation is highly prevalent in patients with ischemic stroke: a case-control study.

Ischemic stroke has a high recurrence rate despite treatment. This underlines the significance of investigating new possible cerebrovascular risk factors, such as the acquired gene mutation JAK2V617F found in 3.1% of the general population. We aimed to investigate the prevalence of the JAK2V617F mutation in a population with ischemic stroke compared with that in matched controls. We enrolled 538 consecutive Danish patients with ischemic stroke (mean age, 69.5 ± 10.9 years; 39.2% female) within 7 days of symptom onset. Using multiple-adjusted conditional logistic regression analysis, we compared the prevalence of JAK2V617F with that in age- and sex-matched controls free of ischemic cerebrovascular disease (ICVD) from the Danish General Suburban Population Study. DNA was analyzed for JAK2V617F mutation using sensitive droplet digital polymerase chain reaction in patients and controls. Of the 538 patients with ischemic stroke, 61 (11.3%) had JAK2V617F mutation. There were no differences in patient demographics or cerebrovascular comorbidities between the patients with and without mutations. Patients with ischemic stroke were more likely to have the JAK2V617F mutation than matched controls, in whom the JAK2V617F prevalence was 4.4% (odds ratio, 2.37; 95% confidence interval, 1.57-3.58; P < .001). A subanalysis stratified by smoking history revealed that the association was strongest in current smokers (odds ratio, 4.78; 95% confidence interval, 2.22-10.28; P < .001). Patients with ischemic stroke were 2.4 times more likely to have the JAK2V617F mutation than matched controls without ICVD when adjusting for other cerebrovascular risk factors. This finding supports JAK2V617F mutation as a novel cerebrovascular risk factor.