COVID-19 and the Stroke Patient

U Republici Hrvatskoj proglašena je opasnost od epidemije COVID-19. Zdravstveni sustav, zdravstveni radnici i resursi su pri tome usmjereni na borbu protiv COVID-19. Formiraju se ustanove kao respiracijski centri te dodatni kapaciteti za zbrinjavanje oboljelih od COVID-19, a odvajaju se ustanove u kojima se zbrinjavaju bolesnici s akutnim neurološkim bolestima i stanjima, kao npr. s moždanim udarom. Za sada je nepoznat učinak infekcije COVID-19 na nastanak moždanog udara, ali očekuje se teža prezentacija bolesti. Iako se očekuje da će osobe zahvaćene zaraznim bolestima kao COVID-19 biti izložene povećanom riziku od ishemijskoga i hemoragičnoga moždanog udara, u hitnim službama diljem svijeta neočekivano se registrira smanjenje broja oboljelih od moždanog udara. Pretpostavlja se da bolesnici s blažim oblicima ili tranzitornim ishemijskim atakom ostaju kod kuće jer se od njih tako traži, da ograniče posjete hitnim službama i minimiziraju putovanja. Također, bolesnicima je prioritet izbjegavanje zaraze te najčešće ostaju kod kuće. Organizacija službe u Republici Hrvatskoj usmjerena je na aktivno liječenje moždanog udara u sveobuhvatnim centrima za liječenje moždanog udara prema definiranim protokolima, neovisno o statusu infekcije COVID-19. Započinje se sekundarna prevencija moždanog udara, a tendencija je usmjeravanje bolesnika na rehabilitaciju u svrhu smanjenja invalidnosti. Organizacija službe trebala bi omogućavati kontrolne posjete bolesnika liječniku, bez kontakta licem u lice, a mogu se odvijati preko telefona ili telemedicine, za što je neophodna informatička podrška. Na taj bi se način zaštitili bolesnici od zaraze i provjerilo pridržavaju li se mjera sekundarne prevencije.The Republic of Croatia has declared a risk of COVID-19 outbreaks throughout the country. The Croatian health system, healthcare professionals and resources are thus focused on the fight against the virus. Establishments and additional facilities are being set up as respiratory centers for the care of COVID-19 patients, as well as other locations to treat patients with acute neurological diseases and conditions such as stroke. The effects of COVID-19 infection on stroke is currently unknown, but more severe disease presentation is expected. Although people affected by infectious diseases such as COVID-19 are expected to be at increased risk of ischemic and hemorrhagic stroke, there is an unexpected decrease in the number of stroke patients in emergency services worldwide. It is presumed that patients with milder symptoms or transient ischemic attack are at home because they are required to do so, as well as limit emergency room visits and minimize travel. The patients’ own priority is to avoid contagion, and so they most often stay at home. The organization of the service in the Republic of Croatia is focused on the active treatment of stroke patients in comprehensive stroke centers according to defined protocols, regardless of the status of the COVID-19 infection. Secondary stroke prevention begins, and the tendency is to direct patients to rehabilitation in order to reduce disability. The organization of the service should allow for non-face-to-face patient control visits, which may take place over the phone or via telemedicine - which requires IT support. This would protect patients from infection and check that they comply with the control of risk factors

Uloga neurosonologije u vertigu

Vertigo is a common symptom, and may represent a serious neurological disorder. If it develops suddenly, it may be a symptom of an acute stroke. Neurosonology can be used in cerebrovascular disorders in order to asses the vessel patency, or to present different craniocervical artery diseases. Atherosclerotic changes may be seen, as well as inflammatory diseases, dissections, vasculopathies or vascular malformations. By means of a transcranial Doppler the intracranial hemodynamics can be assessed. A development of collateral pathways in extra- or intracranial occlusive diseases can be presumed, cerebral vasomotor reactivity can be tested, and, with the application of new softwares, microembolic signals can be detected. Neurosonology can be used in a variety of neurological disorders presenting with vertigo.Vertigo je čest simptom koji može predstavljati i ozbiljan neurološki poremećaj. Ako vertigo naglo nastane, može biti simptom akutnog moždanog udara. Neurosonologija se može upotrijebiti u cerebrovascularnih poremećaja kako bi se procijenilo stanje krvnih žila, ili u dijagnostici različitih bolesti kraniocervikalnih arterija. Mogu se prikazati aterosklerotske promjene, upalne bolesti, disekcije, vaskulopatije i vaskularne malformacije. Primjenom transkranijskog doplera može se procijeniti intrakranijska hemodinamika, može se prikazati nastanak kolateralnih puteva u ekstra- i intrakranijakim i okluzivnim bolestima, može se ispitati cerebralna vazomotorna reaktivnost, a primjena novih softwera omogućuje detekciju mikroembolijskih signala. Neurosonologija se može primijeniti u različitim neurološkim poremećajima koji imaju vertigo kao simptom

Do We Recognize a Stroke on Time?

Moždani udar je hitno stanje koje zahtijeva hitno zbrinjavanje kako bi se omogućilo djelotvorno akutno liječenje i poboljšao ishod liječenja. Vremenski prozor za liječenje moždanog udara je uzak, stoga je neophodno pravodobno prepoznavanje simptoma moždanog udara te adekvatna i brza akcija koja omogućava brzi pristup bolesnika centrima za liječenje moždanog udara. Radna skupina Povjerenstva za neurologiju Ministarstva zdravstva Republike Hrvatske formirana je kako bi izradila Strategiju za moždani udar, koja je prihvaćena na Odboru za zdravstvo Hrvatskog sabora. Strategija je u skladu s Akcijskim planom za moždani udar u Europi. Definirani su ciljevi primarne prevencije moždanog udara, započete su javnozdravstvene akcije u svrhu prepoznavanja čimbenika rizika za nastanak moždanog udara, simptoma moždanog udara te načina djelovanja kod simptoma moždanog udara. U javnozdravstvene akcije uključila su se stručna društva Hrvatskoga liječničkog zbora, klinike i odjeli neurologije hrvatskih akutnih bolnica, udruge građana kao i Hrvatski zavod za javno zdravstvo. Javnozdravstvene kampanje osmišljene su kroz obilježavanje Dana moždanog udara, kao i javnozdravstvene akcije Dana crvenih haljina. Upotrijebljen je akronim GROM kako bi se osvijestili simptomi moždanog udara. Takve su akcije podigle svijest o moždanom udaru, ne samo u ciljanoj populaciji već i u školama i vrtićima, što će omogućiti preventivno djelovanje, ali i pravodobnu akciju u slučaju pojave simptoma u člana obitelji. Hrvatska ima 25 akutnih bolnica s mogućnošću prijema bolesnika s akutnim moždanim udarom, te aktivnim liječenjem moždanog udara. Potrebno je nastaviti javnozdravstvene akcije u smislu primarne prevencije moždanog udara kao i prepoznavanje simptoma moždanog udara te načina djelovanja u kritičnom trenutku.Stroke is a medical emergency that requires urgent management for effective acute treatment to improve treatment outcome. The time window for the treatment of stroke is narrow, so it is necessary to recognize the symptoms of stroke and take adequate and fast action that allows quick access of patients to the stroke centers. A working group of the Committee for Neurology of the Ministry of Health of the Republic of Croatia was formed to draft a Stroke Strategy, which was adopted by the Parliamentary Committee on Health. The strategy is in line with the Stroke Action Plan for Europe. The goals of primary stroke prevention have been defined, public health actions have been initiated in order to identify risk factors for stroke and stroke symptoms, and how to act on them. Professional societies of the Croatian Medical Association, Clinics and Departments of Neurology of Croatian Acute Hospitals, citizens’ associations and the Croatian Institute of Public Health joined the public health actions. Public health campaigns are designed through the marking of Stroke Day, as well as public health actions of the Red Dress Day. The acronym FAST (Facial drooping, Arm weakness, Speech difficulties and Time) was used to raise awareness of stroke symptoms. Such actions have raised awareness of stroke, not only in the target population, but also in schools and kindergartens, which will enable preventive action, but also timely action in case of symptoms in a family member. Croatia has 25 acute hospitals equipped to admit patients with acute stroke and active treatment of stroke. It is necessary to continue public health actions in terms of primary prevention of stroke as well as recognizing the symptoms of stroke, and how to act at a critical moment

Uloga neurosonologije u vertigu

Vertigo is a common symptom, and may represent a serious neurological disorder. If it develops suddenly, it may be a symptom of an acute stroke. Neurosonology can be used in cerebrovascular disorders in order to asses the vessel patency, or to present different craniocervical artery diseases. Atherosclerotic changes may be seen, as well as inflammatory diseases, dissections, vasculopathies or vascular malformations. By means of a transcranial Doppler the intracranial hemodynamics can be assessed. A development of collateral pathways in extra- or intracranial occlusive diseases can be presumed, cerebral vasomotor reactivity can be tested, and, with the application of new softwares, microembolic signals can be detected. Neurosonology can be used in a variety of neurological disorders presenting with vertigo.Vertigo je čest simptom koji može predstavljati i ozbiljan neurološki poremećaj. Ako vertigo naglo nastane, može biti simptom akutnog moždanog udara. Neurosonologija se može upotrijebiti u cerebrovascularnih poremećaja kako bi se procijenilo stanje krvnih žila, ili u dijagnostici različitih bolesti kraniocervikalnih arterija. Mogu se prikazati aterosklerotske promjene, upalne bolesti, disekcije, vaskulopatije i vaskularne malformacije. Primjenom transkranijskog doplera može se procijeniti intrakranijska hemodinamika, može se prikazati nastanak kolateralnih puteva u ekstra- i intrakranijakim i okluzivnim bolestima, može se ispitati cerebralna vazomotorna reaktivnost, a primjena novih softwera omogućuje detekciju mikroembolijskih signala. Neurosonologija se može primijeniti u različitim neurološkim poremećajima koji imaju vertigo kao simptom

Migraine and Stroke

Migrena je česta primarna glavobolja. Pokazana je pozitivna povezanost migrene s vaskularnim bolestima, osobito s ishemijskim moždanim udarom, hemoragijskim moždanim udarom, infarktom miokarda, venskom tromboembolijom i fibrilacijom atrija. Veza je jača u migrene s aurom nego u migrene bez aure, a također je veza izraženija u žena nego u muškaraca. Migrena s aurom povećava rizik od ishemijskoga moždanog udara i abnormalnosti bijele tvari. Migrena bez aure povećava rizik od disekcije cervikalne arterije kao uzroka ishemijskoga moždanog udara, a postoji preklapanje i s reverzibilnim cerebralnim vazokonstrikcijskim sindromom i fibromuskularnom displazijom. Migrena je povezana sa specifičnim rizicima od cerebrovaskularnih događaja kod pušača, žena koje koriste oralne kontraceptive, osobito u mlađih odraslih osoba. Migrenski infarkt je rijedak, ali mora biti uključen u diferencijalnu dijagnozu ishemijskoga moždanog udara, osobito kod mladih žena.Migraine is a common primary headache. Migraine has been shown to be positively associated with vascular disease, particularly with ischemic stroke, hemorrhagic stroke, myocardial infarction, venous thromboembolism, and atrial fibrillation. The connection is stronger in migraines with aura than in migraines without aura, and also the connection is more pronounced in women than in men. Migraine with aura increases the risk of ischemic stroke and white matter abnormalities. Migraine without aura increases the risk of cervical artery dissection as a cause of ischemic stroke, and there is overlap with reversible cerebral vasoconstriction syndrome and fibromuscular dysplasia. Migraine is associated with specific risks of cerebrovascular events in smokers, women who use oral contraceptives, especially in younger adults. Migraine infarction is rare, but must be included in the differential diagnosis of ischemic stroke, especially in young women

Do We Recognize a Stroke on Time?

Moždani udar je hitno stanje koje zahtijeva hitno zbrinjavanje kako bi se omogućilo djelotvorno akutno liječenje i poboljšao ishod liječenja. Vremenski prozor za liječenje moždanog udara je uzak, stoga je neophodno pravodobno prepoznavanje simptoma moždanog udara te adekvatna i brza akcija koja omogućava brzi pristup bolesnika centrima za liječenje moždanog udara. Radna skupina Povjerenstva za neurologiju Ministarstva zdravstva Republike Hrvatske formirana je kako bi izradila Strategiju za moždani udar, koja je prihvaćena na Odboru za zdravstvo Hrvatskog sabora. Strategija je u skladu s Akcijskim planom za moždani udar u Europi. Definirani su ciljevi primarne prevencije moždanog udara, započete su javnozdravstvene akcije u svrhu prepoznavanja čimbenika rizika za nastanak moždanog udara, simptoma moždanog udara te načina djelovanja kod simptoma moždanog udara. U javnozdravstvene akcije uključila su se stručna društva Hrvatskoga liječničkog zbora, klinike i odjeli neurologije hrvatskih akutnih bolnica, udruge građana kao i Hrvatski zavod za javno zdravstvo. Javnozdravstvene kampanje osmišljene su kroz obilježavanje Dana moždanog udara, kao i javnozdravstvene akcije Dana crvenih haljina. Upotrijebljen je akronim GROM kako bi se osvijestili simptomi moždanog udara. Takve su akcije podigle svijest o moždanom udaru, ne samo u ciljanoj populaciji već i u školama i vrtićima, što će omogućiti preventivno djelovanje, ali i pravodobnu akciju u slučaju pojave simptoma u člana obitelji. Hrvatska ima 25 akutnih bolnica s mogućnošću prijema bolesnika s akutnim moždanim udarom, te aktivnim liječenjem moždanog udara. Potrebno je nastaviti javnozdravstvene akcije u smislu primarne prevencije moždanog udara kao i prepoznavanje simptoma moždanog udara te načina djelovanja u kritičnom trenutku.Stroke is a medical emergency that requires urgent management for effective acute treatment to improve treatment outcome. The time window for the treatment of stroke is narrow, so it is necessary to recognize the symptoms of stroke and take adequate and fast action that allows quick access of patients to the stroke centers. A working group of the Committee for Neurology of the Ministry of Health of the Republic of Croatia was formed to draft a Stroke Strategy, which was adopted by the Parliamentary Committee on Health. The strategy is in line with the Stroke Action Plan for Europe. The goals of primary stroke prevention have been defined, public health actions have been initiated in order to identify risk factors for stroke and stroke symptoms, and how to act on them. Professional societies of the Croatian Medical Association, Clinics and Departments of Neurology of Croatian Acute Hospitals, citizens’ associations and the Croatian Institute of Public Health joined the public health actions. Public health campaigns are designed through the marking of Stroke Day, as well as public health actions of the Red Dress Day. The acronym FAST (Facial drooping, Arm weakness, Speech difficulties and Time) was used to raise awareness of stroke symptoms. Such actions have raised awareness of stroke, not only in the target population, but also in schools and kindergartens, which will enable preventive action, but also timely action in case of symptoms in a family member. Croatia has 25 acute hospitals equipped to admit patients with acute stroke and active treatment of stroke. It is necessary to continue public health actions in terms of primary prevention of stroke as well as recognizing the symptoms of stroke, and how to act at a critical moment

Migraine and Stroke

Migrena je česta primarna glavobolja. Pokazana je pozitivna povezanost migrene s vaskularnim bolestima, osobito s ishemijskim moždanim udarom, hemoragijskim moždanim udarom, infarktom miokarda, venskom tromboembolijom i fibrilacijom atrija. Veza je jača u migrene s aurom nego u migrene bez aure, a također je veza izraženija u žena nego u muškaraca. Migrena s aurom povećava rizik od ishemijskoga moždanog udara i abnormalnosti bijele tvari. Migrena bez aure povećava rizik od disekcije cervikalne arterije kao uzroka ishemijskoga moždanog udara, a postoji preklapanje i s reverzibilnim cerebralnim vazokonstrikcijskim sindromom i fibromuskularnom displazijom. Migrena je povezana sa specifičnim rizicima od cerebrovaskularnih događaja kod pušača, žena koje koriste oralne kontraceptive, osobito u mlađih odraslih osoba. Migrenski infarkt je rijedak, ali mora biti uključen u diferencijalnu dijagnozu ishemijskoga moždanog udara, osobito kod mladih žena.Migraine is a common primary headache. Migraine has been shown to be positively associated with vascular disease, particularly with ischemic stroke, hemorrhagic stroke, myocardial infarction, venous thromboembolism, and atrial fibrillation. The connection is stronger in migraines with aura than in migraines without aura, and also the connection is more pronounced in women than in men. Migraine with aura increases the risk of ischemic stroke and white matter abnormalities. Migraine without aura increases the risk of cervical artery dissection as a cause of ischemic stroke, and there is overlap with reversible cerebral vasoconstriction syndrome and fibromuscular dysplasia. Migraine is associated with specific risks of cerebrovascular events in smokers, women who use oral contraceptives, especially in younger adults. Migraine infarction is rare, but must be included in the differential diagnosis of ischemic stroke, especially in young women

Noninvasive imaging of craniocervical artery dissection

Craniocervical arterial dissections (CCAD) are being increasingly identified due to growing awareness of diverse clinical picture along with advances in imaging technologies. Although rare, CCADare frequent cause of stroke in young adults. Neurosonological tests serve as an excellent noninvasive screening and monitoring tool, but brainMR andMRA are necessary for confirmation of the diagnosis. Ultrasound examination may show direct or indirect signs. Direct signs are: echolucent intramural hematoma, string sign, double lumen, or stenosis and/or occlusion of an arterial segment usually not affected by atherosclerosis. Indirect signs are: increased or decreased pulsatility index upstream or downstream of the suspected lesion, more than 50% difference in blood flow velocity compared to the unaffected side, or detection of intracranial collateral flow. Since CCAD have been increasingly identified, a whole spectrum of clinical pictures are been recognizes. Neurosonology showed high sensitivity in CCAD detection