Antiplatelets in Secondary Stroke Prevention

The aim of this review is to provide evidence-based recommendations on the secondary prevention of atherothrombotic ischemic stroke. Antiplatelets are the major therapy for the secondary stroke prevention. The most commonly used antiplatelets agents are aspirin, clopidogrel, and extended-release dipyridamole. A lot of progress had been made in last years regarding aspirin resistance and genotyping of clopidogrel metabolism. According to the results of the accomplished studies it is difficult to broadly recommend one antithrombotic agent in favor of the other. Instead, a review of the currently published data suggests the importance of focusing on the individualizing approach in antiplatelet therapy

Moždana vazomotorna reaktivnost i okluzivna bolest karotidnih arterija

Cerebral autoregulation is a mechanism that enables relatively constant cerebral blood flow during variations of cerebral perfusion pressure. The differences between cerebral blood flow at rest and after administration of a potent vasodilatory stimulus test such as hypercapnia reflect cerebral vasomotor reactivity defined as the vasodilation capacity of cerebral arterioles to external stimuli, providing important information about the cerebral hemodynamic status. Cerebral vasomotor reactivity provides important information about the cerebral hemodynamic status. In this article, cerebral vasomotor reactivity assessment tests are presented, with emphasis on transcranial Doppler, as well as the use of transcranial Doppler in assessing cerebral vasomotor reactivity in carotid stenosis, occlusion, and the importance of cerebral vasomotor reactivity for carotid surgery.Moždana autoregulacija je mehanizam koji omogućava relativno ustaljeni moždani protok krvi za vrijeme promjena tlaka prokrvljenosti mozga. Razlike između moždanog protoka krvi u mirovanju i nakon testa snažne vazodilatacijske stimulacije poput hiperkapnije odražavaju moždanu vazomotornu reaktivnost definiranu kao vazodilatacijski kapacitet moždanih arteriola za vanjske poticaje, pružajući važne podatke o moždanom hemodinamskom statusu. Moždana vazomotorna reaktivnost daje važne informacije o statusu moždane hemodinamike. U članku se prikazuju testovi za procjenu moždane vazomotorne reaktivnosti s naglaskom na transkranijski Doppler, te primjena transkranijskog Dopplera u procjeni moždane vazomotorne reaktivnosti kod karotidne stenoze, okluzije, kao i važnost moždane vazomotorne reaktivnosti za kirurgiju karotidnih arterija

Transient ischemic attack (TIA) is an emergency

Transient ischemic attack (TIA) is a warning sign of stroke, and stroke is one of the leading causes of morbidity and mortality in the world. The assessment and management of TIAs can be difficult even for an experienced neurologist. The purpose of this article is to increase the awareness and establish a diagnostic and therapeutic approach to patientswith TIA. In terms of therapy, patients with TIA share the same recommendations as those with acute ischemic stroke. Based on the etiology, therapeutic measures for secondary prevention after a TIA include antithrombotic, antihypertensive, statins therapy, aswell as carotid intervention as appropriate. Itwas shown that early evaluation following appropriate treatment after TIA reduces the risk of the first and early recurrent stroke by about 80%, therefore TIA should be considered as an emergency and should be treated as such

Duretovo krvarenje: rijetka komplikacija ishemijskog moždanog udara u području središnje moždane arterije - Prikaz slučaja

We report on an unusual case of brainstem Duret hemorrhage after ischemic stroke in the anterior circulation. The patient showed a clinical and neuroradiological picture of an acute and malignant middle cerebral artery infarct with increased intracranial pressure followed by a brainstem hemorrhage. The report suggests that the descending transtentorial herniation of any etiology might be complicated by a Duret hemorrhage.Opisuje se rijedak slučaj Duretova krvarenja moždanoga debla nakon ishemijskog moždanog udara u prednjem krvotoku. Bolesnik je pokazivao kliničku i neuroradiološku sliku akutnog i zloćudnog infarkta središnje moždane arterije uz povišen intrakranijski tlak, nakon čega je uslijedilo krvarenje u moždanom deblu. Ovaj prikaz ukazuje na to da se Duretovo krvarenje može pojaviti kao komplikacija kod silazne transtentorijske hernijacije bilo koje etiologije

Pre-hospital stroke monitoring past, present, and future: a perspective

Integrated brain-machine interface signifies a transformative advancement in neurological monitoring and intervention modalities for events such as stroke, the leading cause of disability. Historically, stroke management relied on clinical evaluation and imaging. While today’s stroke landscape integrates artificial intelligence for proactive clinical decision-making, mainly in imaging and stroke detection, it depends on clinical observation for early detection. Cardiovascular monitoring and detection systems, which have become standard throughout healthcare and wellness settings, provide a model for future cerebrovascular monitoring and detection. This commentary reviews the progression of continuous stroke monitoring, spotlighting contemporary innovations and prospective avenues, and emphasizes the influential roles of cutting-edge technologies in shaping stroke care

Stroke care indicators in the Republic of Moldova – the RES-Q registry

Introducere. Până la aderarea Moldovei in anul 2016 la platforma internațională RES-Q (Registry of Stroke Care Quality) - Registrul Calității Îngrijirii Accidentului Vascular Cerebral (AVC), nu au existat date privind indicatorii de calitate intraspitalicești ai ictusului. Scopul acestei lucrări a fost de a evalua calitatea asistenței medicale acordată pacienților cu AVC în Moldova în baza datelor registrului RES-Q. Material și metode. Au fost analizate datele tuturor pacienților cu ictus ischemic și hemoragic acut din registrul RES-Q din 15 spitale din Moldova. Datele au fost colectate timp de o lună pe an pe parcurs a 3 ani (2017-2019). Analiza datelor între spitale s-a realizat din considerentul accesului acestora la computer tomografia cerebrală. Adițional, datele din Moldova au fost comparate cu cele din trei țări ale proiectului ESO-EAST (European Stroke Organization Enhancing and Accelerating Stroke Treatment): România, Lituania și Georgia. Rezultate. Studiul a inclus un număr total de 1660 pacienți, cu vârsta medie de 68 ani (49% - bărbați). Moldova a înregistrat rezultate mai slabe la numărul de CT efectuate (81% [95% CI 79-84%]), la evaluarea disfagiei (29% [95% CI 27-32%]), efectuarea trombolizei intravenoase (3% [95% CI 2-4%]), administrarea de anticoagulante (44% [95% CI 39-49%]) și statine (42% [95% CI 39-45%]) la externare, la mortalitatea intraspitalicească prin AVC (17% [95% CI 15- 19%]). În interiorul Moldovei calitatea asistenței prin AVC s-a comparat reieșind din accesul la CT. Concluzii. Studiul nostru a identificat lacune serioase ale performanțelor asistenței intraspitalicești în ictus, cum ar fi lipsa scanărilor prin CT în multe spitale publice, absența unei rețele naționale centralizate în domeniul AVC, acces extrem de scăzut la tratamentul prin tromboliză și implementarea nesatisfăcătoare a tratamentului de profilaxie secundară a ictusului.Introduction. There were no data on in-hospital stroke care indicators until Moldova’s accession to the international Registry of Stroke Care Quality (RES-Q) platform in 2016. The aim of this paper was to assess the acute stroke care quality in Moldova based on the data of the RES-Q registry. Material and methods. We analyzed the data of all patients with acute ischemic and hemorrhagic stroke of the RES-Q from 15 Moldovan hospitals. Data were collected for one month each year, during a 3-year period (2017-2019). Data analysis was performed between hospitals according to their access to a brain CT facility for Moldovan participating hospitals. Additionally, Moldovan data were compared with other three ESO-EAST (European Stroke Organization Enhancing and Accelerating Stroke Treatment) project countries: Romania, Lithuania, and Georgia. Results. A total of 1660 patients were recruited in the study, mean age of 68 years (49% men). Moldova registered poorer results in number of brain CT performed (81% [95% CI 79-84%]), dysphagia screening (29% [95% CI 27-32%]), IV thrombolysis performed (3% [95% CI 2-4%]), administration of anticoagulants (44% [95% CI 39-49%]) and statins (42% [95% CI 39-45%]) at discharge, in-hospital stroke mortality (17% [95% CI 15- 19%]). Within Moldova the stroke care quality was driven by the access to CT scan. Conclusions. Our study highlighted some serious gaps of in-hospital stroke care performance in Moldova, such as the lack of CT scans in many public hospitals, the absence of a national stroke center network, extremely low accessibility of IV thrombolysis and unsatisfactory implementation of secondary stroke prevention treatment

One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke

BACKGROUND Previous studies conducted between 1997 and 2003 estimated that the risk of stroke or an acute coronary syndrome was 12 to 20% during the first 3 months after a transient ischemic attack (TIA) or minor stroke. The TIAregistry.org project was designed to describe the contemporary profile, etiologic factors, and outcomes in patients with a TIA or minor ischemic stroke who receive care in health systems that now offer urgent evaluation by stroke specialists. METHODS We recruited patients who had had a TIA or minor stroke within the previous 7 days. Sites were selected if they had systems dedicated to urgent evaluation of patients with TIA. We estimated the 1-year risk of stroke and of the composite outcome of stroke, an acute coronary syndrome, or death from cardiovascular causes. We also examined the association of the ABCD2 score for the risk of stroke (range, 0 [lowest risk] to 7 [highest risk]), findings on brain imaging, and cause of TIA or minor stroke with the risk of recurrent stroke over a period of 1 year. RESULTS From 2009 through 2011, we enrolled 4789 patients at 61 sites in 21 countries. A total of 78.4% of the patients were evaluated by stroke specialists within 24 hours after symptom onset. A total of 33.4% of the patients had an acute brain infarction, 23.2% had at least one extracranial or intracranial stenosis of 50% or more, and 10.4% had atrial fibrillation. The Kaplan–Meier estimate of the 1-year event rate of the composite cardiovascular outcome was 6.2% (95% confidence interval, 5.5 to 7.0). Kaplan–Meier estimates of the stroke rate at days 2, 7, 30, 90, and 365 were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively. In multivariable analyses, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD2 score of 6 or 7 were each associated with more than a doubling of the risk of stroke. CONCLUSIONS We observed a lower risk of cardiovascular events after TIA than previously reported. The ABCD2 score, findings on brain imaging, and status with respect to large-artery atherosclerosis helped stratify the risk of recurrent stroke within 1 year after a TIA or minor stroke. (Funded by Sanofi and Bristol-Myers Squibb.)Supported by an unrestricted grant from Sanofi and Bristol-Myers Squibb

Implant for Augmentation of Cerebral Blood Flow Trial-1 (ImpACT-1). A single-arm feasibility study evaluating the safety and potential benefit of the Ischemic Stroke System for treatment of acute ischemic stroke

Background The Ischemic Stroke System is a novel device designed to deliver stimulation to the sphenopalatine ganglion(SPG).The SPG sends parasympathetic innervations to the anterior cerebral circulation. In rat stroke models, SPG stimulation results in increased cerebral blood flow, reduced infarct volume, protects the blood brain barrier, and improved neurological outcome. We present here the results of a prospective, multinational, single-arm, feasibility study designed to assess the safety, tolerability, and potential benefit of SPG stimulation inpatients with acute ischemic stroke(AIS). Methods Patients with anterior AIS, baseline NIHSS 7–20 and ability to initiate treatment within 24h from stroke onset, were implanted and treated with the SPG stimulation. Patients were followed up for 90 days. Effect was assessed by comparing the patient outcome to a matched population from the NINDS rt-PA trial placebo patients. Results Ninety-eight patients were enrolled (mean age 57years, mean baseline NIHSS 12 and mean treatment time from stroke onset 19h). The observed mortality rate(12.2%), serious adverse events (SAE)incidence(23.5%) and nature of SAE were within the expected range for the population. The modified intention to treat cohort consisted of 84 patients who were compared to matched patients from the NINDS placebo arm. Patients treated with SPG stimulation had an average mRS lower by 0.76 than the historical controls(CMH test p = 0.001). Conclusion The implantation procedure and the SPG stimulation, initiated within 24hr from stroke onset, are feasible, safe, and tolerable. The results call for a follow-up randomized trial (funded by BrainsGate; clinicaltrials.gov number, NCT03733236)

Selected acute phase CSF factors in ischemic stroke: findings and prognostic value

<p>Abstract</p> <p>Background</p> <p>Study aimed at investigation of pathogenic role and prognostic value of several selected cerebrospinal fluid acute phase factors that can reflect the severity of ischemic brain damage.</p> <p>Methods</p> <p>Ninety five acute ischemic stroke patients were investigated. Ischemic region visualized at the twenty fourth hour by conventional Magnetic Resonance Imaging. Stroke severity evaluated by National Institute Health Stroke Scale. One month outcome of disease was assessed by Barthel Index. Cerebrospinal fluid was taken at the sixth hour of stroke onset. CSF pro- and anti-inflammatory cytokines were studied by Enzyme Linked Immunosorbent Assay. Nitric Oxide and Lipoperoxide radical were measured by Electron Paramagnetic Resonance. CSF Nitrate levels were detected using the Griess reagent. Statistics performed by SPSS-11.0.</p> <p><b>Results</b></p> <p>At the sixth hour of stroke onset, cerebrospinal fluid cytokine levels were elevated in patients against controls. Severe stroke patients had increased interleukin-6 content compared to less severe strokes (P < 0.05). Cerebrospinal fluid Electron Paramagnetic Resonance signal of nitric oxide was increased in patients against controls. Severe stroke group had an elevated Electron Paramagnetic Resonance signal of lipoperoxiradical compared to less severe stroke. Cerebrospinal fluid nitrate levels in less severe stroke patients were higher than those for severe stroke and control. Positive correlation was established between the initial interleukin-6 content and ischemic lesion size as well as with National Institute Health Stroke Scale score on the seventh day. Initial interleukin-6 and nitrate levels in cerebrospinal fluid found to be significant for functional outcome of stroke at one month.</p> <p><b>Conclusion</b></p> <p>According to present study the cerebrospinal fluid contents of interleukin-6 and nitrates seem to be the most reliable prognostic factors in acute phase of ischemic stroke.</p