Interactive Training of the Emergency Medical Services Improved Prehospital Stroke Recognition and Transport Time

Funding Information: This study received funding from Boehringer Ingelheim GmbH & Co KG Lithuania. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit for publication. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding Information: We greatly acknowledge the EMS staff for taking part in the training. LS was supported by the Swiss National Science Foundation postdoctoral scholarship (P2GEP3_191584). This article/publication is based on work from the IRENE COST Action—Implementation Research Network in Stroke Care Quality (CA18118), supported by COST (European Cooperation in Science and Technology; www.cost.eu ). Publisher Copyright: Copyright © 2022 Sveikata, Melaika, Wiśniewski, Vilionskis, Petrikonis, Stankevičius, Jurjans, Ekkert, Jatužis and Masiliūnas.Background and Purpose: Acute stroke treatment outcomes are predicated on reperfusion timeliness which can be improved by better prehospital stroke identification. We aimed to assess the effect of interactive emergency medical services (EMS) training on stroke recognition and prehospital care performance in a very high-risk cardiovascular risk population in Lithuania. Methods: We conducted a single-center interrupted time-series study between March 1, 2019 and March 15, 2020. Two-hour small-group interactive stroke training sessions were organized for 166 paramedics serving our stroke network. We evaluated positive predictive value (PPV) and sensitivity for stroke including transient ischemic attack identification, onset-to-door time, and hospital-based outcomes during 6-months prior and 3.5 months after the training. The study outcomes were compared between EMS providers in urban and suburban areas. Results: In total, 677 suspected stroke cases and 239 stroke chameleons (median age 75 years, 54.8% women) were transported by EMS. After the training, we observed improved PPV for stroke recognition (79.8% vs. 71.8%, p = 0.017) and a trend of decreased in-hospital mortality (7.8% vs. 12.3, p = 0.070). Multivariable logistic regression models adjusted for age, gender, EMS location, and stroke subtype showed an association between EMS stroke training and improved odds of stroke identification (adjusted odds ratio [aOR] 1.6 [1.1–2.3]) and onset-to-door ≤ 90 min (aOR 1.6 [1.1–2.5]). The improvement of PPV was observed in urban EMS (84.9% vs. 71.2%, p = 0.003), but not in the suburban group (75.0% vs. 72.6%, p = 0.621). Conclusions: The interactive EMS training was associated with a robust improvement of stroke recognition, onset to hospital transport time, and a trend of decreased in-hospital mortality. Adapted training strategies may be needed for EMS providers in suburban areas. Future studies should evaluate the long-term effects of the EMS training and identify optimal retraining intervals.publishersversionPeer reviewe

Intracerebral Hemorrhage Genetics

Intracerebral hemorrhage (ICH) is a devastating type of stroke, frequently resulting in unfavorable functional outcomes. Up to 15% of stroke patients experience ICH and approximately half of those have a lethal outcome within a year. Considering the huge burden of ICH, timely prevention and optimized treatment strategies are particularly relevant. Nevertheless, ICH management options are quite limited, despite thorough research. More and more trials highlight the importance of the genetic component in the pathogenesis of ICH. Apart from distinct monogenic disorders of familial character, mostly occurring in younger subjects, there are numerous polygenic risk factors, such as hypertension, neurovascular inflammation, disorders of lipid metabolism and coagulation cascade, and small vessel disease. In this paper we describe gene-related ICH types and underlying mechanisms. We also briefly discuss the emerging treatment options and possible clinical relevance of the genetic findings in ICH management. Although existing data seems of more theoretical and scientific value so far, a growing body of evidence, combined with rapidly evolving experimental research, will probably serve clinicians in the future

Inflammatory Disorders of the Central Nervous System Vessels: Narrative Review

Inflammatory disorders of the central nervous system (CNS) vessels, also called CNS vasculitides, can cause substantial disability or even be fatal. Inflammation of the CNS vessels can be caused by primary angiitis of the CNS (PACNS), inflammatory cerebral amyloid angiopathy, or systemic inflammatory disorders. Clinical symptoms of these disorders are often non-specific, such as encephalopathy, cognitive and affective abnormalities, headache and focal neurological symptoms. Diagnostic workup includes a thorough neuropsychiatric examination, blood and cerebrospinal fluid analysis and magnetic resonance imaging (MRI) of the brain and its vessels. Biopsy of the brain remains the gold standard diagnostic test. Timely diagnosis and treatment initiation is of high importance, as it might prevent severe complications, such as ischemic and hemorrhagic stroke. In this review, we describe the specific characteristics of primary and secondary non-infectious CNS vasculitides which help to establish the diagnosis, discuss the peculiarities of the diagnostic workup and present current treatment recommendations

Ischemic Stroke Genetics: What Is New and How to Apply It in Clinical Practice?

The etiology of ischemic stroke is multifactorial. Although receiving less emphasis, genetic causes make a significant contribution to ischemic stroke genesis, especially in early-onset stroke. Several stroke classification systems based on genetic information corresponding to various stroke phenotypes were proposed. Twin and family history studies, as well as candidate gene approach, are common methods to discover genetic causes of stroke, however, both have their own limitations. Genome-wide association studies and next generation sequencing are more efficient, promising and increasingly used for daily diagnostics. Some monogenic disorders, despite covering only about 7% of stroke etiology, may cause well-known clinical manifestations that include stroke. Polygenic disorders are more frequent, causing about 38% of all ischemic strokes, and their identification is a rapidly developing field of modern stroke genetics. Current advances in human genetics provide opportunity for personalized prevention of stroke and novel treatment possibilities. Genetic risk scores (GRS) and extended polygenic risk scores (PRS) estimate cumulative contribution of known genetic factors to a specific outcome of stroke. Combining those scores with clinical information and risk factor profiles might result in better primary stroke prevention. Some authors encourage the use of stroke gene panels for stroke risk evaluation and further stroke research. Moreover, new biomarkers for stroke genetic causes and novel targets for gene therapy are on the horizon. In this article, we summarize the latest evidence and perspectives of ischemic stroke genetics that could be of interest to the practitioner and useful for day-to-day clinical work

Peculiarities and recommendations of acute stroke treatment during the COVID-19 pandemic

The global COVID-19 pandemic poses enormous challenges to healthcare systems and has a major impact on the treatment and care of stroke patients. In the article, the authors review the issues of acute stroke diagnosis, treatment, and prevention during the COVID-19 pandemic and share their own observations. Limited data on the clinical manifestations of COVID-19-associated stroke and the mechanisms of cerebrovascular injury are summarized. Practical recommendations for the organization of acute stroke care, reperfusion treatment, and secondary stroke prevention are provided. The principle is emphasized that, despite all the additional constraints imposed by the pandemic, treatment for acute stroke patients must be provided as soon as possible

The diagnosis and treatment of migraine among medical students in 2010–2011 and 2019

Background. Migraine prevalence in Lithuania is 18.8%. The aim of this study was to evaluate the prevalence of migraine, quality of life, professionally confirmed diagnosis rate, and treatment among medical students (aged 18-28 years) in 2010-11 and in 2019. Materials and methods. 478 Vilnius university medicine and odontology students participated in the anonymous survey. 252 students were queried in 2010-11 study (aged 23.0±7.8) and 226 in 2019 (aged 23.0±1.5). Questionnaire consisted of questions, based on headache characteristics, triggers, impact on life, presence of confirmed diagnosis, and treatment. The data was analyzed by SPSS 23.0 software, a p value of <0.05 was considered significant. Results. Based on questionnaire, prevalence of migraine with and without aura remained stable between the periods of 2010-11 (27.8%) and 2019 (27.9%) (p=0.98); women were affected more often (p=0.02). Pain remained moderately intense (p=0.07), but migraine disability worsened over the time (p=0.01). Migraine was professionally diagnosed more often in 2019 (10% vs. 25.4%, p=0.03); increased use of specific acute therapy (5.7% vs. 19%, p=0.03) and prophylaxis (0% vs 9.6%, p=0.003) was observed. Likelihood of diagnosis significantly increased with more intense pain (OR=2.7, p=0.006) and aura (OR=2.7, p=0.037). Presence of confirmed diagnosis was an independent determinant of increased triptans (OR=6.9, p=0.012) and prophylaxis (OR=30.3, p=0.036) use. Conclusions. Comparing the 2010-11 and 2019 periods, migraine prevalence is similar. Pain remains to be valued as moderate, but quality of life has worsened. Prevalence of professionally diagnosed migraine has increased over the time, what was accompanied by an increased use of triptans and prophylaxis, however, migraine still remains underdiagnosed and undertreated

Endovascular Treatment of Basilar Artery Occlusion: What Can We Learn from the Results?

Background and Objectives: Current guidelines lack specific endovascular treatment (EVT) recommendations for posterior circulation stroke (PCS). The results of earlier studies are controversial. We aimed to compare early hospital outcomes of stroke caused by large-vessel occlusion (LVO) treated with EVT or bridging therapy (BT) in anterior circulation stroke (ACS) versus PCS (middle cerebral artery occlusion (MCAO) and basilar artery occlusion (BAO), and establish the risk factors for poor outcome. Materials and Methods: we analyzed the data of 279 subjects treated with EVT due to LVO-caused stroke in a comprehensive stroke centre in 2015–2021. The primary outcome was hospital mortality, secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) after 24 h, early neurological deterioration, futile recanalization (FR), the ambulatory outcome at discharge, and complications. Results: BAO presented with higher baseline NIHSS scores (19 vs. 14, p p = 0.034), compared to MCAO. Hospital mortality and the percentage of FR were the same in BAO and almost two times higher than in MCAO (20.0% vs. 10.3%, p = 0.048), other outcomes did not differ. In BAO, unsuccessful recanalization was the only significant predictor of the lethal outcome, though there were trends for PAD and RF predicting lethal outcome. A trend for higher risk of symptomatic intracranial hemorrhage (sICH) was observed in the BAO group when BT was applied. Nevertheless, neither BT nor sICH predicted lethal outcomes in the BAO group. Conclusions: Compared to the modern gold standard of EVT in the ACS, early outcomes in BAO remain poor, there is a substantial amount of FR. Nevertheless, unsuccessful recanalization remains the strongest predictor of lethal outcomes. BT in PCS might pose a higher risk for sICH, but not the lethal outcome, although this finding requires further investigation in larger trials

Changes in prehospital stroke care and stroke mimic patterns during the COVID-19 lockdown

The impact of COVID-19 lockdown on prehospital stroke care is largely unknown. We aimed to compare stroke care patterns before and during a state-wide lockdown. Thus, we analysed prospective data of stroke alerts referred to our stroke centre between 1 December 2019 and 16 June 2020, and compared them between two periods—15 weeks before and 13 weeks during the state-wide lockdown declared in Lithuania on 16 March 2020. Among 719 referrals for suspected stroke, there was a decrease in stroke alerts (rate ratio 0.61, 95% CI (0.52–0.71)), stroke admissions (0.63, 95% CI (0.52–0.76)), and decrease in prehospital stroke triage quality (positive predictive value 72.1% vs. 79.9%, p = 0.042) during the lockdown. The onset-to-door time was longer (153.0 vs. 120.5 min, p = 0.049) and seizures and intracranial tumours were more common among stroke mimics (16.9% vs. 6.7%, p = 0.012 and 9.6% vs. 3.0%, p = 0.037, respectively). We conclude that there was a decline in prehospital stroke triage quality during the lockdown despite low COVID-19 incidence in the country. Moreover, we observed an increase in hospital arrival delays and severe conditions presenting as stroke mimics. Our findings suggest that improved strategies are required to maintain optimal neurological care during public health emergencie

Novel in-frame deletion in HTRA1 gene, responsible for stroke at a young age and dementia - a case study

Biallelic mutations in the high-temperature requirement A serine peptidase 1 (HTRA1) gene are known to cause an extremely rare cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), which belongs to the group of hereditary cerebral small vessel diseases and is mainly observed in the Japanese population. Even though this pathology is inherited in an autosomal recessive manner, recent studies have described symptomatic carriers with heterozygous HTRA1 mutations who have milder symptoms than patients with biallelic HTRA1 mutations. We present the case of a Lithuanian male patient who had a stroke at the age of 36, experienced several transient ischemic attacks, and developed an early onset, progressing dementia. These clinical symptoms were associated with extensive leukoencephalopathy, lacunar infarcts, and microbleeds based on brain magnetic resonance imaging (MRI). A novel heterozygous in-frame HTRA1 gene deletion (NM_002775.5:c.533_535del; NP_002766.1:p.(Lys178del)) was identified by next generation sequencing. The variant was consistent with the patient’s phenotype, which could not be explained by alternative causes, appeared highly deleterious after in silico analysis, and was not reported in the medical literature or population databases to date

High prevalence of atrial fibrillation in a Lithuanian stroke patient cohort

Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a five-fold increased risk for acute ischemic stroke (AIS). We aimed to estimate the prevalence of AF in a Lithuanian cohort of stroke patients, and its impact on patients regarding case fatality, functional outcome, and health-related quality of life (HRQoL) at 90 days. Materials and Methods: A single-center prospective study was carried out for four non-consecutive months between December 2018 and July 2019 in one of the two comprehensive stroke centers in Eastern Lithuania. A telephone-based follow-up was conveyed at 90 days using the modified Rankin Scale (mRS) and EuroQoL five-dimensional three-level descriptive system (EQ-5D-3L) with a self-rated visual analog scale (EQ-VAS). One-year case fatality was investigated. Results: We included 238 AIS patients with a mean age of 71.4 ± 11.9 years of whom 45.0% were female. A striking 97 (40.8%) AIS patients had a concomitant AF, in 68 (70.1%) of whom the AF was pre-existing. The AIS patients with AF were at a significantly higher risk for a large vessel occlusion (LVO; odds ratio 2.72 [95% CI 1.38–5.49], p = 0.004), and had a more severe neurological impairment at presentation (median NIHSS score (interquartile range): 9 (6–16) vs. 6 (3–9), p < 0.001). The LVO status was only detected in those who had received computed tomography angiography. Fifty-five (80.9%) patients with pre-existing AF received insufficient anticoagulation at stroke onset. All patients received a 12-lead ECG, however, in-hospital 24-h Holter monitoring was only performed in 3.4% of AIS patients without pre-existing AF. Although multivariate analyses found no statistically significant difference in one-year stroke patient survival and favorable functional status (mRS 0–2) at 90 days, when adjusted for age, gender, reperfusion treatment, baseline functional status, and baseline NIHSS, stroke patients with AF had a significantly poorer self-perceived HRQoL, indicated by a lower EQ-VAS score (regression coefficient ± standard error: β = −11.776 ± 4.850, p = 0.017). Conclusions: In our single-center prospective observational study in Lithuania, we found that 40.8% of AIS patients had a concomitant AF, were at a higher risk for an LVO, and had a significantly poorer self-perceived HRQoL at 90 days. Despite the high AF prevalence, diagnostic tools for subclinical AF were greatly underutilized