Stroke recovery and lesion reduction following acute isolated bilateral ischaemic pontine infarction : a case report

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Acknowledgements The initial scan was offered as part of the standard clinical service provided by NHS Grampian and the follow-up scan was funded by a grant from the NHS Grampian Endowments Trust (grant number 12/35). We thank Dr Olive Robb, Dr Arnab Rana, Professor Alison Murray for reporting the imaging scans, Lisa Marshall for providing information regarding the patient’s on-going community physiotherapy input following discharge from Aberdeen Royal Infirmary, Gordon Buchan for his technical support during scanning, the research radiographers (Baljit Jagpal, Beverly Maclennan, Nichola Crouch and Katrina Klaasen), the Aberdeen Biomedical Imaging Centre staff especially Teresa Morris and Dawn Younie for coordinating the scanning appointments, the stroke research nurses (Anu Joyson, Heather Gow and Janice Irvine) and above all the patient for agreeing to take part in this case study.Peer reviewedPublisher PD

Marine-derived n-3 fatty acids therapy for stroke

We thank the Cochrane Stroke Group, and in particular Hazel Fraser (Managing Editor) and Joshua Cheyne (Trials Search Coordinator and Information Specialist), for their support in the development of this protocol. CG Alvarez Campano is funded by the Mexican Council for Science and Technology (CONACyT) and the Institute of Innovation and Technology Transfer (I²T²) (grant number 457349).Peer reviewedPublisher PD

Stroke patients admitted within normal working hours are more likely to achieve process standards and to have better outcomes

Acknowledgements The authors are grateful to David Murphy of the SSCA for providing data and to Lynsey Waugh of ISD Scotland for linking the SSCA data with General Register Office data. The authors also acknowledge the help of all who enter data into SSCA. Funding This study was funded by Chest, Heart and Stroke Scotland (Grant no R14/A156). The SSCA is funded by NHS Scotland via ISD.Peer reviewedPublisher PD

Is There a Difference in Clinical Measures and Structural Magnetic Resonance Imaging Metrics Between Minor Stroke and Migraine Patients?

Background: Patients presenting with minor acute focal neurological symptoms are often diagnosed with minor stroke, transient ischaemic attack, or migraine. Early diagnosis and treatment, in the case of the first two, is important to reduce risk of major strokes. The aim of this study was to assess whether there was a difference in clinical measures and structural magnetic resonance imaging (MRI) metrics between minor stroke and migraine patients. Methods: Twenty-two minor stroke (54.2 ±13.8 years; 10:12 female:male) and twenty-four migraine patients (44.2 ±13.0 years; 12:12 female:male) were enrolled. Clinical measures and structural MRI metrics, the latter extracted with FreeSurfer, were analysed using t test, Pearson correlation coefficient and ordinal regression in SPSS, version 26. The Benjamini-Hochberg post-hoc analysis, with FDR of 0.05, was applied for the t tests and correlations. Results: Systolic (p=0.001, t=3.774), mean arterial (p=0.002, t=3.348), diastolic blood pressure (p=0.009, t=2.721) and pulse pressure (p=0.003, t=3.207) were higher in minor stroke compared to migraine. Grey matter hyperintensities (p=0.002, t=3.350), white matter hyperintensities (p=0.018, t=2.462) and total Scheltens Score (p=0.013, t=2.580) were higher in minor stroke compared to migraine. Left (p=0.007, t=-2.389), right (p=0.009, t=-2.722) and total (p=0.007, t=-2.815) cortical thickness were higher in migraine compared to minor stroke. A significant correlation was observed between pulse pressure and total Scheltens score (r=0.653, p=0.001) in migraine patients. Ordinal regression showed an association between increased age and minor stroke with an odds ratio of 0.948 (95% CI, 0.902-0.996), Wald χ2 (1) = 4.449 p=0.034. Conclusion: The minor stroke results are consistent with current literature. The increased cortical thickness in migraine, could possibly be linked to the cortical spreading theory. This finding and the significant positive correlation between pulse pressure and Scheltens score in migraine warrant further investigation

Marine-derived n-3 fatty acids therapy for stroke

We thank the Cochrane Stroke Group, and in particular Hazel Fraser (Managing Editor) and Joshua Cheyne (Trials Search Coordinator and Information Specialist), for their support in the development of this protocol. CG Alvarez Campano is funded by the Mexican Council for Science and Technology (CONACyT) and the Institute of Innovation and Technology Transfer (I²T²) (grant number 457349).Peer reviewedPublisher PD

Brain hyperintensities in magnetic resonance imaging of patients with mild acute focal neurology

Purpose: Hyperintensities are common in neuroimaging scans of patients with mild acute focal neurology. However, their pathogenic role and clinical significance is not well understood. We assessed whether there was an association between hyperintensity score with diagnostic category and clinical assessments/measures. Methods: One hundred patients (51 ± 12 years; 45:55 women:men), with symptomatology suggestive of short duration ischemia referred for magnetic resonance imaging, were prospectively recruited in NHS Grampian between 2012 and 2014. Hyperintensities were quantified, on T2 and FLAIR, using the Scheltens score. Results: The most frequent diagnosis was minor stroke (33%), migraine (25%) and transient ischemic attack (17%). The mean total Scheltens score was 28.49 ± 11.93 with all participants having various loads of hyperintensities. Statistically significant correlations between hyperintensity scores and clinical assessments/measures (age, systolic blood pressure, pulse pressure, MoCA) at the global level were also reflected regionally. These provide further supporting data in terms of the robustness of the Scheltens scale. Conclusion: Hyperintensities could serve as a diagnostic and prognostic imaging biomarker for patients, presenting with mild acute focal neurology, warranting application of automated quantification methods. However, larger cohorts are required to provide a definitive answer especially as this is a heterogenous group of patients

Phase II randomised, placebo-controlled, clinical trial of interleukin-1 receptor antagonist in intracerebral haemorrhage: BLOcking the Cytokine IL-1 in ICH (BLOC-ICH)

PURPOSE: Recombinant human interleukin-1 receptor antagonist (anakinra) is an anti-inflammatory with efficacy in animal models of stroke. We tested the effect of anakinra on perihaematomal oedema in acute intracerebral haemorrhage (ICH) and explored effects on inflammatory markers. METHODS: We conducted a multicentre, randomised, double-blind, placebo-controlled trial in patients with acute, spontaneous, supratentorial ICH between May 2019 and February 2021. Patients were randomised to 100 mg subcutaneous anakinra within 8 h of onset, followed by five, 12-hourly, 100 mg subcutaneous injections, or matched placebo. Primary outcome was oedema extension distance (OED) on a 72 h CT scan. Secondary outcomes included plasma C-reactive protein (CRP) and interleukin-6 (IL-6). FINDINGS: 25 patients (target = 80) were recruited, 14 randomised to anakinra, 11 to placebo. Mean age was 67 and 52% were male. The anakinra group had higher median baseline ICH volume (12.6 ml, interquartile range[IQR]:4.8-17.9) versus placebo (5.5 ml, IQR:2.1-10.9). Adjusting for baseline, 72 h OED was not significantly different between groups (mean difference OED anakinra vs placebo -0.05 cm, 95% confidence interval [CI]: -0.17-0.06, p = 0.336). There was no significant difference in area-under-the-curve to Day 4 for IL-6 and CRP, but a post-hoc analysis demonstrated IL-6 was 56% (95% CI: 2%-80%) lower at Day 2 with anakinra. There were 10 and 2 serious adverse events in anakinra and placebo groups, respectively, none attributed to anakinra. CONCLUSION: We describe feasibility for delivering anakinra in acute ICH and provide preliminary safety data. We lacked power to test for effects on oedema thus further trials will be required

The association of atrial fibrillation and ischaemic stroke in patients on haemodialysis: a competing risk analysis

Background: Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective: The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design: A national record linkage cohort study. Setting: All renal and stroke units in Scotland, UK. Patients: All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements: Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods: Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results: Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations: Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions: The incidence of stroke in HD patients is high. The competing risk of “prestroke” mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes

Prevalence and causes of prescribing errors: the prescribing outcomes for trainee doctors engaged in clinical training (PROTECT) study

Objectives Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing. Method A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors' self-efficacy were established. Results 4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p&#60;0.001), surgical (p = &#60;0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p&#60;0.001), a greater number of prescribed medicines (p&#60;0.001) and the months December and June (p&#60;0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen. Conclusions Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.</p