Predictors and outcomes of neurological deterioration in intracerebral hemorrhage: results from the TICH-2 randomised controlled trial

Neurological deterioration is common after intracerebral hemorrhage (ICH). We aimed to identify the predictors and effects of neurological deterioration and whether tranexamic acid reduced the risk of neurological deterioration. Data from the Tranexamic acid in IntraCerebral Hemorrhage-2 (TICH-2) randomized controlled trial were analyzed. Neurological deterioration was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of ≥ 4 or a decline in Glasgow Coma Scale of ≥ 2. Neurological deterioration was considered to be early if it started ≤ 48 h and late if commenced between 48 h and 7 days after onset. Logistic regression was used to identify predictors and effects of neurological deterioration and the effect of tranexamic acid on neurological deterioration. Of 2325 patients, 735 (31.7%) had neurological deterioration: 590 (80.3%) occurred early and 145 (19.7%) late. Predictors of early neurological deterioration included recruitment from the UK, previous ICH, higher admission systolic blood pressure, higher NIHSS, shorter onset-to-CT time, larger baseline hematoma, intraventricular hemorrhage, subarachnoid extension and antiplatelet therapy. Older age, male sex, higher NIHSS, previous ICH and larger baseline hematoma predicted late neurological deterioration. Neurological deterioration was independently associated with a modified Rankin Scale of > 3 (aOR 4.98, 3.70–6.70; p [less than] 0.001). Tranexamic acid reduced the risk of early (aOR 0.79, 0.63–0.99; p = 0.041) but not late neurological deterioration (aOR 0.76, 0.52–1.11; p = 0.15). Larger hematoma size, intraventricular and subarachnoid extension increased the risk of neurological deterioration. Neurological deterioration increased the risk of death and dependency at day 90. Tranexamic acid reduced the risk of early neurological deterioration and warrants further investigation in ICH

A feasibility and safety study of immediate blood pressure manipulation in acute post-stroke patients

This thesis examines the feasibility and safety of blood pressure (BP) lowering using labetalol or lisinopril, in acute ischaemic or haemorrhagic stroke within the confines of a randomised double-blind placebo-controlled trial.;A systematic review of pressor therapy in acute stroke identified pilot studies which have reported no harmful effects, and no randomised controlled trials. While pressor therapy was not investigated in this study, centres with established rapid admission protocols, availability of urgent computerized tomography and intensive monitoring facilities will be needed for such a study.;Elevated BP following acute stroke is associated with adverse prognosis. Whether BP lowering in this situation is beneficial or harmful is unknown. Active intervention in this study significantly reduced SBP during the first 24 hours and at two weeks, but not DBP, compared to placebo. No significant difference in short-term outcome (death and dependency at 2 weeks), or adverse events (including early neurological deterioration) was seen.;Sublingual lisinopril for dysphagic patients was as effective and well-tolerated as oral lisinopril. This is a novel method of administering anti-hypertensives in acute stroke, which could be administered at first contact with healthcare providers, and does not require intensive monitoring as with intravenous agents like labetalol.;Recruitment to the study was poor, primarily due to inadequate number of centres, fewer patients conforming to eligibility criteria than initially estimated, and delays in hospital admission. Analysis of screening data showed that only a small minority of patients with acute stroke were randomised to one of two stroke-BP studies (<9%). This will limit the applicability of results to the clinical scenario.;A definitive trial of BP lowering in acute stroke with adequate sample size is needed

Incorporating Simulation-Based Education Into Stroke Training.

Simulation-based education (SBE) has become a mainstay in medical education. It is a versatile educational technique that can be applied not only to refine psychomotor skills, but also to develop the care pathways, inter-professional behavior, and clinical decision-making needed for practice as a stroke clinician.Nil

Short-term blood pressure variability in acute stroke: a post hoc analysis of the CHHIPS and COSSACS trial

Short-term blood pressure variability (BPV) may predict outcome in acute stroke. We undertook a post hoc analysis of data from 2 randomized controlled trials to determine the effect of short-term BPV on 2-week outcome

Interventions for Improving Modifiable Risk Factor Control in the Secondary Prevention of Stroke.

People with stroke or transient ischemic attack are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximize the adoption of evidence-based strategies for secondary stroke prevention. This review assessed the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control. These included systolic and diastolic blood pressure, body mass index, HbA1c, lipid profile, medication adherence, and cardiovascular events

Measurement of cerebral blood flow responses to the thigh cuff maneuver: a comparison of TCD with a novel MRI method

Cerebral autoregulation (CA) describes the mechanism responsible for maintaining cerebral blood flow (CBF) relatively constant, despite changes in mean arterial blood pressure (ABP). This paper introduces a novel method for assessing CA using magnetic resonance imaging (MRI). Images are rapidly and repeatedly acquired using a gradient-echo echo-planar imaging pulse sequence for a period of 4 minutes, during which a transient decrease in ABP is induced by rapid release of bilateral thigh cuffs. The method was validated by comparing the observed MRI signal intensity change with the CBF velocity change in the middle cerebral arteries, as measured by transcranial Doppler (TCD) ultrasound, using a standardized thigh cuff maneuver in both cases. Cross-correlation analysis of the response profiles from the left and right hemispheres showed a greater consistency for MRI measures than for TCD, both for interhemisphere comparisons and for repeated measures. The new MRI method may provide opportunities for assessing regional autoregulatory changes following acute stroke, and in other conditions in which poor autoregulation is implicated

Pathophysiological and clinical considerations in the perioperative care of patients with a previous ischaemic stroke: a multidisciplinary narrative review.

With an ageing population and increasing incidence of cerebrovascular disease, an increasing number of patients presenting for routine and emergency surgery have a prior history of stroke. This presents a challenge for pre-, intra-, and postoperative management as the neurological risk is considerably higher. Evidence is lacking around anaesthetic practice for patients with vascular neurological vulnerability. Through understanding the pathophysiological changes that occur after stroke, insight into the susceptibilities of the cerebral vasculature to intrinsic and extrinsic factors can be developed. Increasing understanding of post-stroke systemic and cerebral haemodynamics has provided improved outcomes from stroke and more robust secondary prevention, although this knowledge has yet to be applied to our delivery of anaesthesia in those with prior stroke. This review describes the key pathophysiological and clinical considerations that inform clinicians providing perioperative care for patients with a prior diagnosis of stroke

Is dynamic cerebral autoregulation measurement using transcranial Doppler ultrasound reproducible in the presence of high concentration oxygen and carbon dioxide?

Reliability of cerebral blood flow velocity (CBFV) and dynamic cerebral autoregulation estimates (expressed as autoregulation index: ARI) using spontaneous fluctuations in blood pressure (BP) has been demonstrated. However, reliability during co-administration of O2 and CO2 is unknown. Bilateral CBFV (using transcranial Doppler), BP and RR interval recordings were performed in healthy volunteers (seven males, four females, age: 54  ±  10 years) on two occasions over 9  ±  4 d. Four 5 min recordings were made whilst breathing air (A), then 5%CO2 (C), 80%O2 (O) and mixed O2  +  CO2 (M), in random order. CBFV was recorded; ARI was calculated using transfer function analysis. Precision was quantified as within-visit standard error of measurement (SEM) and the coefficient of variation (CV). CBFV and ARI estimates with A (SEM: 3.85 & 0.87; CV: 7.5% & 17.8%, respectively) were comparable to a previous reproducibility study. The SEM and CV with C and O were similar, though higher values were noted with M; Bland-Altman plots indicated no significant bias across all gases for CBFV and ARI (bias  <0.06 cm s(-1) and  <0.05, respectively). Thus, transcranial-Doppler-ultrasound-estimated CBFV and ARI during inhalation of O2 and CO2 have acceptable levels of reproducibility and can be used to study the effect of these gases on cerebral haemodynamics