23 research outputs found
European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.Peer reviewe
An Online Training Intervention on Prehospital Stroke Codes in Catalonia to Improve the Knowledge, Pre-Notification Compliance and Time Performance of Emergency Medical Services Professionals
Strokes are a time-dependent medical emergency. The training of emergency medical service (EMS) professionals is essential to ensure the activation of stroke codes with pre-notification, as well as a rapid transfer to achieve early therapy. New assessment scales for the detection of patients with suspected large vessel occlusion ensures earlier access to endovascular therapy. The aim of this study was to evaluate the impact on an online training intervention focused on the Rapid Arterial oCclusion Evaluation (RACE) scoring of EMS professionals based on the prehospital stroke code in Catalonia from 2014 to 2018 in a pre-post intervention study. All Catalonian EMS professionals and the clinical records from primary stroke patients were included. The Kirkpatrick model guided the evaluation of the intervention. Data were collected on the knowledge on stroke recognition and management, pre-notification compliance, activated stroke codes and time performance of EMS professionals. Knowledge improved significatively in most items and across all categories, reaching a global achievement of 82%. Pre-notification compliance also improved significantly and remained high in the long-term. Increasingly higher notification of RACE scores were recorded from 60% at baseline to 96.3% in 2018, and increased on-site clinical care time and global time were also observed. Therefore, the online training intervention was effective for increasing EMS professionals' knowledge and pre-notification compliance upon stroke code activation, and the wide adoption of a new prehospital scale for the assessment of stroke severity (i.e., the RACE scale) was achieved
The human Tp53 Arg72Pro polymorphism explains different functional prognosis in stroke
Poor prognosis after ischemic stroke or intracerebral hemorrhage is linked to a particular polymorphism in the human gene encoding p53
REPORTAJE CARMELO ARTILES BOLAÑOS. OBRAS EN TAFIRA U.L.P.G.C. [Material gráfico]
Copia digital. Madrid : Ministerio de Educación, Cultura y Deporte, 201
European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion
Six randomized controlled clinical trials have assessed whether
mechanical thrombectomy (MT) alone is non-inferior to intravenous
thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients
with anterior circulation large vessel occlusion (LVO) ischemic stroke
and no contraindication to IVT. An expedited recommendation process was
initiated by the European Stroke Organisation (ESO) and conducted with
the European Society of Minimally Invasive Neurological Therapy (ESMINT)
according to ESO standard operating procedure based on the GRADE system.
We identified two relevant Population, Intervention, Comparator, Outcome
(PICO) questions, performed systematic reviews and meta-analyses of the
literature, assessed the quality of the available evidence, and wrote
evidence-based recommendations. Expert opinion was provided if
insufficient evidence was available to provide recommendations based on
the GRADE approach. For stroke patients with anterior circulation LVO
directly admitted to a MT-capable center ('mothership') within 4.5 hours
of symptom onset and eligible for both treatments, we recommend IVT plus
MT over MT alone (moderate evidence, strong recommendation). MT should
not prevent the initiation of IVT, nor should IVT delay MT. In stroke
patients with anterior circulation LVO admitted to a center without MT
facilities and eligible for IVT <= 4.5 hours and MT, we recommend IVT
followed by rapid transfer to a MT capable-center ('drip-and-ship') in
preference to omitting IVT (low evidence, strong recommendation). Expert
consensus statements on ischemic stroke on awakening from sleep are also
provided. Patients with anterior circulation LVO stroke should receive
IVT in addition to MT if they have no contraindications to either
treatment
Prognostic Accuracy of N20 Somatosensory Potential in Patients With Acute Ischemic Stroke and Endovascular Thrombectomy
Background Somatosensory evoked potentials may add substantial prognostic value in patients with acute ischemic stroke and contribute to the selection of patients who may benefit from revascularization therapies beyond the accepted therapeutic time windows. We aimed to study the prognostic accuracy of the N20 somatosensory evoked potential component of the ischemic hemisphere in patients with anterior large‐vessel occlusion undergoing endovascular thrombectomy (EVT). Methods Presence and amplitude of the N20 response were recorded before and after EVT. Its adjusted predictive value for functional independence (modified Rankin scale score, ≤2) at day 7 was analyzed by binary logistic regression adjusting by age, mean arterial blood pressure, National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, and serum glucose. N20 predictive power was compared with that of clinical and imaging models by using receiver operating characteristics curve analysis. Results A total of 223 consecutive patients were studied (mean age, 70 years; median National Institute of Health Stroke Scale score, 18). Somatosensory evoked potential recordings identified the presence of N20 in 110 (49.3%), absence in 58 (26%), and not assessable in 55 patients due to radiofrequency interferences in the angiography room. Before EVT, N20 predicted functional independence with a sensitivity of 93% (95% CI, 78%–98%) and negative predictive value of 93% (95% CI, 80%–98%). The adjusted odds ratio for functional independence was 9.9 (95% CI, 3.1–44.6). In receiver operating characteristics curve analysis, N20 amplitude showed a higher area under the curve than prehospital or in‐hospital variables, including advanced imaging. Sensitivity increased to 100% (95% CI, 0.85–1) when N20 was present after EVT. Conclusion Somatosensory evoked potential monitoring is a noninvasive and bedside technique that could help eligibility of patients with acute ischemic stroke for EVT and predict functional recovery
European Stroke Organisation - European Society for Minimally Invasive Neurological Therapy expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion
Six randomized controlled clinical trials have assessed whether
mechanical thrombectomy (MT) alone is non-inferior to intravenous
thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients
with anterior circulation large vessel occlusion (LVO) ischaemic stroke
and no contraindication to IVT. An expedited recommendation process was
initiated by the European Stroke Organisation (ESO) and conducted with
the European Society of Minimally Invasive Neurological Therapy (ESMINT)
according to ESO standard operating procedure based on the GRADE system.
We identified two relevant Population, Intervention, Comparator, Outcome
(PICO) questions, performed systematic reviews and meta-analyses of the
literature, assessed the quality of the available evidence and wrote
evidence-based recommendations. Expert opinion was provided if
insufficient evidence was available to provide recommendations based on
the GRADE approach. For stroke patients with anterior circulation LVO
directly admitted to a MT-capable centre ('mothership') within 4.5 hours
of symptom onset and eligible for both treatments, we recommend IVT plus
MT over MT alone (moderate evidence, strong recommendation). MT should
not prevent the initiation of IVT, nor should IVT delay MT. In stroke
patients with anterior circulation LVO admitted to a centre without MT
facilities and eligible for IVT <= 4.5 hrs and MT, we recommend IVT
followed by rapid transfer to a MT capable-centre ('drip-and-ship') in
preference to omitting IVT (low evidence, strong recommendation). Expert
consensus statements on ischaemic stroke on awakening from sleep are
also provided. Patients with anterior circulation LVO stroke should
receive IVT in addition to MT if they have no contraindications to
either treatment
Door‐In–Door‐Out Time Effect on Clinical Outcome According to Reperfusion Time in Endovascular Treatment
Background Door‐in–door‐out time (DIDO) in nonthrombectomy stroke centers is a key performance indicator in acute stroke care. Nonetheless, the relative importance of DIDO on outcome in patients transferred for endovascular treatment (EVT) is not widely known. Therefore, we aim to explore the association between DIDO and clinical outcome according to onset to reperfusion time in patients undergoing EVT. Methods Observational multicenter study including patients transferred to a thrombectomy‐capable center from a local stroke center who underwent thrombectomy. The primary outcome was favorable clinical outcome, as evaluated by a modified Rankin Scale score of 0 to 2 at 3 months. We evaluated the association between DIDO and clinical outcome according to onset to reperfusion time and factors related to shorter DIDO time. Results Among 2710 patients transferred for thrombectomy evaluation, 970 (43.8%) patients received EVT. Median baseline National Institutes of Health Stroke Scale and DIDO time were 12 (interquartile range [IQR], 6–19) and 83 minutes (IQR, 66–108), respectively. Among patients undergoing EVT, no association was found between DIDO and clinical outcome. Considering only patients treated in the early time window (onset to reperfusion time ≤240 minutes), patients with favorable outcome had a shorter DIDO (60 [IQR, 52–68] versus 73 [IQR, 61–83] minutes; P=0.013). A receiver operating characteristic curve identified a cutoff of 67 minutes of DIDO time that better predicted favorable outcome (sensitivity, 70%; specificity, 73%; area under the curve, 0.741). A multivariate analysis showed that DIDO ≤67 minutes emerged as an independent factor associated with favorable outcome (odds ratio [OR], 5.29 [95% CI, 1.38–20.27]; P=0.015). Door to computed tomography time was the only factor associated with DIDO ≤67 minutes (OR, 1.113 [95% CI, 1.018–1.261]; P=0.022) in a multivariate analysis in this time frame. Conclusions In transferred patients undergoing EVT, DIDO has a significant impact on clinical outcome, mainly in the first hours from stroke onset. A benchmark of 67 minutes in DIDO time is proposed. Shorter door to computed tomography time appears to be an independent factor associated to achieve DIDO time ≤67 minutes. Measures to optimize workflow into referral centers are warranted
Treatment of multisystem inflammatory syndrome in children
BACKGROUND: Evidence is urgently needed to support treatment decisions for children with multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2.METHODS: We performed an international observational cohort study of clinical and outcome data regarding suspected MIS-C that had been uploaded by physicians onto a Web-based database. We used inverse-probability weighting and generalized linear models to evaluate intravenous immune globulin (IVIG) as a reference, as compared with IVIG plus glucocorticoids and glucocorticoids alone. There were two primary outcomes: the first was a composite of inotropic support or mechanical ventilation by day 2 or later or death; the second was a reduction in disease severity on an ordinal scale by day 2. Secondary outcomes included treatment escalation and the time until a reduction in organ failure and inflammation.RESULTS: Data were available regarding the course of treatment for 614 children from 32 countries from June 2020 through February 2021; 490 met the World Health Organization criteria for MIS-C. Of the 614 children with suspected MIS-C, 246 received primary treatment with IVIG alone, 208 with IVIG plus glucocorticoids, and 99 with glucocorticoids alone; 22 children received other treatment combinations, including biologic agents, and 39 received no immunomodulatory therapy. Receipt of inotropic or ventilatory support or death occurred in 56 patients who received IVIG plus glucocorticoids (adjusted odds ratio for the comparison with IVIG alone, 0.77; 95% confidence interval [CI], 0.33 to 1.82) and in 17 patients who received glucocorticoids alone (adjusted odds ratio, 0.54; 95% CI, 0.22 to 1.33). The adjusted odds ratios for a reduction in disease severity were similar in the two groups, as compared with IVIG alone (0.90 for IVIG plus glucocorticoids and 0.93 for glucocorticoids alone). The time until a reduction in disease severity was similar in the three groups.CONCLUSIONS: We found no evidence that recovery from MIS-C differed after primary treatment with IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone, although significant differences may emerge as more data accrue. (Funded by the European Union's Horizon 2020 Program and others; BATS ISRCTN number, ISRCTN69546370.).</p