Prehospital Stroke Care. Paramedic Training Needs, and Hospital-Directed Feedback in Lithuania

Background: Emergency medical services (EMS) are the first health care contact for the majority of stroke patients. However, there is a lack of data on the current paramedics’ hospital-directed feedback and training needs across different health care settings. We aimed to evaluate paramedics’ prehospital stroke care knowledge, training needs, and current status of feedback on suspected stroke patients. Methods: We surveyed paramedics from the Vilnius region from September to November 2019 and compared the answers between the city and the district agencies. The questionnaire content included questions on paramedics’ demographic characteristics, prehospital stroke care self-assessment, knowledge on stroke mimics, stroke training needs, and the importance of hospital-directed feedback on suspected stroke patients. Results: A total number of 161 paramedics (or 49.4% of all paramedics from our stroke care network) were surveyed, with more district paramedics rating their prehospital stroke care knowledge as inadequate (44.8% (95% confidence interval (CI) 32.8–57.6) vs. 28.1% (95% CI 20.1–27.8), p = 0.028). In addition, more district paramedics indicated a need for additional stroke training (83.1% (95% CI 71.5–90.5) vs. 69.8% (60.0–78.1), p = 0.043). However, respondents reported being the most confident while dealing with stroke (71.3%, 95% CI 63.8–77.7) compared to other time-critical conditions (p < 0.001). Vertigo (60.8%, 95% CI 53.0–68.0), brain tumors (56.3%, 95% CI 48.5–63.8), and seizures (54.4%, 95% CI 46.7–62.0) were indicated as the most common stroke mimics. Only 6.2% (95% CI 3.4–11.1) of respondents received formal feedback on the outcome of suspected stroke patients brought to the emergency department. Conclusions: A high proportion of paramedics self-perceive having inadequate stroke knowledge and an urgent need for further stroke training. The EMS staff indicate receiving insufficient feedback on suspected stroke patients, even though its usefulness is perceived as paramount.publishersversionPeer reviewe

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

History of vascular cognitive impairment and dementia

Stroke is one of the leading causes of disability and death worldwide. It has become the first disease leading to neurologic referrals to hospital and, while recognized in medicine since antiquity, stroke did not acquire a proper place within neurology until the second part of the 20th century. The main reason for this is that, because it deals with blood vessels and circulation, neurologists themselves did not want to include stroke as a primary disorder of the nervous system. However, this is one of the many reasons the historical development of stroke and cerebrovascular disease is of unique interest; it touches not only on neurology but also on internal medicine, angiology, cardiology, rehabilitation, and psychiatry within the frame of secondary behavioral and personality changes after stroke. For the same reasons, the study of the developments in the field of stroke over time is an excellent mirror of historical developments in medicine in general, encompassing many different domains. It is, thus, rather paradoxical that the last book on the history of stroke was published over thirty years ago (Fields and Lemak’s History of Stroke in 1989). Along with the many new developments in stroke diagnosis, acute management and prevention, a new look at the evolution of stroke concepts over time has become necessary, and this is what the present volume is attempting to accomplish. Since stroke has developed into several different smaller fields, we have organized the book with four editors from different fields who have chosen authors with specific expertise in the corresponding overviewed issues. Our principle goal is to underline how and to follow the paths of these developments over the years. History is not a minor part of medical knowledge. Indeed, history defines what we are and think today and how we will envision and plan the future. This fresh look at history of stroke may also have a significant impact on future advances and research in cerebrovascular disease and stroke

Verbal memory in temporal lobe epilepsy surgery: the link between postictal and post-operative memory

Post-operative memory decline is one of the feared complications of temporal lobe epilepsy surgery. In the current study, we investigate the relation between post-operative memory and postictal memory and the predictive value of postictal testing in temporal lobe epilepsy surgery patients

Syndrome du volet et impact de la cranioplastie sur la récupération neurologique : une étude prospective longitudinale

Le « Syndrome of the Trephined » (SoT) se manifeste par une atteinte neurologique survenant après une craniectomie décompressive (CD). La prévalence du SoT et l’impact de cranioplastie sur la récupération neurologique ne sont pas bien connus. Le but de cette étude prospective longitudinale est (1) de définir la prévalence de SoT et (2) d’évaluer l’impact de la cranioplastie sur la récupération neurologique. Nous avons classé les cas de SoT par 'à priori' lorsque l'aggravation neurologique précédait la cranioplastie et 'à posteriori' lorsqu'une amélioration neurologique se manifestait immédiatement après la cranioplastie. Entre 2012 et 2017, 40 patients consécutifs ont été inclus dans l’étude. Au total, 26/40 (65%) ont développé un SoT : 14/40 (35%) ont manifesté un SoT 'a priori' et 12/40 (30%) 'à posteriori'. La cranioplastie a eu un impact positif sur la récupération neurologique. Elle devrait donc être effectuée dès que possible chez le craniectomisé

Commentary: Prevalence of Alternative Diagnoses and Implications for Management in Idiopathic Normal Pressure Hydrocephalus Patients

Idiopathic normal pressure hydrocephalus (iNPH)–the leading cause of reversible dementia in aging–affects 5.9% of adults older than 80.1 The clinical presentation of iNPH combining gait disorders, impaired cognition (ie, poor executive function and memory), and urinary incontinence is unspecific in aging and frequently found in alternate neurological and non-neurological conditions, such as Parkinson disease or vascular dementia, also called iNPH mimics or iNPH mimickers. In the Geneva Normal Pressure Hydrocephalus cohort, we reported a prevalence of 45.6% of iNPH mimics among a cohort of 125 patients with suspicion of iNPH

Vessels Sing Their ARIAs: The Role of Vascular Amyloid in the Age of Aducanumab

We review the implications of the recently approved aducanumab amyloid-β immunotherapy for treating Alzheimer disease with comorbid cerebral amyloid angiopathy. In clinical trials, amyloid-β immunotherapy has been associated with a high rate of amyloid-related imaging abnormalities, potentially driven by coexisting cerebral amyloid angiopathy. Therefore, immunotherapy’s efficacy in patients may be modified by coexisting cerebrovascular pathology. We discuss the contributions of cerebral amyloid angiopathy on the development of amyloid-related imaging abnormalities and propose strategies to identify cerebral amyloid angiopathy in patients considered for immunotherapy

Cerebral small vessel disease and vascular cognitive impairment: from diagnosis to management

Purpose of review: We present recent developments in the field of small vessel disease (SVD)-related vascular cognitive impairment, including pathological mechanisms, updated diagnostic criteria, cognitive profile, neuroimaging markers and risk factors. We further address available management and therapeutic strategies. Recent findings: Vascular and neurodegenerative pathologies often co-occur and share similar risk factors. The updated consensus criteria aim to standardize vascular cognitive impairment (VCI) diagnosis, relying strongly on cognitive profile and MRI findings. Aggressive blood pressure control and multidomain lifestyle interventions are associated with decreased risk of cognitive impairment, but disease-modifying treatments are still lacking. Recent research has led to a better understanding of mechanisms leading to SVD-related cognitive decline, such as blood-brain barrier dysfunction, reduced cerebrovascular reactivity and impaired perivascular clearance. Summary: SVD is the leading cause of VCI and is associated with substantial morbidity. Tackling cardiovascular risk factors is currently the most effective approach to prevent cognitive decline in the elderly. Advanced imaging techniques provide tools for early diagnosis and may play an important role as surrogate markers for cognitive endpoints in clinical trials. Designing and testing disease-modifying interventions for VCI remains a key priority in healthcare

Déclin cognitif vasculaire et angiopathie amyloïde cérébrale : petits vaisseaux, gros problèmes

Cerebral amyloid angiopathy (CAA) is a common and well-defined small vessel disease characterized by the deposition of amyloid β in the vascular wall. CAA causes devastating outcomes related to intracerebral hemorrhage and cognitive decline in older adults. The shared pathogenic pathway between CAA and Alzheimer's disease, co-occuring frequently in the same subject, has important implications for cognitive outcomes and novel anti-amyloid-β immunotherapies. In this review, we present the epidemiology, pathophysiology, current diagnostic criteria of CAA, and future developments in the field.L’angiopathie amyloïde cérébrale (AAC) est une maladie fréquente des petits vaisseaux, caractérisée par un dépôt de β-amyloïde dans la paroi vasculaire entraînant des hémorragies cérébrales et un déclin cognitif. L’AAC et la maladie d’Alzheimer présentent des caractéristiques physiopathologiques communes et peuvent se retrouver chez un même individu. Cela influence le tableau cognitif et sera à prendre en compte lors de l’utilisation prochaine des nouvelles immunothérapies anti-amyloïde. Dans cet article, nous passons en revue l’épidémiologie, la pathophysiologie, les présentations cliniques ainsi que les critères diagnostiques de l’AAC et discutons des futurs développements dans le domaine

Démence à corps de Lewy : état de l’art et perspectives pour le clinicien

Dementia with Lewy bodies (DLB) is one of the most common causes of dementia, after Alzheimer's disease (AD) and vascular dementia. Its diagnosis remains a challenge for the clinician because of the variety of clinical presentations and comorbidities. The diagnosis is based on clinical criteria such as cognitive fluctuations, visual hallucinations, progressive cognitive impairment, Parkinsonian signs and REM sleep behavioral disorder. Although not specific, biomarkers are helpful for increasing the likelihood of LBD diagnosis and for differentiating LBD from other differential diagnoses such as Parkinson's disease with dementia and Alzheimer's disease. Clinicians should be aware of LBD clinical features and actively look for them in patients with cognitive symptoms, take into consideration the often-associated co-pathologies and to optimize patient's management.La démence à corps de Lewy (DCL) est l’une des démences les plus fréquentes, après la maladie d’Alzheimer (MA) et la démence vasculaire. Son diagnostic est un défi pour le clinicien du fait de la variété des présentations cliniques et des comorbidités. Le diagnostic repose sur des critères cliniques comme des fluctuations cognitives, des hallucinations visuelles, des troubles cognitifs progressifs, des signes parkinsoniens et un trouble comportemental du sommeil paradoxal. L’utilisation des biomarqueurs, bien que non spécifiques, permet d’augmenter la probabilité de diagnostic de la DCL et de la différencier de la maladie de Parkinson avec démence et de la MA. De ce fait, devant tout sujet âgé avec trouble cognitif, une recherche des symptômes de la DCL est à réaliser en considérant aussi les traitements iatrogènes et les copathologies