Late Window Imaging Selection for Endovascular Therapy of Large Vessel Occlusion Stroke: An International Survey

Background - Current stroke guidelines recommend advanced imaging (computed tomography [CT] perfusion or magnetic resonance imaging) prior to endovascular therapy (EVT) in patients with late presentation of large vessel occlusion. Adherence to guidelines may be constrained by resources or timely access to imaging. We sought to understand the factors which influence late window imaging selection for EVT candidates with large vessel occlusion. Methods - We conducted an international survey from January to May 2022. The questions aimed to identify advanced imaging and treatment decisions based on access to imaging, time delays, and simulated patient scenarios. Results - There were 3000 invited participants and 1506 respondents, the majority (89.6%) from comprehensive stroke centers in high‐income countries. Neurointerventionalists comprised 31.8% and noninterventionalists 68.2% of respondents. Overall, 70.7% reported routine use of advanced imaging for late EVT selection, and 63.6% reported its usage in every case. There was greater availability of advanced imaging in comprehensive stroke centers versus primary stroke centers (67.0% versus 33.7%; P Conclusion - Current guidelines for imaging late window EVT candidates are inconsistent with imaging decisions by physicians. Most respondents consider an imaging delay of greater than 20 minutes unacceptable. Access to advanced imaging was greater in comprehensive stroke centers and high‐income countries. In the case of limited access most respondents would consider EVT based on CT only

Cerebral venous sinus thrombosis in traumatic brain injury: A systematic review of its complications, effect on mortality, diagnostic and therapeutic management, and follow-up

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.Objective: Cerebral venous sinus thrombosis (CVST) is increasingly being recognized in the setting of traumatic brain injury (TBI), but its effect on TBI patients and its management remains uncertain. Here, we systematically review the currently available evidence on the complications, effect on mortality and the diagnostic and therapeutic management and follow-up of CVST in the setting of TBI. Methods: Key clinical questions were posed and used to define the scope of the review within the following topics of complications; effect on mortality; diagnostics; therapeutics; recanalization and follow-up of CVST in TBI. We searched relevant databases using a structured search strategy. We screened identified records according to eligibility criteria and for information regarding the posed key clinical questions within the defined topics of the review. Results: From 679 identified records, 21 studies met the eligibility criteria and were included, all of which were observational in nature. Data was deemed insufficiently homogenous to perform meta-analysis and was narratively synthesized. Reported rates of venous infarctions ranged between 7 and 38%. One large registry study reported increased in-hospital mortality in CVSP and TBI compared to a control group with TBI alone in adjusted analyses. Another two studies found midline CVST to be associated with increased risk of mortality in adjusted analyses. Direct data to inform the optimum diagnostic and therapeutic management of the condition was limited, but some data on the safety, and effect of anticoagulation treatment of CVST in TBI was identified. Systematic data on recanalization rates to guide follow-up was also limited, and reported complete recanalization rates ranged between 41 and 86%. In the context of the identified data, we discuss the diagnostic and therapeutic management and follow-up of the condition. Conclusion: Currently, the available evidence is insufficient for evidence-based treatment of CVST in the setting of TBI. However, there are clear indications in the presently available literature that CVST in TBI is associated with complications and increased mortality, and this indicates that management options for the condition must be considered. Further studies are needed to confirm the effects of CVST on TBI patients and to provide evidence to support management decisions.publishedVersio

Gamification of the National Institutes of Health Stroke Scale (NIHSS) for simulation training—a feasibility study

Background Training prehospital personnel in identifying patients with acute stroke is key to providing rapid treatment. This study aimed to investigate whether game-based digital simulation training is a feasible alternative to standard in-person simulation training. Methods Second-year paramedic bachelor students at Oslo Metropolitan University in Norway were invited to participate in a study to compare game-based digital simulation (intervention) to standard in-person training (control). For 2 months, students were encouraged to practice the NIHSS, and both groups logged their simulations. Then, they performed a clinical proficiency test, and their results were assessed using a Bland-Altman plot with corresponding 95% limits of agreement (LoA). Results Fifty students participated in the study. Individuals in the game group (n = 23) spent an average (SD) of 42:36 min (36) on gaming and performed 14.4 (13) simulations on average, whereas the control group (n = 27) spent 9:28 min (8) simulating and performed 2.5 (1) simulations. Comparing time variables collected during the intervention period, the mean time for each simulated assessment was significantly shorter in the game group (2:57 min vs. 3:50 min, p = 0.004). In the final clinical proficiency test, the mean difference from the true NIHSS score was 0.64 (LoA: − 1.38 to 2.67) in the game group and 0.69 (LoA: − 1.65 to 3.02) in the control group. Conclusion Game-based digital simulation training is a feasible alternative to standard in-person simulation training to acquire competence in NIHSS assessment. Gamification seemed to give an incentive to simulate considerably more and to perform the assessment faster, with equal accuracy.publishedVersio

Noninvasive intracranial pressure assessment by optic nerve sheath diameter : automated measurements as an alternative to clinician-performed measurements

DATA AVAILABILITY STATEMENT : The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.INTRODUCTION : Optic nerve sheath diameter (ONSD) has shown promise as a noninvasive parameter for estimating intracranial pressure (ICP). In this study, we evaluated a novel automated method of measuring the ONSD in transorbital ultrasound imaging. METHODS : From adult traumatic brain injury (TBI) patients with invasive ICP monitoring, bedside manual ONSD measurements and ultrasound videos of the optic nerve sheath complex were simultaneously acquired. Automatic ONSD measurements were obtained by the processing of the ultrasound videos by a novel software based on a machine learning approach for segmentation of the optic nerve sheath. Agreement between manual and automated measurements, as well as their correlation to invasive ICP, was evaluated. Furthermore, the ability to distinguish dichotomized ICP formanual and automaticmeasurements of ONSD was compared, both for ICP dichotomized at 20 mmHg and at the 50th percentile ( 14 mmHg). Finally, we performed an exploratory subgroup analysis based on the software’s judgment of optic nerve axis alignment to elucidate the reasons for variation in the agreement between automatic and manual measurements. RESULTS : A total of 43 ultrasound examinations were performed on 25 adult patients with TBI, resulting in 86 image sequences covering the right and left eyes. The median pairwise difference between automatically and manually measured ONSD was 0.06mm (IQR −0.44 to 0.38mm; p = 0.80). The manually measured ONSD showed a positive correlation with ICP, while automatically measured ONSD showed a trend toward, but not a statistically significant correlation with ICP. When examining the ability to distinguish dichotomized ICP, manual and automatic measurements performed with similar accuracy both for an ICP cuto at 20 mmHg (manual: AUC 0.74, 95% CI 0.58–0.88; automatic: AUC 0.83, 95% CI 0.66–0.93) and for an ICP cuto at 14 mmHg (manual: AUC 0.70, 95% CI 0.52–0.85; automatic: AUC 0.68, 95% CI 0.48–0.83). In the exploratory subgroup analysis, we found that the agreement between measurements was higher in the subgroup where the automatic software evaluated the optic nerve axis alignment as good as compared to intermediate/poor. CONCLUSION: The novel automatedmethod ofmeasuring theONSD on the ultrasound videos using segmentation of the optic nerve sheath showed a reasonable agreement with manual measurements and performed equally well in distinguishing high and low ICP.The South- Eastern Norway Regional Health Authority.http://www.frontiersin.org/Neurologyam2024SurgerySDG-03:Good heatlh and well-bein

Ambient Temperature and Stroke Occurrence: A Systematic Review and Meta-Analysis

Abstract: Biologically plausible associations exist between climatic conditions and stroke risk, but study results are inconsistent. We aimed to summarize current evidence on ambient temperature and overall stroke occurrence, and by age, sex, and variation of temperature. We performed a systematic literature search across MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and GEOBASE, from inception to 16 October 2015 to identify all population-based observational studies. Where possible, data were pooled for meta-analysis with Odds ratios (OR) and corresponding 95% confidence intervals (CI) by means of the random effects meta-analysis. We included 21 studies with a total of 476,511 patients. The data were varied as indicated by significant heterogeneity across studies for both ischemic stroke (IS) and intracerebral hemorrhage (ICH). Pooled OR (95% CI) in every 1 degree Celsius increase in ambient temperature was significant for ICH 0.97 (0.94–1.00), but not for IS 1.00 (0.99–1.01) and subarachnoid hemorrhage (SAH) 1.00 (0.98–1.01). Meta-analysis was not possible for the pre-specified subgroup analyses by age, sex, and variation of temperature. Change in temperature over the previous 24 h appeared to be more important than absolute temperature in relation to the risk of stroke, especially in relation to the risk of ICH. Older age appeared to increase vulnerability to low temperature for both IS and ICH. To conclude, this review shows that lower mean ambient temperature is significantly associated with the risk of ICH, but not with IS and SAH. Larger temperature changes were associated with higher stroke rates in the elderly

Stroke in women — from evidence to inequalities

Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke — including diabetes mellitus and atrial fibrillation — are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials — despite governmental actions highlighting the need to include both men and women in clinical trials — resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women

Veien inn til sykehus for pasienter innlagt ved mistanke om akutt hjerneslag

Bakgrunn: Hjerneslag er en tidskritisk tilstand, men fremdeles ankommer under halvparten av pasientene sykehus innen fire timer fra symptomdebut. En mulig forklaring på forsinkelsen kan være at første kontakt med helsevesenet er hos legevakten eller fastlegen. Hensikt: Hensikten med denne studien var å kartlegge innleggende instans for pasienter ved mistanke om akutt hjerneslag før de kom til akuttmottaket ved Oslo universitetssykehus OUS på Ullevål. Vi ville også kartlegge hvorvidt innleggelsesinstans kunne korreleres til slagdiagnose ved utskrivelse. Metode: En retrospektiv observasjonsstudie identifiserte alle pasienter der mistanke om hjerneslag var innleggelsesårsaken på akuttmottaket ved Ullevål i 2018. Vi grupperte pasientene etter innleggende instans: ambulanse, legevakt, fastlege eller direkte kontakt. Vi sammenliknet utskrivelsesdiagnoser «hjerneslag» eller «ikke hjerneslag» etter innleggende instans og fordelte på alder ved å bruke kjikvadrattest. Resultat: Totalt 1399 pasienter med mistanke om hjerneslag ble innlagt, hvorav 594 42 prosent) fikk en hjerneslagdiagnose. Medianalderen var 72 år, og 52 prosent var kvinner. Halvparten ble innlagt direkte med ambulanse, en tredel via legevakten og 12 prosent fra fastlegen. Signifikant flere pasienter av de som ble innlagt med ambulanse 51 prosent), fikk hjerneslag som utskrivelsesdiagnose sammenliknet med pasienter som kom via henholdsvis legevakt 29 prosent) eller fastlege 40 prosent) (kjikvadrat p < 0,001. Pasientene som ble innlagt med ambulanse, var signifikant eldre enn pasientene som kom via legevakten 72 år versus 65 år, p < 0,001. Konklusjon: Kun halvparten av pasientene med symptomer på mistenkt hjerneslag ble innlagt med ambulanse. Pasientene som ble innlagt direkte med ambulanse, ble oftere utskrevet med en hjerneslagdiagnose. Vi trenger mer kunnskap om årsakene til at de resterende pasientene kom via fastlegen eller legevakten.publishedVersio