Blood glucose variability during the first 24 hours and prognosis in acute stroke patients treated with IV thrombolysis

INTRODUCTION: Hyperglycemia in acute ischemic stroke decreases the effectiveness of intravenous tissue plasminogen activator (IV tPA) and increases its hemorrhagic complications. Therefore, optimization of blood glucose (BG) is suggested. But, no consensus is achieved on which of the BG parameters to be used such as admission BG, post-treatment BG, first day maximum and average BG (maxBG and aveBG), or BG variability indices such as the standard deviation of mean BG (SDBG), coefficient of variation of BG (CVBG) and J-index. METHODS: Admission and 24h BG were measured in 145 acute stroke patients (55% female, age: 70±13 yr; NIHSS: 14 ± 6, symptom-to-needle time: 160 ± 58 minutes) treated with IV tPA. BG variability indices were evaluated in 107 patients with serial BG measurement available. RESULTS: AveBG was significantly higher in patients with 3rd month mRS>2 (46.2%), but admission BG, SDBG, CVBG and J-index were not significantly different. An exploratory regression analysis indicated that the connection of aveBG to worse prognosis (β=-0.155, p=0.045) persisted after adjustment for admission NIHSS, age and DM history. No BG parameter predicted symptomatic tPA-associated type-II intracerebral hemorrhage (6.7%), albeit these patients had marginally higher average BG levels (p=0.045). Presence of diabetes, HbA1c, admission BG, average first day BG and variability indices had not modified the beneficial (52%) and dramatic response (28%) to IV tPA. DISCUSSION AND CONCLUSION: Sustained hyperglycemia, not glucose variability, during the first 24 hour predicts poor prognosis in acute stroke patients treated with IV thrombolysis

Lesion Pattern on Magnetic Resonance Imaging and Stroke Etiology in Multi-territorial Infarctions

INTRODUCTION: Presence of ischemic lesions in multiple vascular territories is suggestive of an embolic etiology, which could therefore necessitate a detailed etiologic work-up to uncover the underlying pathology. Lesion patterns on diffusion-weighted imaging (DWI) might be used as a marker of certain stroke etiologies and guide the clinician in prioritizing diagnostic investigations. In this study, we sought to identify the relationship between certain lesion characteristics on DWI and stroke etiologies in a consecutive series of ischemic stroke patients with multi-territorial lesions. METHODS: Patients with acute and subacute ischemic lesions simultaneously present in multiple cerebral arterial territories were retrospectively identified from a departmental database. The distribution, number and size of these lesions, and their association with different stroke etiologies were assessed for all patients. RESULTS: A total of 74 patients were included into the study. Patients with ‘other’ causes of stroke more commonly had lesions distributed in all cerebral arterial territories (p=0.02), ≥10 lesions (p<0. 01) and a heterogeneous pattern composed of multiple small and large lesions (p=0.03) when compared to the remaining patients. In contrast, patients with undetermined/unclassified origin of stroke had lower number of lesions (p<0.01) that were distributed mainly in only two circulations (p=0.04) and were primarily homogenously small in nature (p<0.01). DISCUSSION AND CONCLUSION: Lesion patterns on DWI are significantly associated with certain stroke etiologies in patients with multi-territorial infarctions, and therefore might be used in planning of the diagnostic work-up in such cases

Türkiye’de inme hastalarında atrial fibrilasyonun yönetimi: NöroTek çalışması gerçek hayat verileri

Objective: Atrial fibrillation (AF) is the most common directly preventable cause of ischemic stroke. There is no dependable neurology-based data on the spectrum of stroke caused by AF in Turkiye. Within the scope of NoroTek-Turkiye (TR), hospital-based data on acute stroke patients with AF were collected to contribute to the creation of acute-stroke algorithms.Materials and Methods: On May 10, 2018 (World Stroke Awareness Day), 1,790 patients hospitalized at 87 neurology units in 30 health regions were prospectively evaluated. A total of 929 patients [859 acute ischemic stroke, 70 transient ischemic attack (TIA)] from this study were included in this analysis.Results: The rate of AF in patients hospitalized for ischemic stroke/TIA was 29.8%, of which 65% were known before stroke, 5% were paroxysmal, and 30% were diagnosed after hospital admission. The proportion of patients with AF who received "effective" treatment [international normalization ratio >= 2.0 warfarin or non-vitamin K antagonist oral anticoagulants (NOACs) at a guideline dose] was 25.3%, and, either no medication or only antiplatelet was used in 42.5% of the cases. The low dose rate was 50% in 42 patients who had a stroke while taking NOACs. Anticoagulant was prescribed to the patient at discharge at a rate of 94.6%; low molecular weight or unfractionated heparin was prescribed in 28.1%, warfarin in 32.5%, and NOACs in 31%. The dose was in the low category in 22% of the cases discharged with NOACs, and half of the cases, who received NOACs at admission, were discharged with the same drug.Conclusion: NoroTekTR revealed the high but expected frequency of AF in acute stroke in Turkiye, as well as the aspects that could be improved in the management of secondary prophylaxis. AF is found in approximately one-third of hospitalized acute stroke cases in Turkiye. Effective anticoagulant therapy was not used in three-quarters of acute stroke cases with known AF. In AF, heparin, warfarin, and NOACs are planned at a similar frequency (one-third) within the scope of stroke secondary prophylaxis, and the prescribed NOAC dose is subtherapeutic in a quarter of the cases. Non-medical and medical education appears necessary to prevent stroke caused by AF.Amaç: Atrial fibrilasyon (AF) iskemik inmenin doğrudan önlenebilir en sık nedendir. Ülkemizde AF nedenli inme spektrumuna dair nöroloji kaynaklı geniş ölçekte bir veri bulunmamaktadır. NöroTek-Türkiye (TR) kapsamında akut inme algoritmalarının oluşturulmasına katkı yapması beklenen AF tespit edilen akut inme hastalarına dair hastane verisi toplanmıştır. Gereç ve Yöntem: 10 Mayıs 2018 Dünya İnme Farkındalık Günü’nde 30 sağlık bölgesine yer alan 87 nöroloji biriminde yatmakta olan 1.790 hasta prospektif olarak değerlendirilmiştir. Çalışmada yer alan toplam 929 hasta [859 akut iskemik inme, 70 geçici iskemik atak (GİA)] bu analize dahil edilmiştir. Bulgular: İskemik inme/GİA sebebiyle ile interne edilmiş hastalarda AF oranı %29,8 olup bunların %65’i bilinmekte olan, %5’i paroksismal ve %30’u yeni tanıdır. AF tanısı ile gelen hastalarda “etkin” tedavi [internasyonel normalizasyon oranı ≥2,0 varfarin veya rehber dozunda non-vitamin K antagonist oral antikoagülan (NOAK)] alanların oranı %25,3 olup, %42,5 olguda ya hiç ilaç kullanılmamakta ya da sadece antiplatelet kullanılmaktaydı. Düşük doz kullanım oranı 42 NOAK alırken inme geçirmiş olguda %50 idi. Taburcu edilirken antikoagülan %94,6 (düşük molekül ağırlıklı veya non-fraksiyone heparin %28,1; varfarin %32,5 ve NOAK %31) hastaya reçete edilmişti. NOAK ile taburcu edilen olguların %22’sinde doz düşük kategoride olup gelişte NOAK almakta olan olguların yarısı aynı ilaçla taburcu edilmiştir. Sonuç: NöroTekTR ülkemizde AF’nin akut inmedeki sıklığı yanı sıra sekonder proflaksi perspektifinde yönetiminin geliştirilebilecek yönlerini ortaya koydu. Türkiye’de hastanede yatan akut inme olgularının yaklaşık üçte birinde AF saptanmıştır. AF’si bilinen akut inme olgularının dörtte üçünde etkin antikoagülan tedavi kullanılmamaktaydı. AF’de inme sekonder proflaksisi kapsamında heparin, varfarin ve NOAK planlaması benzer sıklıkta (üçte bir) olup reçete edilen NOAK dozu dörtte bir olguda subterapötiktir. AF’ye bağlı inmenin önlenebilmesi non-medikal ve medikal eğitim gerekli görünmektedir

Reversible hypertensive brainstem encephalopathy coexistent with acute intracerebral hemorrhage

We report two cases of reversible hypertensive brainstem encephalopathy (RHBE) syndrome with other concurrent manifestations of malignant hypertension. RHBE was accompanied by hypertensive putaminal hemorrhage in one case, and by intra-ventricular hemorrhage resulting acute obstructive hydrocephalus along with multiple small acute infarctions in the other. Diffusion-weighted imaging and corresponding apparent diffusion coefficient mapping disclosed increased diffusion suggestive of vasogenic edema centered in the pons. No lesion indicative for posterior reversible encephalopathy syndrome (PRES) was noted in the supratentorial regions. These cases indicate that mechanisms involved in development of RHBE and hypertensive PRES may have some differences, albeit both share main lines. These cases also underline that awareness and knowledge about relatively specific clinic-radiological syndrome caused by RHBE seem to be critical. Acute treatment and early prognostification are just only accurate with such a familiarity

European Stroke Organization and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant 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 not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD

Impact of Cerebral Microbleeds in Stroke Patients with Atrial Fibrillation

OBJECTIVES: Cerebral microbleeds are associated with the risks of ischemic stroke and intracranial hemorrhage, causing clinical dilemmas for antithrombotic treatment decisions. We aimed to evaluate the risks of intracranial hemorrhage and ischemic stroke associated with microbleeds in patients with atrial fibrillation treated with Vitamin K antagonists, direct oral anticoagulants, antiplatelets, and combination therapy (i.e. concurrent oral anticoagulant and antiplatelet) METHODS: We included patients with documented atrial fibrillation from the pooled individual patient data analysis by the Microbleeds International Collaborative Network. Risks of subsequent intracranial hemorrhage and ischemic stroke were compared between patients with and without microbleeds, stratified by antithrombotic use. RESULTS: A total of 7,839 patients were included. The presence of microbleeds was associated with an increased relative risk of intracranial hemorrhage (aHR 2.74, 95% confidence interval 1.76 - 4.26) and ischemic stroke (aHR 1.29, 95% confidence interval 1.04 - 1.59). For the entire cohort, the absolute incidence of ischemic stroke was higher than intracranial hemorrhage regardless of microbleeds burden. However, for the subgroup of patients taking combination of anticoagulant and antiplatelet therapy, the absolute risk of intracranial hemorrhage exceeded that of ischemic stroke in those with 2-4 microbleeds (25 vs 12 per 1,000 patient-years) and ≥11 microbleeds (94 vs 48 per 1,000 patient-years). INTERPRETATION: Patients with atrial fibrillation and high burden of microbleeds receiving combination therapy have a tendency of higher rate of intracranial hemorrhage than ischemic stroke, with potential for net harm. Further studies are needed to help optimize stroke preventive strategies in this high-risk group. This article is protected by copyright. All rights reserved

Transkranial Renkli Doppler Ultrasonografide Sinyal Tespit Edilememesi Beyin Ölümü Klinik Tanısı Dogrulayıcı Bir Bulgu Olabilir: Olgu Sunumu

Scopu

Neurosonology of emboli detection and monitoring

Cerebral embolism is the leading cause of ischemic stroke. Detection of microembolic signals [MES] in cerebral circulation is uniquely attained by several transcranial Doppler techniques, and can not be obtained with any other available imaging modality. Albeit no uniform picture has emerged from the studies, presence and amount of MES can identify a high-risk status in the setting of potential arterial or cardiac sources of cerebral embolism. Real-time MES monitoring during vascular procedures with high cerebral embolism risk seems also promising. The potential of MES detection in improvement of patient care is usually acknowledged, even though several aspects remain yet to be scientifically established. We herein review theory, technique and clinical potential of the neurosonological emboli detection, and try to add to understanding of the journal readership about the recent development on this subjec