An Overview of Antithrombotics in Ischemic Stroke

The use of antithrombotic medications is an important component of ischemic stroke treatment and prevention. This article reviews the evidence for best practices for antithrombotic use in stroke with focused discussion on the specific agents used to treat and prevent stroke

Telehealth Stroke Education For Rural Elderly Virginians

Objective: Stroke is a prevalent condition found in elderly, rural populations. However, stroke education, which can be effective in addressing the risks, is often difficult to provide in these remote regions. The objective of this study is to evaluate the effectiveness of delivering stroke education to elderly individuals through telehealth versus in-person stroke prevention education methods. Materials and Methods: A quasi-experimental nonequivalent control group design was used in this study. A convenience sample of 11 elderly adults (36% men, 64% women) with a mean age of 70 was selected from an Appalachian Program for All Inclusive Care for the Elderly (day care) facility. Subjects completed preintervention surveys, received a 20-min group in-person or telehealth delivered education session, and then completed the postintervention surveys. Results: Satisfaction with delivery method and post-education knowledge was equivalent between the two groups. Knowledge increased in both groups after the educational programs. Likelihood of reducing risk factors showed no differences pre-posttest. However, there were significant improvements in the pre-post likelihood scores of the telehealth group in contrast to the in-person group. Conclusions: This project provided a rural, high-risk population access to telehealth stroke education, thus enabling these individuals to receive education at a distance from experts in the field. The telehealth program was found to be equivalent to in-person stroke education in regards to satisfaction, knowledge, and likelihood of making changes to decrease vascular risk factors. The study demonstrated feasibility in providing effective stroke education through telehealth, thus suggesting an often overlooked route for providing patient education at a distance

Medical complications of aneurysmal subarachnoid hemorrhage: A report of the multicenter, cooperative aneurysm study

OBJECTIVESThis report examines the frequency, type, and prognostic factors of medical (nonneurologic) complications after subarachnoid hemorrhage in a large, prospective study. The influences of contemporary neurosurgical, neurological, and critical care practice on mortality and morbidity rates after aneurysmal subarachnoid hemorrhage are evaluated. DESIGNA study of medical complications observed in the placebo limb of a large, randomized, controlled trial of the calcium antagonist, nicardipine, after subarachnoid hemorrhage. SETTINGPatients were recruited from 50 hospitals in 41 neurosurgical centers in the United States and Canada. PATIENTSA total of 457 patients with subarachnoid hemorrhage, >or=to18 yrs of age, were randomly assigned to the placebo group. All patients arrived at the participating center within 7 days (mean 1.0 +/- 1.8 [SD] days) of rupture of an angiographically documented saccular aneurysm. MEASUREMENTS AND MAIN RESULTSThe frequency rates of symptomatic vasospasm, rebleeding, and total mortality rate after subarachnoid hemorrhage at 3-month followup were 46%, 7%, and 19%, respectively. The frequency of having at least one severe (life-threatening) medical complication was 40%. The proportion of deaths from medical complications was 23%. This value was comparable with the proportion of deaths attributed to the direct effects of the initial hemorrhage (19%), rebleeding (22%), and vasospasm (23%) after aneurysmal rupture. The frequency of life-threatening cardiac arrhythmias was 5%; less ominous rhythm disturbances occurred in 30% of the patients. There was an increased frequency of cardiac arrhythmias on the day of, or day after, aneurysm surgery. Pulmonary edema occurred in 23% of the patients, with a 6% occurrence rate incidence of severe pulmonary edema. There was a wide variation from center to center, with the greatest frequency on days 3 through 7. There was a nonsignificant association of pulmonary edema with the use of hypertensive hypervolemic therapy (p = .10), and a significant association with the timing of surgery (p < .05). Some degree of hepatic dysfunction was noted in 24% of patients, the majority with only mild abnormalities of hepatic enzymes with no clinical accompaniment (4% frequency of severe hepatic dysfunction). Thrombocytopenia occurred in 4% of patients, usually in the setting of sepsis. Renal dysfunction was reported in 7% of the patients, with 15% of that figure deemed to be of life-threatening severity. There was an association (p = .001) with antibiotic therapy. CONCLUSIONSPotentially preventable medical complications after ruptured cerebral aneurysm add to the total mortality rate of patients, and may increase length of hospital stay in the critical care setting. The proportion of deaths after subarachnoid hemorrhage from medical complications equals those deaths from either direct effects, rebleeding, or vasospasm individually. Pulmonary complications are the most common nonneurologic cause of death. Cardiac arrhythmia, although frequent, was not associated with significant mortality. The frequency of cardiac arrhythmia and pulmonary edema increased on the day of, or day after, aneurysm surgery. Renal and hepatic dysfunction, and blood dyscrasias, were also observed, underscoring the need for meticulous monitoring for metabolic and hematologic derangements.(Crit Care Med 1995; 23:1007-1017

A low-cost, tablet-based option for prehospital neurologic assessment

ObjectivesIn this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations.MethodsWe piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval).ResultsWe conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to -0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites.ConclusionsUtilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms