Memory Trajectories Before and After First and Recurrent Strokes

Background and objectivesThe evidence on timing of memory change after first and recurrent strokes is limited and inconsistent. We investigated memory trajectories before and after first and recurrent strokes in eighteen European countries, and tested whether the country-level acute stroke care was associated with memory change after stroke.MethodsData were from the Survey of Health, Ageing and Retirement in Europe (2004–2019). Incident first and recurrent strokes were identified among baseline stroke-free individuals. Within each country, each participant with incident stroke (case group) was matched with a stroke-free individual (control group) using the Propensity Score Matching. We applied multilevel segmented linear regression to quantify acute and accelerated memory changes (measured by the sum score of immediate and delayed word recall tests; 0–20 words) before and after first and recurrent strokes in both groups. Associations between stroke and memory were compared between countries with different levels of acute stroke care indicators.ResultsThe final analytical sample included 35,164 participants who were stroke-free at baseline (≥50 years). 2,362 incident first and 341 recurrent strokes between 2004 and 2019 were identified. In case group, mean acute decreases in memory scores were 0.48 (95% confidence interval: 0.31, 0.65) and 1.14 (95% confidence interval: 0.80, 1.48) words after first and recurrent stroke, respectively, independent of a range of confounders. No such acute decreases were observed in control group after a hypothetical non-stroke onset date. In both groups, memory declined over time but decline rates were similar (-0.07 [95% confidence interval: -0.10, -0.05] versus -0.06 [95% confidence interval: -0.08, -0.05] words per year). The mean acute decreases in memory scores after first and recurrent strokes were smaller in countries with better access to endovascular treatment.DiscussionWe found acute decreases but not accelerated declines in memory after first and recurrent strokes. Improved endovascular therapy might be associated with smaller memory loss after stroke but more evidence based on individual-level data is needed. More effort should be made in early assessment and intensive prevention of stroke among the ageing population, and promoting access to and delivery of acute stroke care among patients with stroke.

CT perfusion: stroke, seizure or both?

An 88-year-old male with a history of hypertension, ischaemic heart disease and Bell’s palsy presented with symptoms and signs of an acute ischaemic stroke. National Institutes of Health Stroke Scale (NIHSS) was 19 at presentation, indicative of potential large vessel occlusion. The initial CT scan revealed evidence of small vessel disease and arterial calcification. As there were no contraindications, he received thrombolytic treatment. CT angiography and CT perfusion imaging were performed in preparation for possible thrombectomy. There was no evidence of a large vessel thrombus, and changes on CT perfusion were suggestive of seizure activity, with relative hyperperfusion on the cerebral hemisphere of interest. Post thrombolysis, his NIHSS was 5. An MR scan revealed evidence of bilateral thalamic infarcts. After a period of rehabilitation, he was discharged home and independently mobile but with cognitive impairment.Acute stroke care increasingly uses multimodal imaging to confirm the clinical diagnosis and help optimise initial emergency management. Such imaging is useful in determining whether the presentation is a vascular event or stroke mimic. Moreover, seizures complicate and mimic acute strokes, which can lead to therapeutic uncertainty. This case highlights the increasingly sophisticated investigation of patients presenting with suspected acute stroke, with the attendant need for accurate interpretation by experienced clinicians.

Early Termination of Acute Stroke Randomized Controlled Trials Published Between 2013 and 2020: A Systematic Review

Background: Termination of a clinical trial before the maximum planned sample size is accrued can occur for multiple valid reasons but has implications for the interpretation of results. We undertook a systematic review of contemporary acute stroke trials to document the prevalence of and reasons for early termination. Methods: We searched MEDLINE for randomized controlled trials of acute stroke therapies published between 2013 and 2020 in 9 major clinical journals. Manuscripts describing the primary results of phase 2 and phase 3 trials of acute stroke care were included. Data on study characteristics and adherence to CONSORT reporting guidelines were abstracted and summarized using descriptive statistics. Where feasible, we compared treatment effect sizes between trials terminated early and those not terminated early. Results: Of 96 randomized controlled trials, 39 (41%) were terminated early, 84 (88%) had a data and safety monitoring board, and 57 (59%) reported a prespecified statistical stopping rule. Among the 39 trials terminated early, 10 were discontinued for benefit, 10 due to logistical issues, 8 for futility, 6 because of newly available evidence, 1 for harm, and 4 for other or a combination of reasons. The median percentage of the maximum planned sample size accrued among trials terminated early was 63% (range, 8%–89%). Only 55% of trials (53 of 96) reported whether interim efficacy analyses were conducted, as recommended by the CONSORT guidelines. When 10 endovascular therapy trials were compared according to early termination status, the effect sizes of trials terminated early for benefit were only modestly larger than those not terminated early. Conclusions: The high prevalence of early termination in combination with the wide variety of reasons underscores the necessity of meticulous trial planning and adherence to methodological and reporting guidelines for early termination. Registration: URL: https://www.crd.york.ac.uk/prospero/ ; Unique identifier: CRD42019128727.

Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions

Purpose of the ReviewTo provide an up-to-date review of the incidence of stroke and large vessel occlusion (LVO) around the globe, as well as the eligibility and access to IV thrombolysis (IVT) and mechanical thrombectomy (MT) worldwide.Recent FindingsRandomized clinical trials have established MT with or without IVT as the usual care for patients with LVO stroke for up to 24 hours from symptom onset. Eligibility for IVT has extended beyond 4.5 hours based on permissible imaging criteria. With these advances in the last 5 years, there has been a notable increase in the population of patients eligible for acute stroke interventions. However, access to acute stroke care and utilization of MT or IVT is lagging in these patients.SummaryStroke is the second leading cause of both disability and death worldwide, with the highest burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about 10%–20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide in 2016. This highlights the large gap among eligible patients and the low utilization rates of these advances across the globe. Multiple global initiatives are underway to investigate interventions to improve systems of care and bridge this gap.

Imaging as a Selection Tool for Thrombectomy in Acute Ischemic Stroke

Large vessel occlusion (LVO) stroke represents a stroke subset associated with the highest morbidity and mortality. Multiple prospective randomized trials have shown that thrombectomy, alone or in conjunction with IV thrombolysis, is highly effective in reestablishing cerebral perfusion and improving clinical outcomes. In unselected patients and especially in patients with poor collaterals, the benefit of reperfusion therapy is exquisitely time sensitive; the earlier thrombectomy is started, the lower the likelihood of disability or death. Understanding both the pathophysiologic underpinnings and the modifying factors of this strong time-to-treatment effect demonstrated in numerous randomized clinical trials is important for implementation of intrahospital workflow measures to maximize time efficiency of thrombectomy. Reducing delays in reperfusion therapy initiation has become a priority in acute stroke care, and therefore a thorough understanding of the main systems-based factors responsible for these delays is critical. Because the time spent evaluating the patient in the emergency department, which typically includes neuroimaging studies performed in scanners remote from the angiography suite, represents the main source of delays in thrombectomy initiation, the direct to angiography (DTA) model has emerged as a means to substantially reduce treatment times and is being instituted at an increasing number of thrombectomy centers across the world. The aim of this report is to introduce DTA as an emerging stroke care paradigm for patients with suspicion of LVO stroke, review results from studies evaluating its feasibility and impact on outcomes, describe current barriers to its more widespread adoption, and propose potential solutions to overcoming these barriers.

P.061 Stroke Care and Neurological Emergency Response Simulation (SCaNERS): Creation and Implementation into a Resident Curriculum

Background: Resident physicians often observe stroke alerts before managing them alone. However, this practice exposes patients to potential harm from trainees’ lack of experience. To address this, we created a acute stroke simulation course. Simulation training offers a low-risk environment for skill acquisition, complimenting the Royal College’s recent transition away from a time-based to competency-based learning curriculum. The purpose of this project was to develop and implement a stroke simulation training program into resident neurology rotations at the University of Saskatchewan. Methods: Six high-fidelity acute stroke simulation cases were developed with the aid of a Simulation Operation Specialist. We identified objectives corresponding to Royal College Entrustable Professional Activities for Adult Neurology encompassing several diagnostic and therapeutic goals of acute stroke care. To increase fidelity, a standardized patient was recruited and trained on how to respond to neurologic exams given a specific stroke syndrome. A standardized debrief was given after each session in a safe, non-judgemental environment. Results: Simulation sessions have been running monthly since March 25, 2021. Conclusions: The creation and implementation of high-fidelity simulation training into a resident curriculum is feasible. Ongoing data is being collected to explore residents’ experiences and knowledge improvement in stroke, and to asses local reductions in treatment delays.

Maintaining stroke care during the COVID-19 pandemic in lower- and middle-income countries: World Stroke Organization Position Statement endorsed by American Stroke Association and American Heart Association

For more than a year, the SARS-CoV-2 pandemic has had a devastating effect on global health. High-, low-, and middle-income countries are struggling to cope with the spread of newer mutant strains of the virus. Delivery of acute stroke care remains a priority despite the pandemic. In order to maintain the time-dependent processes required to optimize delivery of intravenous thrombolysis and endovascular therapy, most countries have reorganized infrastructure to optimize human resources and critical services. Low-and-middle income countries (LMIC) have strained medical resources at baseline and often face challenges in the delivery of stroke systems of care (SSOC). This position statement aims to produce pragmatic recommendations on methods to preserve the existing SSOC during COVID-19 in LMIC and propose best stroke practices that may be low cost but high impact and commonly shared across the world.

Stroke Care in Pakistan

Increasing incidence of stroke and lack of infrastructure in both urban and rural areas needs immediate attention in Pakistan. There is a high proportion of young stroke with poor stroke outcomes. Acute stroke care is scarce in Pakistan due to the small number of neurologists (1 neurologist per 1 million population), few stroke units, and limited availability of alteplase (recombinant tissue plasminogen activator) in the country.