O’Carroll, Cumara B.

Background: Telestroke can provide indispensable expert stroke care for rural hospitals. The Stroke Telemedicine for Arizona Rural Residents program was developed in 2006 by Mayo Clinic to provide stroke expertise across the region. However, little data currently exist to determine whether this telestroke program had an impact on accepted acute stroke care metrics, such as door-to-needle time. Hypothesis: Participation of spoke sites in a telestroke program improves stroke care over time, as defined by currently accepted metrics, such as door-to-needle time. Methods: A retrospective analysis was performed on the telestroke database from Mayo Clinic Arizona between the years of 2011 to 2018. All patients with a diagnosis of acute ischemic stroke, who underwent a telestroke consultation and received intravenous alteplase were included in the analysis. Univariate linear regression was performed to look for associations between variables and defined outcomes. Results: A total of 563 patients were identified who met inclusion criteria. Average last-known normal to needle times decreased across all telestroke participating spoke sites from 176 to 147 min, with univariate linear regression showing a trend of decreased time of 3.4 min per year, which was statistically significant (p = 0.0042). Average door-to-needle times decreased from 112 to 81 min, with univariate linear regression modeling showing a decreasing trend of 3.7 min per year (p < 0.0001). Conclusions: Telestroke network participation may be associated with improved acute stroke care metrics over time, with the analysis illustrating improved last-known normal to needle and door-to-needle times among participating spoke sites.

Alternating electrical fields can disrupt mitosis leading to apoptosis of rapidly dividing cancer cells. The device that utilizes this mechanism is known as tumor-treating fields (TTFields). TTFields can be applied by ceramic transducer arrays on a shaved scalp to deliver the alternating electric activity to patients with glioblastoma (GBM). It has FDA approval for use in both recurrent and newly diagnosed GBM. The objective is to critically appraise the current evidence for the use of TTFields as adjunctive treatment to newly diagnosed GBM. The objective was addressed through the development of a structured, critically appraised topic. We incorporated a clinical scenario, background information, a structured question, literature search strategy, evidence summary, clinical bottom lines, and expert discussion. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of neurooncology. A randomized controlled trial was selected for critical appraisal. Patients with newly diagnosed GBM completing standard radiation and chemotherapy with temozolomide (TMZ) were subsequently randomized to receive maintenance TMZ with TTFields, or TMZ alone. With the addition of TTFields, median progression-free survival was 6.7 months compared with 4 months without the addition of TTFields (95% confidence interval, 0.52-0.76; P<0.001) and overall survival was 20.9 months compared with 16.0 months without the addition of TTFields (95% confidence interval, 0.53-0.76; P<0.001). TTFields may increase both progression-free and overall survival in patients receiving standard chemoradiation therapy for GBM.

Background: Telestroke care has become a vital feature of expert stroke care for rural hospitals in recent years. The Telemedicine for Arizona Rural Residents (STARR) program was developed in 2006 by the Mayo Clinic in Arizona in order to provide stroke expertise across the region. However, little data currently exists to determine efficacy of telestroke programs on accepted stroke care metrics, such as door-to-needle times. Hypothesis: Participation of spoke sites in a telestroke program improves stroke care over time, as defined by currently-accepted metrics, such as door-to-needle time. Methods: A retrospective analysis was performed on the telestroke database from Mayo Clinic, Arizona, between the years of 2011 to 2018. Patients who received IV-tPA for an acute ischemic stroke were included in the analysis. Patients who did not have radiographic or clinical symptoms of an acute ischemic stroke, as well as those who did not receive IV-tPA, were excluded from the analysis. Univariate linear regression was performed to look for associations between variables and defined outcomes. Results: 565 patients were identified who received IV-tPA via telestroke consultation and met inclusion criteria between 2011 to 2018. Average last known normal (LKN) to needle time decreased across all sites from 176 minutes in 2011 to 147 minutes in 2018, with univariate linear regression showing a trend of decreased time averaging 3 minutes per year, which was statistically significant (p = 0.0084). Average door-to-needle times decreased from 112 minutes in 2011 to 81 minutes in 2018, with univariate linear regression modeling showing a decreasing trend of 3.5 minutes on average per year (p < 0.001). Conclusions: Telestroke participation may be associated with improved stroke care metrics over time, with our analysis illustrating improved LKN-to-needle and door-to-needle times among participating spoke sites.

Background: The risk of developing intracerebral hemorrhage (ICH) after the administration of intravenous tissue plasminogen activator for acute ischemic stroke is well established in the general population. However, the risk associated with stroke thrombolysis in patients with a history of cerebral microbleeds (CMBs) is undetermined. Objective: The main objective of this study was to critically assess current evidence with regard to the risk of development of ICH after the administration of intravenous tissue plasminogen activator for acute ischemic stroke in patients with CMBs. Methods: The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular and hospital neurology. Results: A recent individual patient data meta-analysis was selected for critical appraisal. Cohorts were analyzed with pretreatment magnetic resonance imaging to determine CMB burden and were followed-up to assess subsequent symptomatic ICH, hemorrhagic transformation, parenchymal hemorrhage (PH), and remote PH (PHr) following intravenous thrombolysis. Risk of symptomatic ICH, PH, and PHr was increased in the presence of CMBs, with PHr having the strongest association with increasing CMB burden. Only patients with >10 CMBs were found to have associations with poor outcome at 3 to 6 months, whereas there was no association with 3 to 6 months’ mortality. Conclusions: CMBs are associated with an increased risk of postthrombolysis ICH; however, the clinical implications have yet to be determined.

Mechanical thrombectomy (MT) is the standard of care for patients who present with an acute ischemic stroke within 6 hours of symptom onset, and up to 24 hours in appropriately selected patients. However, optimal postoperative management of these patients remains uncertain, especially with regard to blood pressure control. To review the existing literature to define potential blood pressure goals in the immediate postoperative period in patients who undergo MT for acute ischemic stroke. The topic was defined through a clinical scenario and the subsequent development of a targeted clinical question. A literature search was performed, with relevant articles selected, one of which, a prospective observational study, was critically appraised. Participants included neurology residents and consultants, a medical librarian, clinical epidemiologists, as well as content experts from vascular neurology and interventional neuroradiology. Permissive hypertension (defined as <220/120 or <180/105 mm Hg as per the American Heart Association/American Stroke Association guidelines) may be harmful in the postoperative period following MT, especially in patients who were successfully recanalized. Moderate blood pressure control (<160/90) was found to be a predictor of improved 3-month mortality on multivariable logistic regression analysis in patients who sustained successful reperfusion [odds ratio (OR), 0.08; 95% confidence interval (CI), 0.01-0.054; P=0.01]. A 10 mm Hg increase in systolic blood pressure was found to result in a lower OR of having a favorable 3-month functional independence (OR, 0.70; 95% CI, 0.56-0.85; P=0.001) as well as higher rates of 3-month mortality (OR, 1.49; 95% CI, 1.18-1.88; P=0.001). Blood pressure goals in the immediate postoperative period in patients who undergo MT should differ than those who do not undergo MT, with data suggesting that lower blood pressure than permissive hypertension may be related to improved outcomes, especially in cases of successful reperfusion. However, current data are derived from observational studies; further studies, preferably in the form of randomized-controlled trials, are needed to further clarify the relationship between postoperative blood pressures and outcomes in this patient population.

Introduction: Takayasu arteritis is a large-vessel vasculitis that may cause oculo-cerebral ischemia. We report a patient with visual loss as initial manifestation, and discuss transcranial Doppler (TCD) findings before and after surgical revascularization. Case Description: A 19-year-old female developed episodes of transient positional right vision loss, progressing to permanent right vision loss and bright light-induced left amaurosis. Examination demonstrated subclavian bruits, palpable epigastrium aortic pulsation, faint radial pulses, right retinal pallor, arteriolar narrowing, and bilateral boxcarring. Head and neck computed tomography angiogram demonstrated left subclavian origin and right common carotid artery occlusion, and severe innominate and left common carotid artery stenosis. TCD demonstrated right ophthalmic artery flow reversal and nonpulsatile waveforms with dampened spectra in the right anterior circulation. Corticosteroids, methotrexate, infliximab, and dual-antiplatelet therapy were initiated. Eleven weeks later, the patient underwent ascending aortic aneurysm repair and bilateral carotid artery bypass with an aortic graft. Pathology was consistent with chronic active Takayasu arteritis. Two weeks postoperatively, left eye visual symptoms resolved; right visual loss persisted. Postoperative TCD showed marked improvement in cerebral perfusion. Conclusions: Retinal ischemia in young women should prompt emergent inflammatory and systemic vascular evaluation. In our subject, prolonged right retinal ischemia had dismal prognosis despite carotid-aortic revascularization, whereas left retinal boxcarring reversed. Surgical revascularization is recommended for severely symptomatic oculo-cerebrovascular disease, once inflammation is better controlled with immunosuppressive therapy. TCD documented the presence and monitored the subsequent resolution of blood flow changes causing retinal and brain hypoxia.

Background and Purpose— Rates of intracerebral hemorrhage (ICH) are estimated to be highest globally in sub-Saharan Africa. However, outcomes of ICH are poorly described and standard prognostic markers for ICH have not been validated in the region. Methods— We enrolled consecutive patients with computed tomography-confirmed ICH at a referral hospital in southwestern Uganda. We recorded demographic, clinical, and radiographic features of ICH, and calculated ICH scores. We fit Poisson regression models with robust variance estimation to determine predictors of case fatality at 30 days. Results— We enrolled 73 individuals presenting with computed tomography-confirmed ICH (mean age 60 years, 45% [33/73] female, and 14% [10/73] HIV-positive). The median ICH score was 2 (interquartile range, 1–3; range, 0–5). Case fatality at 30 days was 44% (32/73; 95% CI, 33%–57%). The 30-day case fatality increased with increasing ICH score of 0, 1, and 5 from 17%, 23%, to 100%, respectively. In multivariable-adjusted models, ICH score was associated with case fatality (adjusted relative risk, 1.48; 95% CI, 1.23–1.78), as were HIV infection (adjusted relative risk, 1.92; 95% CI, 1.07–3.43) and female sex (adjusted relative risk, 2.17; 95% CI, 1.32–3.59). The ICH score moderately improved with the addition of a point each for female sex and HIV serostatus (0.81 versus 0.73). Conclusions— ICH score at admission is a strong prognostic indicator of 30-day case fatality in Uganda. Our results support its role in guiding the care of patients presenting with ICH in the region.