RESUMEN
The Quality in Acute Stroke (QASC) trial demonstrated a significant reduction in death and disability when clinicians were assisted to introduce protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following stroke. We describe a unique international collaboration between the Nursing Research Institute at Australian Catholic University; the European Stroke Organisation; and the Angels Initiative, working collaboratively to support implementation of the nurse-led FeSS Protocols in 20 European countries. We currently have 71 hospitals from 16 countries participating (hospitals from four countries are in the preparation phase) with 49 hospitals currently entering data (n=2819 patients to-date). Baseline data have been received from 39 hospitals, with FeSS Protocol implementation commenced at 16 hospitals. Five hospitals have completed the Project. 'Upscale and spread' of these evidence-based, nursing protocols into countries with vastly different healthcare systems, many of whom also have no access to the latest stroke therapies, is likely to make a significant impact in reducing death and disability after stroke.
Asunto(s)
Trastornos de Deglución , Accidente Cerebrovascular , Australia , Trastornos de Deglución/etiología , Europa (Continente) , Humanos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/terapia , AzúcaresRESUMEN
BACKGROUND AND PURPOSE: Chronic hemodynamic impairment in high-grade carotid occlusive disease is thought to cause microstructural abnormalities that might be subclinical or lead to subtle symptoms including cognitive impairment. Quantitative MR imaging allows assessing pathologic structural changes beyond macroscopically visible tissue damage. In this study, high-resolution quantitative T2 mapping combined with DSC-based PWI was used to investigate quantitative T2 changes as a potential marker of microstructural damage in relation to hemodynamic impairment in patients with unilateral high-grade carotid occlusive disease. MATERIALS AND METHODS: Eighteen patients with unilateral high-grade ICA or MCA stenosis/occlusion were included in the study. T2 values and deconvolved perfusion parameters, including relative CBF, relative CBV, and the relative CBF/relative CBV ratio as a potential indicator of local cerebral perfusion pressure, were determined within areas with delayed TTP and compared with values from contralateral unaffected areas after segmentation of normal-appearing hypoperfused WM and cortical regions. Hemispheric asymmetry indices were calculated for all parameters. RESULTS: Quantitative T2 was significantly prolonged (P < .01) in hypoperfused tissue and correlated significantly (P < .01) with TTP delay and relative CBF/relative CBV reduction in WM. Significant correlations (P < .001) between TTP delay and the relative CBF/relative CBV ratio were found both in WM and in cortical areas. CONCLUSIONS: Quantitative T2 can be used as a marker of microstructural tissue damage even in normal-appearing GM and WM within a vascular territory affected by high-grade carotid occlusive disease. Furthermore, the extent of damage correlates with the degree of hemodynamic failure measured by DSC perfusion parameters.
Asunto(s)
Encéfalo/diagnóstico por imagen , Encéfalo/patología , Estenosis Carotídea/complicaciones , Hemodinámica/fisiología , Imagen por Resonancia Magnética/métodos , Adulto , Anciano , Encéfalo/irrigación sanguínea , Circulación Cerebrovascular/fisiología , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
In recent years a considerable number of translational research studies on intracerebral hemorrhage and ischemic stroke have been published, which are characterized by a particular proximity to practical clinical questions. Animal research has provided insights into the pathophysiological processes and therapy effects, which have so far only been insufficiently investigated in clinical studies. This includes the effectiveness of a rapid reversal of anticoagulation in cases of anticoagulation-associated intracerebral hemorrhage and the safety of thrombolytic treatment in ischemic stroke occurring during treatment with anticoagulants. With the approval of the direct oral anticoagulants these problems have become of particular contemporary relevance. Of course, results from experimental translational studies on stroke cannot be directly translated into clinical routine. Nevertheless, these investigations help to understand the underlying processes and mechanisms and provide proof of concept data for new treatment strategies. This review summarizes the most relevant results in this field of research with a particular focus on practical clinical questions.
Asunto(s)
Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Hemorragia Cerebral/inducido químicamente , Hemorragia Cerebral/fisiopatología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/fisiopatología , Investigación Biomédica Traslacional/tendencias , Animales , Hemorragia Cerebral/prevención & control , Medicina Basada en la Evidencia , Humanos , Modelos Cardiovasculares , Resultado del TratamientoRESUMEN
BACKGROUND: Time is of critical importance in acute stroke management. The establishment of thrombectomy now adds to the complexity and interdisciplinarity of the initial phase. In non-medical high-fidelity situations, such as aviation, crew resource management (CRM) has proven to be highly efficient. It has therefore also been implemented in professional cardiovascular life support training. In a setting where every minute counts, CRM and regular training of the high-fidelity stroke team could offer ways to improve treatment of acute stroke patients. OBJECTIVES: We evaluated the effects of a CRM-based stroke team with regular simulation training on the quality of care (e.g. door to needle time and thrombolysis rate) as well as on staff satisfaction and perceived patient safety in the emergency department of a tertiary care neurocenter. MATERIAL AND METHODS: We implemented a dedicated stroke team consisting of 7 persons who are notified by a collective call via speed dial and conceived a simulator-based team training for all new stroke team members which we conduct at monthly intervals. We recorded door to needle times of all consecutive patients, staff satisfaction in the emergency room and the acceptance of this new learning format. RESULTS: This approach led to a relevant and sustained reduction of the mean door to needle time to less than 30 min. It improved perceived patient safety in residents with professional experience of less than 2 years. There was a very high acceptance within the stroke team training and staff and its usefulness was judged to be very high. CONCLUSION: Even though our data do not allow positive effects on patient outcomes to be inferred, the implementation of a CRM-based stroke team and simulator training has had multiple positive effects on the workflow and work satisfaction in the treatment of acute stroke patients.
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Servicios Médicos de Urgencia/métodos , Enseñanza Mediante Simulación de Alta Fidelidad/métodos , Simulación de Paciente , Resucitación/educación , Accidente Cerebrovascular/terapia , Terapia Trombolítica/métodos , Competencia Clínica , Cuidados Críticos/métodos , Alemania , Humanos , Grupo de Atención al Paciente/organización & administración , Accidente Cerebrovascular/diagnósticoRESUMEN
Ceramides induce important intracellular signaling pathways, modulating proliferation, migration, apoptosis, and inflammation. However, the relevance of the ceramide metabolism in the reconvalescence phase after stroke is unclear. Besides its well-known property as a selective serotonin reuptake inhibitor, fluoxetine has been reported to inhibit the acid sphingomyelinase (ASM), a key regulator of ceramide levels which derives ceramide from sphingomyelin. Furthermore, fluoxetine has shown therapeutic potential in a randomized controlled rehabilitation trial in stroke patients. Our aim was to investigate and modulate ceramide concentrations in the peri-infarct cortex, whose morphological and functional properties correlate with long-term functional outcome in stroke. We show that certain ceramide species are modulated after experimental stroke and that these changes do not result from alterations of ASM activity, but rather from nontranscriptional induction of the ceramide de novo pathway. Unexpectedly, although reducing lesion size, fluoxetine did not improve functional outcome in our model and had no significant influence on ASM activity or the concentration of ceramides. The ceramide metabolism could emerge as a potential therapeutic target in the reconvalescence phase after stroke, as its accumulation in the peri-infarct cortex potentially influences membrane functions as well as signaling events in the tissue essential for neurological recovery.
Asunto(s)
Ceramidas/metabolismo , Corteza Cerebral/metabolismo , Infarto Cerebral/tratamiento farmacológico , Infarto Cerebral/metabolismo , Inhibidores Enzimáticos/farmacología , Fluoxetina/uso terapéutico , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico , Esfingomielina Fosfodiesterasa/antagonistas & inhibidores , Esfingomielina Fosfodiesterasa/metabolismo , Animales , Trombosis Intracraneal/complicaciones , Redes y Vías Metabólicas , Ratones , Ratones Endogámicos C57BL , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
Glial fibrillary acidic protein (GFAP) is a highly brain-specific protein that is expressed in large quantities in astrocytes and has important functions in terms of maintaining and stabilizing the cytoskeleton. Acute intracerebral hemorrhage leads to an immediate mechanical destruction of astroglial cells with the subsequent release of GFAP into the extracellular space and the bloodstream. On the other hand, necrosis, cytolysis and GFAP release does not occur before 6-12 h after symptom onset in ischemic stroke. Thus, in the early hours after stroke increased GFAP values could indicate intracerebral hemorrhage. This review article describes the underlying pathophysiology of the test and guides the reader through the available data. Potential implications regarding the prehospital triage of acute stroke patients are discussed, including the possibility to initiate hyperacute treatment, such as blood pressure reduction in patients with intracerebral hemorrhage. Other areas of interest for a potential GFAP test include traumatic brain injury and malignant gliomas.
Asunto(s)
Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/metabolismo , Proteína Ácida Fibrilar de la Glía/metabolismo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/metabolismo , Biomarcadores/metabolismo , Humanos , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
Recombinant tissue-type plasminogen activator (rt-PA) is the mainstay of acute stroke treatment and the only approved medical therapy so far. Because of its fibrinolytic action, it is presumed to aggravate intracerebral hemorrhage (ICH). Since clinical features do not discriminate between ischemic stroke and ICH, brain imaging is strictly required before the initiation of thrombolysis. A recent study has shown that rt-PA does not worsen (primary) ICH in two different experimental mouse models. Here, we further explored this surprising finding and examined hematoma expansion and long-term outcome after rt-PA treatment in a murine model of ICH. We induced ICH by collagenase injection into the right basal ganglia of C57BL/6 mice. At 30 min, 90 min or 4h after ICH induction, respectively, mice were treated with vehicle or 10mg/kg rt-PA. In parallel, we administered the vascular tracer Evans Blue (EB) and sacrificed the mice 2h after injection to assess EB extravasation as a marker of ongoing bleeding and rt-PA induced rebleeding. Additionally, we observed mice which were treated with vehicle or rt-PA 30 min after ICH induction for 72 h and quantified functional outcome and hematoma volume. EB extravasation was highest in the groups that were treated after 30 min and decreased thereafter according to a cessation of active bleeding. At all three time points covering the early phase of ICH, treatment with rt-PA did not increase EB extravasation. In the 72 h observation, there was also no difference in functional outcome and hematoma volume. In our experimental study, we were not able to demonstrate that peracute rt-PA treatment in (primary) ICH has detrimental effects on hematoma expansion, hematoma volume or functional outcome. This finding needs careful consideration in future translational studies.
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Hemorragia Cerebral/tratamiento farmacológico , Hemorragia Cerebral/patología , Fibrinolíticos/uso terapéutico , Hematoma/tratamiento farmacológico , Hematoma/patología , Activador de Tejido Plasminógeno/uso terapéutico , Animales , Hemorragia Cerebral/inducido químicamente , Colagenasas , Interpretación Estadística de Datos , Azul de Evans , Colorantes Fluorescentes , Hematoma/inducido químicamente , Masculino , Ratones , Ratones Endogámicos C57BL , Enfermedades del Sistema Nervioso/etiología , Enfermedades del Sistema Nervioso/fisiopatología , Proteínas Recombinantes/uso terapéutico , Resultado del TratamientoRESUMEN
We present the case of a 49-year-old female patient who underwent a lumbar puncture in the context of an extended diagnostic work-up after a transient ischemic attack. A few days later the patient who suffered from severe post-lumbar puncture headache, developed a lobar hemorrhage due to a cortical venous thrombosis requiring decompression surgery.