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Optimizing Prehospital Triage for Patients With Stroke Involving Large Vessel Occlusion
The past 20 years have witnessed a revolution in the paradigm of acute ischemic stroke treatment. In 1996, intravenous alteplase was shown to improve outcomes among patients treated within 3 hours of stroke onset. This finding upended the historical therapeutic nihilism about stroke, and with it the leisurely armchair approach to stroke treatment. The concept of so-called acute ischemic stroke emerged. This changed the nature and practice of vascular neurology, created a vigorous and sometimes controversial debate between vascular neurologists and emergency physicians about the merits of alteplase, and paved the way for mo...
Source: JAMA Neurology - September 4, 2018 Category: Neurology Source Type: research

The Power of Clinical Registries and Quality Improvement Collaboratives
The American Heart Association established the American Stroke Association in 1998 to improve stroke care and speed the implementation of evidence-based stroke treatments. In 2001, the Centers for Disease Control and Prevention funded the Paul Coverdell National Acute Stroke Registry pilot programs. The Massachusetts pilot program, 1 of 4, was modeled after the Get With the Guidelines –Coronary Artery Disease program and was called Get With the Guidelines–Stroke (GWTG-Stroke). GWTG-Stroke is a collaborative disease-specific clinical data registry and quality improvement program and includes evidence-based quality measu...
Source: JAMA Neurology - August 6, 2018 Category: Neurology Source Type: research

Stroke Quality of Care in GWTG-Stroke Hospitals
This longitudinal cohort study compares quality of stroke care measures for patients admitted to hospitals participating and not participating in Get With The Guidelines –Stroke.
Source: JAMA Neurology - August 6, 2018 Category: Neurology Source Type: research

Leaving Against Medical Advice
She was never even supposed to be in the hospital. We got a telephone call from an ophthalmologist who suspected a stroke in a woman in her early 70s after finding a visual field defect. She had gone to the clinic because she was bumping into objects for a few days, but she expected to do a few tests, get a diagnosis, and go home, because whatever was wrong did not even bother her much. Instead, she was treated to an admission to our stroke center and a nothing by mouth designation overnight after she failed the nurse ’s swallowing screening. The ambient music of the ward—the echoes, beeps, snoring, and nurses and phys...
Source: JAMA Neurology - February 26, 2018 Category: Neurology Source Type: research

Stroke Imaging
In this issue ofJAMA Neurology, Boulouis et al report on the crucial influence of pretreatment collateral blood vessel status in determining the benefit of transfer for endovascular thrombectomy for large vessel acute ischemic stroke. All patients had relatively little evidence of irreversible injury on noncontrast computed tomography (CT) at their referring hospitals. However, when imaging was repeated at the comprehensive stroke center, a substantial proportion of patients had evolved large infarcts that caused them not to proceed to endovascular therapy or foreshadowed a poor outcome. These data contribute to the weight...
Source: JAMA Neurology - September 25, 2017 Category: Neurology Source Type: research

Primary Stroke Centers vs Comprehensive Stroke Centers
During all but the last 5 years of the 20th century, life was rather simple for health care planners who were concerned with care for patients with stroke. There was no proven effective treatment; therefore, no special guidelines were required. Stroke care changed significantly in 1995, when intravenous (IV) tissue plasminogen activator (tPA) was found to be an effective treatment when given soon after stroke onset. With the intent of improving care, hospitals were encouraged to develop primary stroke centers (PSCs) that had sufficient medical personnel, technology, and protocols that would enable them to deliver IV tPA efficiently.
Source: JAMA Neurology - March 20, 2017 Category: Neurology Source Type: research

Worsening Stroke Symptoms in an 80-Year-Old Man
An 80-year-old man presented to the hospital with new-onset slurred speech and left-sided facial droop. Magnetic resonance imaging scans of the head were visually interpreted to show an acute infarct involving the posterior right frontal lobe. What is your diagnosis?
Source: JAMA Neurology - June 6, 2016 Category: Neurology Source Type: research

In-Hospital Stroke
There have been tremendous strides in standardization of the care for acute ischemic stroke since widespread use of thrombolytic therapy began almost 20 years ago. Efficacy is still limited by delayed presentation to the emergency department following stroke symptom onset, although this has also improved in that period with education of emergency medical services and the community at large. The real improvement lies in development of streamlined and standardized protocols for “code stroke,” so that thrombolysis rates of 20% are becoming typical and door-to-needle times are just as typically under 1 hour. These encourag...
Source: JAMA Neurology - May 4, 2015 Category: Neurology Source Type: research

Care and Outcomes of Patients With In-Hospital Stroke
This prospective cohort study examines stroke care delivery and outcomes for patients with in-hospital vs community-onset stroke.
Source: JAMA Neurology - May 4, 2015 Category: Neurology Source Type: research

Carotid Stenting—Why Treating an Artery May Not Treat the Patient
In this issue of JAMA Neurology, Jalbert and colleagues present the results of a detailed analysis of Centers for Medicare & Medicaid Services (CMS) administrative data on patients with carotid artery stenosis treated with carotid artery stenting. Their well-written manuscript and timely study included more than 22 000 patients treated and followed up between 2000 and 2009. They analyzed periprocedural complications (defined as stroke, transient ischemic attack [TIA], myocardial infarction [MI], and death within 30 days), as well as long-term stroke and mortality. Important variables that were analyzed included the degre...
Source: JAMA Neurology - January 12, 2015 Category: Neurology Source Type: research

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