Impact of fasting blood glucose on prognosis after acute large vessel occlusion reperfusion: results from a multicenter analysis

 

So you described something, but DID NOTHING USEFUL THAT WILL HELP STROKE PATIENTS RECOVER. 

Impact of fasting blood glucose on prognosis after acute large vessel occlusion reperfusion: results from a multicenter analysis

Bin Luo^1,2,3†Yi Xiang^4†Fanlei Meng^5†Yubo Wang³Zhenzhong Zhang⁶Hecheng Ren^3*Lin Ma^3*

• ¹Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
• ²Tianjin Neurological Institute, Tianjin Huanhu Hospital, Tianjin, China
• ³Department of Clinical Laboratory, Tianjin Huanhu Hospital, Tianjin, China
• ⁴Department of Neurology, Xianyang Central Hospital, Xianyang, China
• ⁵Department of Neurology, Second Hospital of Tianjin Medical University, Tianjin, China
• ⁶Department of Neurosurgery, Hengshui Fifth People’s Hospital, Hengshui, China

Objective: To analyze the effect of fasting blood glucose levels after reperfusion of acute large vessel occlusion (ALVO) on patient functional prognosis.

Methods: Retrospectively included ALVO patients from three large stroke centers in China, all of whom achieved vascular reperfusion after mechanical thrombectomy or bridging thrombolysis. The prognosis scores of all patients at 90 ± 7 days post-recanalization were categorized into a good prognosis group (mRS 0–2) and a poor prognosis group (mRS 3–6). The relationship between mean blood glucose levels at 72 h post-recanalization and prognosis was explored using multivariable logistic regression analysis. Then we measured the area under the ROC curve for all factors to assess their predictive performance.

Results: (1) Totally 2,056 patients were included in the study, with 1,488 males and 568 females. There were 1,370 patients in the good prognosis group (mRS 0–2) and 686 in the poor prognosis group (mRS 3–6). (2) The two groups exhibited significant differences in terms of age, preoperative mRS score, history of diabetes, and mean fasting blood glucose (MFBG) (p < 0.001). (3) With 90-day mRS as the outcome variable, all independent variables were included in Univariate and multivariate regression analyses analysis, and the results showed that: age, preoperative mRS score, history of diabetes, and MFBG are all independent predictors of prognosis after recanalization of ALVO, with MFBG demonstrating a higher predictive power than the other factors (AUC = 0.644).

Conclusion: Various factors are correlated with the prognosis in patients who have undergone ALVO recanalization. Notably, the MFBG level demonstrates a significant predictive value for outcomes within the first 72 h following the recanalization procedure.

1 Background

Although mechanical thrombectomy (MT) has achieved higher rates of vascular recanalization in patients with acute large vessel occlusion (ALVO), the issue of reperfusion injury to brain tissue after vascular recanalization has always been a challenge that scholars and clinicians cannot avoid. Approximately 20–50% of ALVO patients may experience stress-induced hyperglycemia, caused by the release of cortisol and adrenaline leading to elevated blood glucose levels, a phenomenon commonly seen even in non-diabetic patients (1, 2). Patients undergoing MT procedures need to consider factors such as surgery-related stress, and hyperglycemia has been associated with adverse clinical outcomes in ALVO patients (3–7). Hyperglycemia levels can further exacerbate the hypoxic status of midbrain cells in the ischemic penumbra, leading to increased acidosis, mitochondrial dysfunction, and even failure (8). Besides, elevated blood glucose levels are associated with the formation of free radicals and activation of matrix metalloproteinases, which can further worsen brain edema (9–11). The 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend (12) targeting blood glucose levels to 140–180 mg/dL (7.8–10.0 mmol/L), but this standard lacks a higher level of objective evidence due to limited supporting data (1).

Our team’s previous research findings showed: hyperglycemia is an independent risk factor for poor prognosis in ALVO patients after vascular recanalization. The good prognosis rate in the low blood glucose group was 1.62 times higher than that in the hyperglycemia group; and for every 1 mmol/L decrease in blood glucose, the rate of poor prognosis decreased by 7.2% [OR: 0.928, 95% CI (0.879, 0.979), p = 0.007] (2). Other studies have shown the opposite: However, other studies have yielded conflicting results, with no significant difference in the 90-day modified Rankin Scale (90ds-mRS) between patients on intensified glucose lowering (4.44–7.22 mmol/L) and patients at standard glucose levels (4.44–9.93 mmol/L) (3–5). Further research is needed to determine whether different blood glucose levels affect the 90ds-mRS in patients.

Taking into account the above factors, we conducted a retrospective study on the fasting blood glucose levels of 2,056 post-MT patients with ALVO from three different medical centers, analyzing the relationship between MFBG levels and 90ds-mRS.

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Predictive Factors of Acute Symptomatic Seizures in Patients With Ischemic Stroke Due to Large Vessel Occlusion

 Why the hell are you blithering idiots predicting seizures rather than preventing them from happening?

Oops, I'm not playing by the polite rules of Dale Carnegie,  'How to Win Friends and Influence People'. 

Telling supposedly smart stroke medical persons they know nothing about stroke is a no-no even if it is true. 

Politeness will never solve anything in stroke. Yes, I'm a bomb thrower and proud of it. Someday a stroke 'leader' will try to ream me out for making them look bad by being truthful , I look forward to that day.

Predictive Factors of Acute Symptomatic Seizures in Patients With Ischemic Stroke Due to Large Vessel Occlusion

Lisa Marie Tako^1,2, Adam Strzelczyk^1,2*, Felix Rosenow^1,2, Waltraud Pfeilschifter³, Helmuth Steinmetz¹, Rejane Golbach⁴, Jan Hendrik Schäfer¹, Johann Philipp Zöllner^1,2 and Konstantin Kohlhase¹

• ¹Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
• ²LOEWE Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt, Germany
• ³Department of Neurology and Neurophysiology, Lüneburg Hospital, Lüneburg, Germany
• ⁴Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany

Introduction: Acute symptomatic seizures (ASz) after ischemic stroke are associated with increased mortality; therefore, identifying predictors of ASz is important. The purpose of this study was to analyze predictors of ASz in a population of patients with ischemic stroke due to large arterial vessel occlusion (LVO).

Materials and Methods: This retrospective study examined patients with acute ischemic stroke caused by LVO between 2016 and 2020. Identification of predictive factors was performed using univariate and subsequent multiple logistic regression analysis. In addition, subgroup analysis regarding seizure semiology and time of seizure occurrence (≤ 24 h and > 24 h after stroke) was performed.

Results: The frequency of ASz among 979 patients was 3.9 % (n = 38). Univariate logistic regression analysis revealed an increased risk of ASz in patients with higher National Institutes of Health Stroke Scale (NIHSS) score at admission or 24 h after admission, hypernatremia at admission ≥ 145 mmol/L, and pneumonia. Further multiple logistic regression analysis revealed that NIHSS 24 h after admission was the strongest predictor of ASz, particularly relating to ASz occurring later than 24 h after stroke. Patients who experienced a seizure within the first 24 h after stroke were more likely to have a generalized tonic-clonic (GTCS) and focal motor seizure; beyond 24 h, seizures with impaired awareness and non-convulsive status epilepticus were more frequent.

Conclusion: NIHSS score 24 h after admission is a strong predictive factor for the occurrence of ASz in patients with ischemic stroke caused by LVO. The semiology of ASz varied over time, with GTCS occurring more frequently in the first 24 h after stroke.

Introduction

Cerebrovascular disease is the most common cause of epilepsy in the elderly, accounting for up to 39–49% of all newly diagnosed epilepsies in patients aged > 60 years (1, 2). Due to demographic changes, the incidence of stroke-related epilepsy is expected to rise and pose an increasing challenge for the healthcare system (3). Depending on the time course, seizures after stroke are defined according to the International League Against Epilepsy (ILAE) either as an acute symptomatic seizure (ASz) if they occur within 7 days, or as an unprovoked late seizure if they occur later than 7 days (4). Acute symptomatic seizures are thought to result from local cellular biochemical dysfunction of electrically excitable tissues, whereas late seizures are caused by post-ischemic remodeling of the damaged brain tissue and neuronal network, leading to an acquired predisposition to seizures and the diagnosis of post-stroke epilepsy (5–8). A large systemic review and meta-analysis examined the frequency of seizures after ischemic stroke; the frequency of ASz was found to be 3.3% and the late post-stroke seizure frequency was 1.8% (9). Because ASz are associated with an increased risk of mortality, knowledge of predictive factors is essential (10, 11). Various risk factors with different levels of evidence are described in the literature. The severity of stroke, estimated by the National Institutes of Health Stroke Scale (NIHSS), and cortical involvement were identified as independent risk factors for the occurrence of ASz (11–16). Data are inconclusive regarding other possible risk factors, such as cardioembolic infarct etiology, anterior circulation cerebral infarction, hemorrhagic transformation, previous transient ischemic attack (TIA), acute non-neurological infection, and history of diabetes mellitus (10, 11, 13, 17). Based on these results, different prediction models have been developed to assess the individual risk for post-stroke seizures (18, 19). Furthermore, therapy with statins in the acute phase of stroke was reported to reduce the rate of seizures (20). Systemic thrombolysis and mechanical thrombectomy as established reperfusion procedures have also been the subject of research, with recent studies showing no association with ASz frequency (21, 22).

The variability among identified predictive factors may be explained by the heterogeneous designs of the available studies, with varying levels of evidence (registry studies, retrospective and prospective designs, mono- or multi-centric studies, systematic reviews), inclusion criteria (hemorrhagic and ischemic stroke), and definitions of ASz occurring later than 7 days (17, 23, 24). Furthermore, the studies were conducted over an extended period, including several studies in which neurological treatment in stroke units differed and new therapeutic milestones, such as mechanical recanalization, had not yet been established.

The purpose of this study is to analyze predictive factors for ASz in a well-defined patient population who experienced an ischemic stroke due to large vessel occlusion (LVO) and who were treated after mechanical recanalization had become the standard therapy for LVO in 2016.

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Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial

Useless, you tell us NOTHING on how to stop brain atrophy.  Stroke survivors just might want a solution for that. Will you put your fucking thinking caps on?

Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial

Sven Pr Luijten, Kars Cj Compagne, Adriaan Cgm van Es, Yvo Bwem Roos

BACKGROUND 

Brain atrophy is suggested to impair the potential for functional recovery after acute ischemic stroke. We assessed whether the effect of endovascular treatment is modified by brain atrophy in patients with acute ischemic stroke due to large vessel occlusion.

METHODS 

We used data from MR CLEAN, a multicenter trial including patients with acute ischemic stroke due to anterior circulation large vessel occlusion randomized to endovascular treatment plus medical care (intervention) versus medical care alone (control). We segmented total brain volume (TBV) and intracranial volume (ICV) on baseline non-contrast computed tomography (n = 410). Next, we determined the degree of atrophy as the proportion of brain volume in relation to head size (1 - TBV/ICV) × 100%, analyzed as continuous variable and in tertiles. The primary outcome was a shift towards better functional outcome on the modified Rankin Scale expressed as adjusted common odds ratio. Treatment effect modification was tested using an interaction term between brain atrophy (as continuous variable) and treatment allocation.

RESULTS 

We found that brain atrophy significantly modified the effect of endovascular treatment on functional outcome (P for interaction = 0.04). Endovascular treatment led to larger shifts towards better functional outcome in the higher compared to the lower range of atrophy (adjusted common odds ratio, 1.86 [95% CI: 0.97-3.56] in the lowest tertile vs. 1.97 [95% CI: 1.03-3.74]in the middle tertile vs. 3.15 [95% CI: 1.59-6.24] in the highest tertile).

CONCLUSION 

 Benefit of endovascular treatment is larger in the higher compared to the lower range of atrophy, demonstrating that advanced atrophy should not be used as an argument to withhold endovascular treatment.

Source: International Journal of Stroke

 

Venous outflow profiles are associated with early edema progression in ischemic stroke

So you described a problem, but offered no solution. Useless. 

Venous outflow profiles are associated with early edema progression in ischemic stroke

Noel van Hornhttps://orcid.org/0000-0001-5764-19821, Jeremy J Heit2, Reza Kabiri1, Gabriel Broockshttps://orcid.org/0000-0002-7575-98501, Soren Christensen3, Michael Mlynash3, Lukas Meyer1, Michael H Schoenfeld4, Maarten G Lansberghttps://orcid.org/0000-0002-3545-69273, Gregory W Albers3, Jens Fiehler1, Max Wintermark2, and Tobias D Faizyhttps://orcid.org/0000-0002-1631-20201,2
 

Background:

 

In patients with acute ischemic stroke due to large vessel occlusion (AIS–LVO), development of extensive early ischemic brain edema is associated with poor functional outcomes, despite timely treatment. Robust cortical venous outflow (VO) profiles correlate with favorable tissue perfusion. We hypothesized that favorable VO profiles (VO+) correlate with a reduced early edema progression rate (EPR) and good functional outcomes.
 

Methods:

 

Multicenter, retrospective analysis to investigate AIS–LVO patients treated by mechanical thrombectomy between May 2013 and December 2020. Baseline computed tomography angiography (CTA) was used to determine VO using the cortical vein opacification score (COVES); VO+ was defined as COVES ⩾ 3 and unfavorable as COVES ⩽ 2. EPR was determined as the ratio of net water uptake (NWU) on baseline non-contrast CT and time from symptom onset to admission imaging. Multivariable regression analysis was performed to assess primary (EPR) and secondary outcome (good functional outcomes defined as 0–2 points on the modified Rankin scale).
 

Results:

 

A total of 728 patients were included. Primary outcome analysis showed VO+ (β: –0.03, SE: 0.009, p = 0.002), lower presentation National Institutes of Health Stroke Scale (NIHSS; β: 0.002, SE: 0.001, p = 0.002), and decreased time from onset to admission imaging (β: –0.00002, SE: 0.00004, p < 0.001) were independently associated with reduced EPR. VO+ also predicted good functional outcomes (odds ratio (OR): 5.07, 95% CI: 2.839–9.039, p < 0.001), while controlling for presentation NIHSS, time from onset to imaging, general vessel reperfusion, baseline Alberta Stroke Program Early CT Score, infarct core volume, EPR, and favorable arterial collaterals.
 

Conclusions:

 

Favorable VO profiles were associated with slower infarct edema progression and good long-term functional outcomes as well as better neurological status and ischemic brain alterations at admission.
Keywords
Brain, collaterals, edema, ischemic stroke, mechanical thrombolysis, neuroimaging
1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
2Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
3Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
4Department of Radiology, University Hospital of Cologne, Cologne, Germany
Corresponding author(s):
Noel van Horn, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Email: no.vanhorn@uke.de
Introduction
In patients with acute ischemic stroke due to large vessel occlusion (AIS–LVO), rapid development of extensive early ischemic brain edema is associated with poor functional outcomes.1 However, in these patients, robust arterial collateral blood flow was found to be associated with less ischemic damage to the brain, likely due to the perseverance of blood flow to and through the ischemic tissue.2–4
Arterial collaterals are usually assessed on computed tomography angiography (CTA) images, but only reflect the arterial component of the microvascular circuit and do not reliably measure cerebral perfusion.5 It has been presumed that the critical patterns of tissue hypoperfusion are determined by the most distal arterial branches and the associated venous outflow (VO) profiles.6,7
Recent studies reported that favorable VO profiles are associated with less ischemic lesion net water uptake (NWU) on follow-up imaging and favorable functional outcomes of AIS–LVO patients treated by mechanical thrombectomy (MT).8 However, the association between VO profiles and early edema progression in AIS–LVO patients remains unclear. More comprehensive data on the effect of robust venous drainage on cerebral edema development are needed to better understand the pathophysiological factors that influence early edema progression between the time from symptom onset to baseline imaging.
We hypothesized that favorable VO profiles are associated with less early edema progression in AIS–LVO patients. We tested this hypothesis by determining VO using the cortical vein opacification score (COVES)9 on baseline CTA images and early ischemic NWU10 on admission head non-contrast CT (NCCT) images. Early edema progression rate (EPR) was calculated as the ratio of NWU on admission NCCT imaging divided by the time from symptom onset to baseline imaging.

 

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Relationship Between Body Temperature and Early Neurological Deterioration after Endovascular Thrombectomy for Acute Ischemic Stroke with Large Vessel Occlusion

 So you described a problem, offered no solution, didn't suggest further research; USELESS. And didn't even consider that early neurological deterioration might be caused by all the neurons dying because you've done nothing to stop the 5 causes of the neuronal cascade of death in the first days.

Relationship Between Body Temperature and Early Neurological Deterioration after Endovascular Thrombectomy for Acute Ischemic Stroke with Large Vessel Occlusion

• Yaxi Luo,
• Man Chen,
• Jinghuan Fang,
• Shuju Dong,
• Mengmeng Ma,
• Jiajia Bao,
• Ling Feng &
• Li He 

Neurocritical Care (2022)Cite this article

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Abstract

Background

Early neurological deterioration (END) after endovascular thrombectomy (EVT) is strongly associated with poor prognosis in patients with large vessel occlusion. The relationship between body temperature and END after EVT is unknown, which we aimed to investigate in this study.

Methods

END was defined as an increase of four or more points on the National Institutes of Health Stroke Scale score compared with the baseline assessment within 24 h. Logistic regression and restricted cubic spline models were used to assess the relationship between body temperature and END.

Results

Among 7741 consecutive patients with ischemic stroke, 406 patients with large vessel occlusion who underwent EVT were enrolled. In total, 88 (21.7%) patients developed END. Logistic regression showed that the maximum body temperature within 24 h (odds ratio [OR] = 1.97 per °C, 95% confidence interval [CI] 1.17–3.32, p = 0.010) was independently associated with END. This association was nonlinear and J shaped (p for nonlinearity = 0.010), and the risk of END increased when the maximum body temperature within 24 h was lower or higher than 37.0 °C. Fever burden is also independently associated with END (OR = 1.06 per °C  × hour, 95% CI 1.01–1.11, p = 0.012). In addition, the timing of fever onset was independently associated with END, and the highest risk of END was associated with fever onset within 6 h after EVT (OR = 3.92, 95% CI 1.25–12.27, p = 0.019).

Conclusions

In summary, there is a J-shaped association between the maximum body temperature within 24 h after EVT and END. Moreover, the risk of END differed according to the timing of fever onset.

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Data availability

The data that support the findings of this study are available from the corresponding author on reasonable request.

 

FAST-ED scale smartphone app-based prediction of large vessel occlusion in suspected stroke by emergency medical service

But you tell us nothing about if this is fast enough to get to 100% recovery, SO YOU DIDN'T DO YOUR FUCKING JOB!

FAST-ED scale smartphone app-based prediction of large vessel occlusion in suspected stroke by emergency medical service

Show all authors

Benedikt Frank, Thomas Lembeck, Nina Toppe, ...

First Published November 14, 2021 Research Article 

https://doi.org/10.1177/17562864211054962

Article information

Abstract

Background and Purpose:

Considering the highly time-dependent therapeutic effect of endovascular treatment in patients with large vessel occlusion–associated acute ischemic stroke, prehospital identification of large vessel occlusion and subsequent triage for direct transport to a comprehensive stroke center offers an intriguing option for optimizing patient pathways.

Methods:

This prospective in-field validation study included 200 patients with suspected acute ischemic stroke who were admitted by emergency medical service to a comprehensive stroke center. Ambulances were equipped with smartphones running an app-based Field Assessment Stroke Triage for Emergency Destination scale for transmission prior to admission. The primary measure was the predictive accuracy of the transmitted Field Assessment Stroke Triage for Emergency Destination for large vessel occlusion and the secondary measure the predictive accuracy for endovascular treatment.

Results:

A Field Assessment Stroke Triage for Emergency Destination ⩾4 revealed very good accuracy to detect large vessel occlusion–related acute ischemic stroke with a sensitivity of 82.4% (95% confidence interval = 65.5–93.2), specificity of 78.3% (95% confidence interval = 71.3–84.3), and an area under the curve c-statistics of 0.89 (95% confidence interval = 0.85–0.94). Field Assessment Stroke Triage for Emergency Destination ⩾4 correctly identified 84% of patients who received endovascular treatment [73.5% specificity (95% confidence interval = 66.4–79.8)] with an area under the curve c-statistics of 0.82 (95% confidence interval = 0.74–0.89). In a hypothetical triage model of an urban setting, one secondary transportation would be avoided with every fifth patient screened.

Conclusion:

A smartphone app-based stroke triage completed by emergency medical service personnel showed adequate quality for the Field Assessment Stroke Triage for Emergency Destination to identify large vessel occlusion–associated acute ischemic stroke. We demonstrate feasibility of the use of a medical messaging service in prehospital stroke care. Based on these first results, a randomized trial evaluating the clinical benefit of such a triage system in an urban setting is currently in preparation.

Clinical Trial Registration: https://clinicaltrials.gov Unique identifier: NCT04404504.

Keywords

EMS, FAST-ED, prehospital LVO thrombectomy identification, stroke, triage

Introduction

The introduction of endovascular treatment (EVT) in addition to intravenous thrombolysis (IVT) has vastly improved treatment of patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). However, while IVT can be applied in any hospital with specialized stroke care, EVT requires a much more complex infrastructure and mostly is limited to Comprehensive Stroke Centers (CSCs). In consideration of the highly time-dependent therapeutic effect of the reperfusion therapy in AIS,^1,2 many prehospital patient pathways still focus on transportation to the nearest stroke unit. On the contrary, patients with LVO-related AIS admitted to centers without EVT capability must be referred to CSCs after initiation of IVT by secondary interhospital transfer (drip-and-ship). This procedure is not only expensive and causes inefficient use of emergency medical service (EMS) resources, but also delays the possible use of EVT, resulting in a poorer clinical outcome.³ Therefore, prehospital identification of patients with LVO and subsequent triage for direct transport to a CSC offers an intriguing option for optimizing patient pathways. This is especially useful in urban settings, where delay to first hospital contact is negligible when bypassing a nearby non-EVT center. In this context, several clinical scores were developed to estimate LVO risk in patients with AIS in the emergency setting. Among them, the simple and short Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale yields high sensitivity by adding cortical symptoms to the regular FAST-test.⁴ Previous studies have shown superior prediction quality in comparison to other LVO recognition scores;⁵ however, in-field validation has not yet been studied. In addition, very limited experience with prehospital smartphone-assisted assessment of stroke patients by paramedic EMS personnel is available⁶ and further proof of practicability is urgently needed.⁷

In this prospective study, we performed in-field validation of the smartphone-based FAST-ED scale that was digitally transmitted by paramedic EMS personnel prior to hospital arrival. In addition, we aimed to evaluate the potential impact of prehospital triage of patients with suspected stroke.

Methods

Study setting

This was a prospective in-field validation study for an app-based prehospital stroke triage for patients with suspected acute stroke. The study included 200 consecutive patients who were admitted by EMS to the CSC of the Neurological University Hospital Essen, Germany, from March 2019 to August 2020 and met the following inclusion criteria: suspected acute stroke, age above 18 years, and a digitally transmitted FAST-ED by EMS prior to admission. Patients with confirmed onset of stroke symptoms beyond 24 h were excluded.

EMS personnel of the city of Essen, which is managed by the local fire department (Feuerwehr der Stadt Essen), was systematically trained to use an app-based FAST-ED score. In addition, all ambulances were equipped with a robust smartphone (Caterpillar, CAT S60) running a customized German version of a FAST-ED triage app and a medical messaging service (JoinTriage and Join; Allm, Inc. https://play.google.com/store/apps/details?id=net.allm.fasted&hl=en https://apps.apple.com/us/app/jointriage/id1099779970). EMS personnel used this messaging platform to digitally transmit the examination results to the hospital stroke team prior to arrival.

EMS is designed as a two-tiered system including paramedic staffed ALS-Ambulances and physician staffed response units. In suspected stroke without signs of severe respiratory distress, the EMS dispatch center protocol leads to a single ALS-Ambulance response. Thus, in majority of suspected stroke, only paramedic EMS personnel is involved.

FAST-ED is a simple scale that adds clinical symptoms predicting cortical involvement (gaze deviation, denial, neglect) to the commonly used FAST-test, which already includes the evaluation of facial palsy, arm weakness, and speech disturbances. The app-based FAST-ED scale omits the need to examine symptoms of neglect and denial, if the patient suffers from aphasia or in the absence of arm weakness. The score ranges from zero to eight points (Figure 1) and FAST-ED items as well as basic clinical information (time of symptom onset, age) are entered into the Triage App, which then automatically predicts the likelihood of LVO based on previous data.⁸ Assessment results and the estimated time of arrival are digitally transferred to our hospital via the smartphone App.

Figure 1. Flow chart of the algorithm used in JoinTriage.

The assessment of age was modified from a dichotomized (⩾80 years) to a continuous variable after analyzing the first 40 patients) and information of prior oral anticoagulation was excluded from the assessment due to the lack of validity (the respective data are presented in the result section). The implementation of these changes was completed after the inclusion of 53 patients. The sequence of the FAST-ED items itself remained unchanged.⁸ The final app display and algorithm are presented in Figure 1 and Supplemental Figure S1.

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Protocol for the MAnagement of Systolic blood pressure during Thrombectomy by Endovascular Route for acute ischemic STROKE randomized clinical trial: The MASTERSTROKE trial

If this works then it is your responsibility to get this out to all stroke doctors and hospitals. Since we have fucking failures of stroke associations they don't have the ability to do easy stuff like that. Interesting that they want to maintain a high blood pressure instead of increasing the oxygen content of the red blood cells.

Possible solutions: Obviously not vetted coming from me. Don't do them.

You can look at the years these were reported on and tell how long your hospital has been incompetent.

• Normobaric oxygen (10 posts to January 2020)

• oxygen delivery (4 posts to January 2020)

• brain blood flow (3 posts to April 2019) 

 

How to Improve Your Brain Function with An Oxygen Concentrator April 2018 

Or is it more important to increase the loading ability of red blood cells to carry more oxygen? 

Like this?

University of Glasgow Study Demonstrates the Ability of Oxycyte® to Supply Oxygen to Critical Penumbral Tissue in Acute Ischemic Stroke  August 2012

Or like this?

chronic cannabis users have higher cerebral blood flow and extract more oxygen from brain blood flow than nonusers. August 2017   

Vinpocetine increases cerebral blood flow and oxygenation in stroke patients: a near infrared spectroscopy and transcranial Doppler study May 2015 

Or this? having red blood cells release more oxygen.

Methylene blue shows promise for improving short-term memory

HOW FUCKING LONG WILL YOU LET YOUR INCOMPETENT STROKE HOSPITAL STILL TREAT PATIENTS LIKE NOTHING NEW HAS OCCURRED IN THE PAST 50 YEARS?

The latest here:

Protocol for the MAnagement of Systolic blood pressure during Thrombectomy by Endovascular Route for acute ischemic STROKE randomized clinical trial: The MASTERSTROKE trial

Doug Campbellhttps://orcid.org/0000-0002-4685-76111, Carolyn Deng1, Fiona McBryde2, Robyn Billing1, William K Diprose3, Timothy G Short1,4, Christopher Frampton5, Stefan Brew6, P Alan Barberhttps://orcid.org/0000-0003-2469-90233,7, and on behalf of the MASTERSTROKE Study Group
RegistrationAustralian New Zealand Clinical Trials Registry: ACTRN12619001274167p
RationaleCerebral blood flow is blood pressure-dependent when cerebral autoregulation is impaired. Cerebral ischemia and anesthetic drugs impair cerebral autoregulation. In ischemic stroke patients treated with endovascular thrombectomy, induced hypertension is a plausible intervention to increase blood flow in the ischemic penumbra until reperfusion is achieved. This could potentially reduce final infarct size and improve functional recovery.
Aim

To test if patients with large vessel occlusion stroke treated with endovascular thrombectomy will benefit from induced hypertension.
Design

Prospective, randomized, parallel group, open label, multicenter clinical trial with blinded assessment of outcomes.
Procedures

Patients with anterior circulation stroke treated with endovascular thrombectomy with general anesthesia within 6 h of symptom onset, and patients with ‘wake up’ stroke or presenting within 6 to 24 h with potentially salvageable tissue on computed tomography perfusion scanning, are included. Participants are randomized to a systolic blood pressure target of 140 mmHg or 170 mmHg from procedure initiation until recanalization. Methods to maintain the blood pressure are at the discretion of the procedural anesthesiologist.
Study outcomes 

The primary efficacy outcome is improvement in disability measured by modified Rankin Scale score at 90 days. The primary safety outcome is all-cause mortality at 90 days.
Analysis

The Mann-Whitney U test will be used to test the ordinal shift in the seven-category modified Rankin Scale score. All-cause mortality will be estimated using the Kaplan-Meier method and compared using a log-rank test.
Keywords
Clinical trial, acute stroke therapy, ischemic stroke, protocol, induced hypertension, reperfusion
1Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
2Department of Physiology, University of Auckland, Auckland, New Zealand
3Department of Neurology, Auckland City Hospital, Auckland, New Zealand
4Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
5Department of Statistics, University of Otago, Christchurch, New Zealand
6Department of Radiology, Auckland City Hospital, Auckland, New Zealand
7Department of Neurology, University of Auckland, Auckland, New Zealand
Corresponding author(s):
Doug Campbell, Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland 1023, New Zealand. Email: dcampbell@adhb.govt.nz
Introduction
Cerebral autoregulation, a protective mechanism preserving cerebral blood flow (CBF), is impaired after ischemic stroke1 and also by general anesthesia (GA).2 Consequently, global and regional CBF in ischemic territories of the brain become blood pressure-dependent during GA, and collateral blood flow to the ischemic penumbra may be decreased by relative hypotension and increased by induced hypertension.3 Induced hypertension has the potential to increase collateral blood flow to the ischemic penumbra, but also procedural complications such as groin hematoma, symptomatic intracranial hemorrhage, and cerebral reperfusion injury and edema. These harms can be mitigated by stopping induced hypertension when recanalization is achieved. Therefore, we aim to test the overall effectiveness of induced hypertension (systolic blood pressure [SBP] 170 mmHg) in comparison to current standard practice (SBP 140 mmHg) during GA for endovascular thrombectomy (EVT), by assessing functional recovery as measured by modified Rankin Score (mRS) score at 90 days.
Methods
The trial will be reported according to the CONSORT guidelines.4
Objective
To test whether an SBP target of 170 mmHg during GA for EVT leads to superior functional recovery at three months compared to an SBP target of 140 mmHg in patients with acute anterior circulation LVO stroke.
Design
Prospective, randomized, parallel group, open label, multicenter clinical trial with blinded assessment of outcomes. See Figure 1 for trial flow chart.
Figure 1. MASTERSTROKE trial flow chart.

Study setting
The trial is currently being conducted at academic hospitals with comprehensive stroke units.
Participant inclusion and exclusion criteria
Patients with anterior circulation stroke treated with EVT within 6 h of symptom onset, and patients with ‘wake up’ stroke or presenting within 6 to 24 h with potentially salvageable tissue on computed tomography (CT) perfusion scanning are included. Exclusion criteria include pre-stroke mRS >2, terminal illness with less than one year expected survival, cardiovascular disease where BP targeting is contraindicated, pregnancy, inability to participate in three-month follow-up, or EVT performed as a ‘rescue’ with stroke following medical or surgical procedures.
Written informed consent, waiver of consent, or two physician best interest agreement is sought prior to enrolment after approval of the regional ethics committee. Patients are screened for eligibility before randomization and enrolment.
Randomization and blinding
Group allocation is by web-based central randomization service undertaken with permuted blocks in a 1:1 ratio stratified by study center. The allocation sequence was computer-generated by an independent statistician. Blinding of the attending anesthesiologist is not possible. Participants, neuroradiologists, neurologists, and outcome assessors are blinded. One unblinded researcher collects BP adherence data. Site specific protocols were developed to maintain blinding.
Interventions
The anesthesiologist discloses anesthesia agent prior to randomization to avoid bias prior to randomization. Following randomization, one of two hemodynamic strategies from induction of GA until reperfusion is allocated, or the end of procedure if recanalization is not achieved.
1.
Target SBP of 140 ± 10 mm Hg
2.
Target SBP of 170 ± 10 mmHg
Techniques used to target SBP will be at the discretion of the anesthesiologist and may include vasoactive drugs, dosing of anesthetic maintenance drugs or intravenous fluids. In the pilot study,5 the predominant method to target SBP was titration of the vasopressor metaraminol, rather than anesthetic drug or intravenous fluid titration. Neuromuscular blocking agents will be used to facilitate endotracheal intubation, with control of hemodynamic physiology as described, but also intermittent positive pressure ventilation to normocarbia (end tidal CO2 [ETCO2] 4.5–6.0 kPa or PaCO2 4.5–6.0 kPa) to mitigate effects of abnormal PaCO2 on CBF. Normothermia and normoglycemia will be maintained. Doses and timing of drugs will be recorded in the electronic case record form. Other care during GA will be by routine institutional practice. The study intervention stops at recanalization (or time when thrombectomy attempts stop if the procedure is unsuccessful). Post-procedure blood pressure management is by usual institutional practice. Imaging will be routine 24-h non-contrast CT scanning.
Primary efficacy outcome
Disability measured by the mRS measured at 90 days.
Secondary efficacy outcomes
1.
Functional independence (mRS of 0, 1, or 2 at 90 days)
2.
Excellent functional outcome (mRS of 0 or 1 at 90 days)
3.
Home days, which are the number of days a participant resides at their pre-stroke domicile in the first 90 days post-stroke.
Primary safety outcomes
Incidence of all-cause mortality at 90 days.