Stroke Telemedicine

http://www.youtube.com/watch?v=iQdkBKF8p5g&feature=youtu.be
Dominique Cadilhac and Chris Bladin speak about telemedicine - paper is coming soon to IJS.

IJS is experimenting with coding - have you seen this ground breaking work on fatigue with Gillian Mead and martin Dennis? Keep an eye out for more stroke and fatigue papers as this topic garners more and more attention.

Sri Lanka World Stroke Day

 Launching the Stroke Solidarity String on World Stroke Day 2012 at Temple Trees in Sri Lanka by presenting the string to His Excellency the President Mahinda Rajapaksha by the President of the National Stroke Association of Sri Lanka, Dr. Padma Gunaratne. Hon Maithripala Sirisena, Minister of Health and Dr. Harsha Gunasekara, Secretary of the stroke Association are also present.

Changes in spleen size

International Journal of Stroke Managing Editor spoke to Drs. Sean Savitz and Farhaan Vahidy on the eve of the online publication of this very novel study. You can download this interview here. 

https://itunes.apple.com/gb/podcast/changes-in-spleen-size-in/id580359468

The spleen in stroke patients undergoes dynamic changes of contractions and re-expansion in the days following the onset of stroke symptoms, releasing inflammatory cells and contributing to further brain injury, according to researchers at The University of Texas Health Science Center at Houston (UTHealth) Medical School.

“We’ve known from animal studies that the spleen contracts after stroke, followed by the release of inflammatory white blood cells leading to secondary brain injury, so we wanted to observe what happens to the spleen in patients after a stroke,” said Sean I. Savitz, principal investigator and professor of neurology at the UTHealth Medical School. 

Photo credit: NIH

“This is a completely understudied area. The spleen is not normally an organ that neurologists or neuroscientists pay attention to. This was our initial attempt to look at the size of the spleen in stroke patients.”

The spleen is part of the lymphatic system, which fights infection by releasing white blood cells. It also helps control the amount of blood in the body and destroys old and damaged cells.

The study included 29 stroke patients and 20 healthy volunteers. The research team performed daily abdominal ultrasounds to measure the size of the spleens. In the stroke patients, spleens initially reduced in size and then re-expanded. The spleens of the healthy volunteers showed minimal variation in daily spleen size compared with the stroke patients.

Savitz said the study demonstrated a good correlation between the contraction of the spleen and the amount of white blood cells in the body. The results also suggested that some patients whose spleens contracted for a longer period of time, releasing more inflammatory white blood cells, had poorer clinical outcomes. Further studies will be needed to confirm and explain these early findings, Savitz said.

Savitz and fellow researchers became interested in studying the spleen after animal studies at UT-Health and elsewhere showed that stem cells administered intravenously after a stroke travelled to the spleen, as well as to the brain.

“The big question was why,” said Savitz, who is director of the Stroke Program at UTHealth and an attending physician at Memorial Hermann-Texas Medical Center. “Emerging work by our group and other researchers suggest that some types of stem cells have a dampening effect on the inflammatory response emanating from the spleen. The spleen is a possible target in the future for treating stroke.”

Savitz’s research team at UTHealth included first authors Preeti Sahota, M.D., and Farhaan Vahidy, M.D. 

A little bit of art...

IJS are preparing to interview Swedish Neurologist Barbro B Johansson and I was touched by this image and historical note on her web page.
Her website 'banner' held this picture of a beautiful sculpture and I have left in tact the historical note she made about it as seen below.

Historical note: I took the picture of the sculpture on the top left when I visited the Institute of Neurosurgery and Brain Research in Santiago, Chile 1961. It is made by Marta Covin, a famous Chilean Sculptress (1905-1993), using the hands of Alfonso Asenjo as a model. Asenjo was a pioneer in neurosurgery that founded the Institute of Neurosurgery and Brain Research in Chile already in 1939. Because he was a friend of Salvador Allende the sculpture was removed and disappeared in connection with the military coop in Chile 1973. I think that the sculpture is a too beautiful illustration of what makes us human to be forgotten.

This re-empahsises for me as Managing Editor for the journal, the important work people do in neurology and how globally this work in undertaken in all conditions; how each individual treatment and care impacts on each human being which resonates globally. This gift of quality of life is why we at this journal, the flagship of the World Stroke Organization must always remember that we are a global platform for a global voice, so no matter the conditions that people work in, or the resources available to them, we are there to share knowledge and support these amazing practitioners to reduce the burden of stroke.

Trade-offs between effectiveness and efficiency in stroke rehabilitation

Trade-offs between effectiveness and efficiency in stroke rehabilitation

Keywords:

• activities of daily living;
• effectiveness;
• efficiency;
• rehabilitation;
• stroke;
• trade-off

Background Most stroke research has studied rehabilitation effectiveness and rehabilitation efficiency separately and not investigated the potential trade-offs between these two indices of rehabilitation.

Aims To determine whether there is a trade-off between independent factors of rehabilitation effectiveness and rehabilitation efficiency.

Methods Using a retrospective cohort study design, we studied all stroke patients (n=2810) from two sub-acute rehabilitation hospitals from 1996 to 2005, representing 87·5% of national bed-years during the same period.

Results Independent predictors of poorer rehabilitation effectiveness and log rehabilitation efficiency were • older age • race-ethnicity • caregiver availability • ischemic stroke • longer time to admission • dementia • admission Barthel Index score, and • length of stay.

Rehabilitation effectiveness was lower in females, and the gender differences were significantly lower in those aged ≤70 years (β −4·7 (95% confidence interval −7·4 to −2·0)). There were trade-offs between effectiveness and efficiency with respect to admission Barthel Index score and length of stay. An increase of 10 in admission Barthel Index score predicted an increase of 3·6% (95% confidence interval 3·2–4·0) in effectiveness but a decrease of 0·04 (95% confidence interval −0·05 to −0·02) in log efficiency (a reduction of efficiency by 1·0 per 30 days). An increase in log length of stay by 1 (length of stay of 2·7 days) predicted an increase of 8·0% (95% confidence interval 5·7–10·3) in effectiveness but a decrease of 0·82 (95% confidence interval −0·90 to −0·74) in log efficiency (equivalent to a reduction in efficiency by 2·3 per 30 days). For optimal rehabilitation effectiveness and rehabilitation efficiency, the admission Barthel Index score was 30–62 and length of stay was 37–41 days.

Conclusions

There are trade-offs between effectiveness and efficiency during inpatient sub-acute stroke rehabilitation with respect to admission functional status and length of stay.

WSC in pictures

Marc Fisher and Geoffrey Donnan talk about journals STROKE and IJS

INCOMING WSO PRESIDENT STEPHEN DAVIS

GEOFFREY DONNAN AT THE IJS BOARD MEETING

Dominique Cadhilaic, Marion Walker, Geoffrey Donnan and Julie Bernhardt

The Canadian Stroke Network

http://www.canadianstrokenetwork.ca/index.php/about/our-partners-links-page/provincialterritorial-strategies/

The Canadian Stroke Network have a great blog. This blog is an excellent example of where content can be published, free and easily accessible for the public. The International Journal of Stroke are planning on working with SSOs to build a public stroke network here on our blog, which has as of this month had over 31,000 views! Blogs are a great way of disseminating important information at low, or no cost!

Aphasia the Movie

Aphasia the movie is playing at the Other Film Festival this coming Friday and IJS will attend. I briefly caught the end of this film and a fantastic forum with Carl, the films subject; and an audience of stroke survivors with aphasia, and clinicians at the Stroke Society Australasia in Sydney last month. 

In 2005 Carl McIntyre suffered a stroke resulting in aphasia - his journey is the subject of this film.

IJS will speak to Carl on Thursday morning before the screening and hopefully bring back a great video and sound recording capturing some of Carl's story and why the film was made.  

Stroke Society Australasia in pictures

Joanne Murray and Coralie English

Valerie Pomeroy

Stephanie Ho and Brenda Booth

Sandy Middleton and Simeon Dale  

Chris Levi and Jane Maguire

David Howells and Milos Pekny

Atte Meretoja

Nadine Andrew and Monique Kilkenny

Leonid Churilov Florey Statistician, Elise Cowley and Tina Soulis from NTA

Bernard Yan and Bruce Campbell

Ian Mosely

Lisa Walker, Sue Mosely, Sandra Petrolo, and WenWen Zhang

Tissa Wijeratne, Julie Bernhardt Director of the AVERT trial and Erin Godeke

Mhairi Macrae, Neuroscientist University of Glasgow

Fiona Ellery from NTA and AVERT Trial with Carmen Lahiff-Jenkins from IJS

Mark Longworth Smartstrokes, Richard Lindley SSA organiser and Dennis Crimmins

The WSO has a new website...

The WSO has a new website

http://www.world-stroke.org/

If you're having trouble with membership access to the journal please contact me: carmenl@unimelb.edu.au

Stroke Society Australasia 2012; it begins.

This week is the Stroke Society Australasia Meeting in Sydney incorporating Smart Strokes, IJS will be in attendance keeping you up to date. Andrei Alexandrov will be there speaking on his imaging 'helmet', Val Pomeroy on Neurorehabilitation, Rustam Al-Shahi Salman on mechanisms of intracerebral and subarachnoid haemorrhage, and Christian Stapf whose interests are brain vascular malformations and other conditions predisposing to intracranial haemorrhage. Caroline Watkins will be be talking about stoke service development. Stephanie Ho stroke survivor and Noel Hayman, Queensland Australian of the Year 2011 who works in Indigenous Health.

Last year IJS collected a fabulous series of interviews from SSA.

Werner Hacke

Argye Hillis

Elizabeth Holliday

Susan Hillier

Jocelyn Bowden

Karlea Kremer

Michelle McDonnell

Timothy Kleinig

Protocol for the perfusion and angiography imaging sub- study of the Third International Stroke Trial (IST-3) of alteplase treatment within six hours of acute ischaemic stroke.

Joanna Wardlaw, Reudiger von Krummer, Trevor Carpenter, Mark Parsons, Richard Lindley, Geoff Cohen, Veronica Murray, Adam Kobayashi, Andre Peeters, Francesca Chappell and Peter Sandercock.   

Abstract
Rationale: Intravenous thrombolysis with recombinant tissue plasminogen Activator (rt- PA) improves outcomes in patients treated early after stroke but at the risk of causing intracranial haemorrhage. Restricting rt-P A use to patients with evidence of still salvageable tissue, or with definite arterial occlusion, might help reduce risk, increase benefit and identify patients for treatment at late time windows.
Aims: To determine if perfusion or angiographic imaging with CT or MR help identify patients who are more likely to benefit from rt-PA in the context of a large multicentre randomised trial of rt-PA given within six hours of onset of acute ischaemic stroke, the Third International Stroke Trial (IST-3).
Design: IST-3 is a prospective multicentre randomised controlled trial testing rt-PA (0.9mg/kg, maximum dose 90mg) started up to six hours after onset of acute ischaemic stroke, in patients with no clear indication for or contraindication to rt-PA. Brain imaging (CT or MR) was mandatory pre-randomisation to exclude haemorrhage. Scans were read centrally, blinded to treatment and clinical information. In centres where perfusion and/or angiography imaging were used routinely in stroke, these images were also collected centrally, processed and assessed using validated visual scores and computational measures.
Study Outcomes: The primary outcome in IST-3 is alive and independent (Oxford Handicap Score 0-2) at 6 months; secondary outcomes are symptomatic and fatal intracranial haemorrhage, early and late death. The perfusion and angiography study additionally will examine interactions between rt-PA and clinical outcomes, infarct growth and recanalisation in the presence or absence of perfusion lesions and/or arterial occlusion at presentation. The study is registered ISRCTN25765518. 

Coming to IJS.

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NeuroThera® Efficacy and Safety Trial – 3 (NEST-3): a double-blind, randomized, sham-controlled, parallel group, multicenter, pivotal study to assess the safety and efficacy of transcranial laser therapy with the NeuroThera® Laser System for the treatment of acute ischemic stroke within 24 h of stroke onset

Rationale Transcranial laser therapy is undergoing clinical

trials in patients with acute ischemic stroke. The NeuroThera

® Efficacy and Safety Trial-1 was strongly positive for

90-day functional benefit with transcranial laser therapy,

and post hoc analyses of the subsequent NeuroThera® Efficacy

and Safety Trial-2 trial suggested a meaningful beneficial

effect in patients with moderate to moderately severe

ischemic stroke within 24 h of onset. These served as the

basis for the NeuroThera® Efficacy and Safety Trial-3 randomized

controlled trial.

Aim The purpose of this pivotal study was to demonstrate

safety and efficacy of transcranial laser therapy with the

NeuroThera® Laser System in the treatment of subjects diagnosed

with acute ischemic stroke.

Design NeuroThera® Efficacy and Safety Trial-1-3 is a

double-blind, randomized, sham-controlled, parallel group,

multicenter, pivotal study that will enroll 1000 subjects at up

to 50 sites. All subjects will receive standard medical management

based on the American Stroke Association and

European Stroke Organization Guidelines. In addition to

standard medical management, both groups will undergo

transcranial laser therapy procedure between 4·5 and 24 h of

stroke onset. The study population will be randomized into

two arms: the sham control group will receive a sham transcranial

laser therapy procedure and the transcranial laser

therapy group will receive an active transcranial laser

therapy procedure. The randomization ratio will be 1:1 and

will be stratified to ensure a balanced subject distribution

between study arms.

Study Outcomes The primary efficacy end point is disability

at 90 days (or the last rating), as assessed on the modified

Rankin Scale, dichotomized as a success (a score of 0–2) or a

failure (a score of 3 to 6).

Translational Research Themed Edition of the International Journal of Stroke

'The mortality and morbidity associated with stroke makes the development of new drugs a research priority. Recent unsuccessful clinical trials have reduced enthusiasm for the development of neuroprotective drugs. Here, we use empirical evidence derived from systematic reviews of stroke drug development to identify stages of drug development which might be improved. We then propose exemplar strategies which may be helpful, along with some basic economic modelling of what the impact of such strategies might be. This suggests that relatively straightforward measures might reduce the costs of drug development by $5·8 bn or 31%.'


Abstract from Improving the efficiency of the development of drugs for stroke
Authors: 

David W. Howells^1,2,*, 

Emily S. Sena^1,2,

Victoria O'Collins¹, 

Malcolm R. Macleod

ESC IST-3 announcement

Researchers from the International Stroke Trial 3; have released results from the worlds largest ever trial of the clot busting drug rt-PA. Published today concurrently in the Lancet, and presented at the European Stroke Conference in Lisbon.

The IST-3 trial found patients receiving clot-busting drugs have a better chance of survival and avoiding disability. In patients over 80, a previously untreated group in the European Union, the use of rt-PA will dramatically increase their survival rates post stroke.

Research has found patients under 80 benefit from rt-PA when treated within four and a half hours of stroke. Co investigator Richard Lindley, Professor of Geriatric Medicine from the University of Sydney’s Medical School is adamant ‘Please don’t ignore the over 80s – they benefit hugely’.   

Richard Lindley, Joanna Wardlaw and Michael Hennerici at todays ESC announcement 

The trial found fatal bleeding was a risk factor associated with rt-PA use within the first week of treatment, although the researchers insist that the early hazard is greatly outweighed by the late substantial benefit. Dr Lindley insists that in his practical experience patients over 80 have an extremely high risk of death after stoke within the six month period indicated and that the risk of rt-PA bleed is minimal compared to the risk of no treatment at all.

This latest study sought to establish rt-PA treatment as effective in patients over 80, and it has done exactly that. As the population ages and age becomes a primary risk factor in Australia these treatments will be able to alleviate the extreme costs of stroke on the community and increase quality of life for stroke patients.

IST-3 Imaging Lead Professor Joanna Wardlaw for the University of Edinburgh Centre for Clinical Brain Sciences, is also pushing for better managed clinical windows so that patients can access rt-PA within the required time, ‘the faster you treat the better the outcome’ she said ‘ and faster treatment will result from better communication (among health workers)’.

Carmen Lahiff-Jenkins

Managing Editor the International Journal of Stroke

Attending the European Stroke Conference, Lisbon, Portugal