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In patients with suspected acute stroke, immediate brain imaging, most frequently with computed tomography (CT), is essential to distinguish between an ischemic lesion and a hemorrhage. In ischemic stroke, timely treatment with intravenous tissue plasminogen activator or thrombectomy results in substantial clinical improvement. The treatment is time dependent with a 5% decrease in mortality for every 15-minute reduction in door-to-needle times. Although access to cranial CT scanners poses few problems in urban areas, this may be challenging in rural settings. The recent installation of portable scanners in ambulances (i.e., mobile stroke unit) facilitates rapid evaluation and treatment of patients with acute stroke. Although the emphasis is currently on the evaluation and management of acute stroke, the mobile stroke unit may be used in the management of other neurologic and neurosurgical emergencies.Portable CT technology continues to improve. Introduction of CT angiography and CT perfusion into mobile stroke units will allow for detection of major arterial occlusions in patients with acute stroke, allowing for diversion to specialized hospitals that offer thrombectomy services.

Mobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.

OBJECTIVE: Admission hyperglycemia has been associated with worse outcomes in ischemic stroke. We hypothesized that hyperglycemia (glucose >8.0 mmol/l) in the hyperacute phase would be independently associated with increased mortality, symptomatic intracerebral hemorrhage (SICH), and poor functional status at 90 days in stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). RESEARCH DESIGN AND METHODS: Using data from the prospective, multicenter Canadian Alteplase for Stroke Effectiveness Study (CASES), the association between admission glucose >8.0 mmol/l and mortality, SICH, and poor functional status at 90 days (modified Rankin Scale >1) was examined. Similar analyses examining glucose as a continuous measure were conducted. RESULTS: Of 1,098 patients, 296 (27%) had admission hyperglycemia, including 18% of those without diabetes and 70% of those with diabetes. After multivariable logistic regression, admission hyperglycemia was found to be independently associated with increased risk of death (adjusted risk ratio 1.5 [95% CI 1.2-1.9]), SICH (1.69 [0.95-3.00]), and a decreased probability of a favorable outcome at 90 days (0.7 [0.5-0.9]). An incremental risk of death and SICH and unfavorable 90-day outcomes was observed with increasing admission glucose. This observation held true for patients with and without diabetes. CONCLUSIONS: In this cohort of IV-tPA-treated stroke patients, admission hyperglycemia was independently associated with increased risk of death, SICH, and poor functional status at 90 days. Treatment trials continue to be urgently needed to determine whether this is a modifiable risk factor for poor outcome.

Leukoaraiosis regions may be more vulnerable to decreases in cerebral perfusion. We aimed to assess perfusion in leukoaraiosis regions in acute intracerebral hemorrhage (ICH) patients. We tested the hypothesis that aggressive acute BP reduction in ICH patients is associated with hypoperfusion in areas of leukoaraiosis. In the ICH Acutely Decreasing Arterial Pressure Trial (ICH ADAPT), patients with ICH <24 hours duration were randomized to two systolic BP (SBP) target groups (<150 mmHg vs. <180 mmHg). Computed tomography perfusion (CTP) imaging was performed 2h post-randomization. Leukoaraiosis tissue volumes were planimetrically measured using semi-automated threshold techniques on the acute non-contrast CT. CTP source leukoaraiosis region-of-interest object maps were co-registered with CTP post-processed maps to assess cerebral perfusion in these areas. Seventy-one patients were included with a mean age of 69±11.4 years, 52 of whom had leukoaraiosis. The mean relative Tmax (rTmax) of leukoaraiotic tissue (2.3±2s) was prolonged compared to that of normal appearing white matter in patients without leukoaraiosis (1.1±1.2s, p = 0.04). In the 52 patients with leukoaraiosis, SBP in the aggressive treatment group (145±20.4 mmHg, n = 27) was significantly lower than that in the conservative group (159.9±13.1 mmHg, n = 25, p = 0.001) at the time of CTP. Despite this SBP difference, mean leukoaraiosis rTmax was similar in the two treatment groups (2.6±2.3 vs. 1.8±1.6 seconds, p = 0.3). Cerebral perfusion in tissue affected by leukoaraiosis is hypoperfused in acute ICH patients. Aggressive BP reduction does not appear to acutely aggravate cerebral hypoperfusion.

Background Aggressively lowering blood pressure (BP) in acute intracerebral hemorrhage (ICH) may improve outcome. Although there is no evidence that BP reduction changes cerebral blood flow, retrospective magnetic resonance imaging (MRI) studies have demonstrated sub-acute ischemic lesions in ICH patients. The primary aim of this study is to assess ischemic lesion development in patients randomized to two different BP treatment strategies. We hypothesize aggressive BP reduction is not associated with ischemic injury after ICH. Methods The I ntra c erebral H emorrhage A cutely D ecreasing B lood P ressure T rial II (ICH ADAPT II) is a phase II multi-centre randomized open-label, blinded-endpoint trial. Acute ICH patients ( N  = 270) are randomized to a systolic blood pressure (SBP) target of <140 or <180 mmHg. Acute ICH patients within 6 h of onset and two SBP measurements ≥140 mmHg recorded >2 mins apart qualify. SBP is managed with a pre-defined treatment protocol. Patients undergo MRI at 48 h, Days 7 and 30, with clinical assessment at Day 30 and 90. The primary outcome is diffusion weighted imaging (DWI) lesion frequency at 48 h. Secondary outcomes include cumulative DWI lesion rate frequency within 30 days, absolute hematoma growth, prediction of DWI lesion incidence, 30-day mortality rates, day 90 functional outcome, and cognitive status. Discussion This trial will assess the impact of hypertensive therapies on physiological markers of ischemic injury. The findings of this study will provide evidence for the link, or lack thereof, between BP reduction and ischemic injury in ICH patients. Trial registration This study is registered with clinicaltrials.gov  ( NCT02281838 , first received October 29, 2014).

Despite a gradual trend toward urbanization resulting in an increased share of the non-rural population overtime in relative terms, the absolute number of people living rurally is still increasing.3 Stroke care must be appropriate, safe, efficient, acceptable, accessible, and effective.4 These quality benchmarks are easier to achieve in urban centers, but severe inequalities may appear in rural communities. [...]Ontario and British Columbia are the most urbanized provinces with a rural share of 14% each.6 Stroke care services access will likely fall short of the Ontario average in multiple domains if a similar analysis was conducted for provinces and territories with higher rural proportions and a less organized stroke system. Unfortunately, endovascular treatment services are not even available in Yukon Territory, Northwest Territories, or Nunavut.10 Many other aspects of organized stroke care may also be lacking in these places in which more than 100,000 Canadians abide permanently, many in rural areas.11 The results of the current paper suggest that 77% of rural Ontarians have access to inpatient stroke rehabilitation services within 60 min of drive time.

Case 1: A previously healthy 51-year-old man came to hospital complaining of headache of 3 weeks' duration and several days of nausea, vomiting and confusion. He had some difficulty recalling the events of the preceding 3 weeks, but the results of his general and neurologic examinations were otherwise normal. A CT scan of the brain showed bilateral, symmetric infarcts in the heads of the caudate nuclei, with hyperdensity surrounding the anterior communicating artery. The infarcts were confirmed via MRI; conventional angiography showed a 4-mm saccular aneurysm of the anterior communicating artery (Fig. 1). To treat the aneurysm, we successfully inserted detachable coils endovascularly. Afterward, the patient remained medically stable and was discharged home 2 weeks later. In the pre-antibiotic era, symptomatic neurosyphilis developed in about one-third of patients; parenchymal forms involving the brain and spinal cord (syphilitic encephalitis, tabes dorsalis) were seen the most often. With the advent of penicillin therapy, the typical clinical presentation has shifted away from chronic forms of neurosyphilis, which involve CNS parenchyma, to earlier forms that involve CNS meninges and blood vessels (e.g., syphilitic meningitis, meningovascular syphilis with associated ischemie stroke).3 Persistent and prominent headache in a patient can alert the clinician to early neurosyphilis. Unfortunately, the nonspecific nature of headache and a lack of other obvious signs can leave patients vulnerable to undiagnosed deterioration, particularly in cases of syphilitic vasculitis. Aneurysms of the aorta are known to occur in syphilis, but a cerebral aneurysm secondary to syphilitic vasculopathy has been reported only once, in a patient with an aneurysm of the posterior communicating artery.5 We were unable to locate another report of an anterior communicating artery aneurysm associated with meningovascular syphilis; in fact, the aneurysm may have been an incidental finding.

With regard to arterial thromboembolism, Lide- gaard and colleagues10 found relative risks of stroke of 1.60 (95% confidence interval [CI] 1.37- 1.86; NNH 29 762), 1.75 (95% CI 1.61-1.92; NNH 23810) and 1.97 (95% CI 1.45-2.66; NNH 18 409) among patients taking combined hor- monal contraceptives containing EE at a dose of 20 µg, 30-40 µg and 50 µg, respectively, compared with nonusers. The corresponding relative risks for myocardial infarction were found to be 1.40 (95% CI 1.07-1.81; NNH 357 143), 1.88 (95% CI 1.66- 2.13; NNH 162 338) and 3.73 (95% CI 2.78-5.00; NNH 52 329).10 We calculated the above NNH val- ues per year of treatment using baseline risks in our patient's age group of 5.6/100 000 person- years for stroke and 0.7/100 000 person-years for myocardial infarction. It seems likely that CPA-EE also increases the risk of thrombosis. The relative risk of venous thromboembolism among users of CPA- EE compared with nonusers is 6.35 (95% CI 5.09-7.93), and the NNH is calculated to be 890.9 The relative risk and calculated NNH is 1.4 (95% CI 0.97-2.03; 44 643) and 1.47 (95% CI 0.83-2.61; 303 951) for ischemic stroke and myocardial infarction, respectively.10 The relative risk of arterial events, although not statistically significant, is roughly proportional to rates seen with other combined hormonal contraceptives.10 The relative risk of venous thromboembolism is comparable to that of most third- and fourth- generation combined hormonal contraceptives, and double that of second-generation hormonal contraceptives.9,11 Cyproterone acetate-ethinyl estradiol, like many other hormonal medications, has been shown to increase the risk of venous thromboembolism. Although a corresponding risk of arterial throm- boembolism has not been as well established, our case provides evidence for a probable link between stroke and CPA-EE. However, given the much higher relative risk of venous throm- boembolism compared with that of arterial thromboembolism, coupled with a higher base- line risk in the population that uses this agent, the venous risk tends to convey more harm than the arterial risk. When used appropriately as a second-line agent for a short duration to treat severe acne in women with other signs of andro- genicity, the risk-benefit profile is favourable. However, clinicians should reconsider the off- label use of this medication, because safer inter- ventions exist for contraception and the treat- ment of mild to moderate acne.

We present a conceptual approach to determine the optimal solution to delivering a health technology, consistent with the objective of maximizing patient outcomes subject to resources available to a publicly funded health system. The article addresses two key policy questions: 1) adding system values through appropriate planning of health services delivery and 2) considering the tradeoff between patient outcomes and costs to the health system through appropriate use of health technologies for conditions with time-dependent treatment outcomes. We develop a health technology optimization framework that considers geographical variation and searches for the best delivery method through a pairwise comparison of all possible strategies, factoring in controlled variables including disease epidemiology, time or distance to hospitals, available medical services, treatment eligibility, treatment efficacy, and costs. Taking variations of these factors into account would help support a more efficient allocation of health resources. Drawing identified strategies together then creates a map of optimal strategies. We apply the proposed method to a policy-relevant health technology assessment of endovascular therapy (EVT) for treating acute ischemic stroke. The best strategy for providing EVT relies on the geographical location of stroke onset and the decision maker’s preference for either patient outcomes or economic efficiency. The proposed method produced an optimization map showing the optimal strategy for EVT delivery, which maximizes patient outcomes while minimizing health system costs. In the illustrative case study, there were no tradeoffs between health outcomes and costs, meaning that the delivery strategies that were clinically optimal for patients were also the most cost-effective. In conclusion, the health technology optimization approach is a useful tool for informing implementation decisions and coordinating the delivery of complex health services such as EVT.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multi-organ condition occurring with a 1 in 3800 prevalence in Alberta. This genetic disorder leads to vascular malformations in different organs including the lungs and brain, commonly affecting pulmonary vasculature leading to pulmonary arteriovenous malformations (PAVMs). PAVMs lead to right-to-left shunts, which may be associated with neurologic complications. We aimed to evaluate and summarize the reported neurologic manifestations of individuals with HHT with pre-existing PAVMs. We performed a qualitative systematic review to determine available literature on neurological complications among patients with PAVMs and HHT. Published studies included observational studies, case studies, prospective studies, and cohort studies including search terms HHT, PAVMs, and various neurologic complications using MEDLINE and EMBASE. A total of 449 manuscripts were extracted including some duplicates of titles, abstracts, and text which were screened. Following this, 23 publications were identified for inclusion in the analysis. Most were case reports ( = 15). PAVMs were addressed in all these articles in association with various neurological conditions ranging from cerebral abscess, ischemic stroke, hemorrhagic stroke, embolic stroke, and migraines. Although HHT patients with PAVMs are at risk for a variety of neurological complications compared to those without PAVMs, the quality and volume of evidence characterizing this association is low. Individuals with PAVMs have a high prevalence of neurological manifestations such as cerebral abscess, transient ischemic attack, cerebral embolism, hemorrhage, and stroke. Mitigating stroke risk by implementing proper standardized screening techniques for PAVMs is invaluable in preventing increased mortality.