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More than just a discussion of the medical and practical aspects of stroke and stroke recovery, this book focuses on the emotional, psychological, and social consequences of stroke and the deeply personal side of caregiving. When Your Spouse Has a Stroke will relieve your burden and strengthen your partnership.

Tenecteplase for thrombolysis in a 4.5-to-24-hour window did not improve disability outcomes at 90 days in patients with ischemic stroke who had been chosen on the basis of imaging. Most patients had endovascular thrombectomy.

Trials of the efficacy and safety of endovascular thrombectomy in patients with large ischemic strokes have been carried out in limited populations. We performed a prospective, randomized, open-label, adaptive, international trial involving patients with stroke due to occlusion of the internal carotid artery or the first segment of the middle cerebral artery to assess endovascular thrombectomy within 24 hours after onset. Patients had a large ischemic-core volume, defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower scores indicating larger infarction) or a core volume of at least 50 ml on computed tomography perfusion or diffusion-weighted magnetic resonance imaging. Patients were assigned in a 1:1 ratio to endovascular thrombectomy plus medical care or to medical care alone. The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Functional independence was a secondary outcome. The trial was stopped early for efficacy; 178 patients had been assigned to the thrombectomy group and 174 to the medical-care group. The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51 (95% confidence interval [CI], 1.20 to 1.89; P<0.001). A total of 20% of the patients in the thrombectomy group and 7% in the medical-care group had functional independence (relative risk, 2.97; 95% CI, 1.60 to 5.51). Mortality was similar in the two groups. In the thrombectomy group, arterial access-site complications occurred in 5 patients, dissection in 10, cerebral-vessel perforation in 7, and transient vasospasm in 11. Symptomatic intracranial hemorrhage occurred in 1 patient in the thrombectomy group and in 2 in the medical-care group. Among patients with large ischemic strokes, endovascular thrombectomy resulted in better functional outcomes than medical care but was associated with vascular complications. Cerebral hemorrhages were infrequent in both groups. (Funded by Stryker Neurovascular; SELECT2 ClinicalTrials.gov number, NCT03876457.).

Endovascular therapy for stroke is generally avoided if the cerebral infarction is large. In a trial conducted in Japan, the percentage of patients who had a good functional outcome at 90 days was higher with endovascular therapy than with medical care, but there were more cerebral hemorrhages with endovascular therapy.

In a large trial, the estimated incidence of stroke, systemic embolism, hemorrhage, or death was 2.8 percentage points lower to 0.5 percentage points higher with early than with later use of direct oral anticoagulants.

In this trial involving 543 patients with stroke due to occlusion of medium or distal vessels, endovascular treatment within 24 hours after the onset of symptoms was not effective in improving functional outcome at 90 days.

Motor impairments contribute substantially to long-term disability following stroke. Studies of transcranial direct current stimulation (tDCS), combined with various rehabilitation therapies, have shown promising results in reducing motor impairment. We aimed to evaluate the safety and efficacy of three doses of tDCS in combination with modified constraint-induced movement therapy (mCIMT) in people who have had their first ischaemic stroke in the preceding 1–6 months. We conducted a phase 2, multicentre, randomised, triple-blind, sham-controlled study with a blinded centrally scored primary outcome. The trial was conducted at 15 medical centres in the USA. Eligible participants were enrolled between 1 month and 6 months after their first ischaemic stroke. Inclusion criteria required participants to have a persistent motor deficit, defined as a Fugl–Meyer Upper-Extremity (FM-UE) score of 54 or lower (out of 66), and two consecutive baseline visits (separated by 7–14 days) with an absolute difference of 2 or fewer points on the FM-UE scale. Participants were randomly assigned to treatment groups by an adaptive randomisation algorithm hosted on the TRANSPORT2 WebDCU study website. Participants received either sham, 2 mA, or 4 mA of bi-hemispheric tDCS for the first 30 min and mCIMT with 120 min of active therapy time per session, administered over ten sessions during a 2-week period. The primary endpoint was the change in FM-UE score from baseline to day 15, which was analysed in all participants who have data both at baseline and post-baseline (modified intention-to-treat group). Safety outcomes were analysed in all participants. TRANSPORT2 is registered at clinicaltrials.gov (NCT03826030) and its status is completed. 129 participants were recruited between Sept 9, 2019, and June 14, 2024, and 43 participants were randomly assigned to each group. 54 (42%) of 129 participants were female, and 69 (53%) were White. Two participants in the sham plus mCIMT group withdrew consent before the day 15 assessment and were excluded from the primary analysis. The median baseline FM-UE score was 39·0 (IQR 30·0–46·0) in the sham plus mCIMT group, 39·0 (27·0–48·0) in the 2 mA plus mCIMT group, and 40·0 (27·0–48·0) in the 4 mA plus mCIMT group. For the primary outcome, the adjusted mean change from baseline to day 15 in FM-UE was 4·91 (3·00–6·82) for sham plus mCIMT, 3·87 (2·00–5·74) for 2 mA plus mCIMT, and 5·53 (3·64–7·42) for 4 mA plus mCIMT (p=0·39). No clinically important adverse events were observed in any group and no deaths were reported. tDCS at doses of 2 mA or 4 mA, in addition to mCIMT, did not lead to further reduction in motor impairment in patients 1–6 months after stroke, but it was safe, well tolerated, and feasible for clinical practice. tDCS at higher doses (ie, >4 mA) might be a consideration for future trials in addition to balancing known covariates affecting stroke recovery during the group allocation. National Institute of Neurological Disorders and Stroke.

BackgroundTransthoracic echocardiography (TTE) with bubble study remains the first-line investigation for patent foramen ovale (PFO) detection, despite limitations in sensitivity (73–85%) compared to transoesophageal echocardiography with bubble contrast. We evaluated real-world performance, focusing on indication appropriateness, diagnostic accuracy, and clinical outcome.MethodsAll TTE bubble studies performed in adults ≤65 years between June 2023 and July 2024 were retrospectively analysed. Referral forms were cross-referenced with clinical records to validate indication appropriateness. Two BSE-accredited echocardiographers independently reclassified negative studies as true negative, positive (>5 bubbles in the left ventricle within 5 cardiac cycles), or equivocal (incomplete storage, absent Valsalva despite interatrial septal movement, or <5 bubbles). Clinical data, including RoPE scores and PFO closure decisions, were extracted from electronic records.ResultsNinety-five unique TTE bubble studies were analysed. Of these, 46 (48%) were appropriate referrals, while 49 (52%) were inappropriate; most inappropriate cases had an alternative stroke aetiology (table 1). Thirteen studies (14%) were performed before infarct confirmation, representing premature investigation.Thirty-seven of the 46 appropriately indicated studies were initially reported as negative and were reviewed. Three were reclassified as positive and 5 as equivocal, leaving 29 confirmed negative.Of the 37 initially reported negative, 4 (10.8%) proceeded to further evaluation with TOE, 2 from the reclassified equivocal group and 2 from the reclassified positive group. Three of these 4 proceeded to closure. Reasons for non-closure and not proceeding to TOE are summarised in figure 1.Of the 12 patients with confirmed PFO, 8 were identified on initial TTE bubble study, whereas 4 required further evaluation with TOE before confirmation.ConclusionsThis study demonstrates that, when used in the appropriate clinical context, TTE bubble study is a suitable first-line investigation for PFO detection. Following expert review, only 10.8% of cases required further evaluation with TOE. However, more than half of referrals were inappropriate, with some performed prematurely. These findings highlight the need for stricter referral triage to optimise resource use and ensure appropriate patient selection.Abstract 85 Table 1Referral indications for TTE bubble studies (N=95) Category Indication subtype n % of total Appropriate Indication≤60 years old cryptogenic stroke with confirmed infarction3942%Platypneoa Orthodeoxia / Hepatopulmonary Syndrome22%Systemic embolism55%Inappropriate Indication>60 years old stroke, RoPE Score <71415%Large-vessel disease (carotid/vertebral)1818%TIA without infarction on MRI66%Haemorrhagic Stroke33%Intracranial mass22%Other/No clear indication66%Abstract 85 Figure 1[Image Omitted. See PDF.]

In a trial conducted in China, patients with large cerebral infarctions as determined by imaging criteria within 24 hours after onset had better outcomes with endovascular therapy than with medical therapy alone.