The Phase 2 randomized, double-blind, placebo-controlled, multicenter dose-escalation trial will consist of three treatment cohorts, including a placebo group, and two treatment groups involving dose tiers of either 400 million or 1200 million cells per patient. Patients will be treated at 24–36 h after stroke. The two primary objectives are to determine the highest well-tolerated and safe single dose of MultiStem up to a maximum of 1200 million total cells in subjects with ischemic stroke and to determine the efficacy of MultiStem on functional outcome in subjects with stroke as measured by the modified Rankin Scale at 90 days. Patients will also be evaluated using the National Institutes of Health Stroke Scale and Barthel Index. The study will explore other aspects including, uniquely, the measurement of spleen size after stroke by magnetic resonance imaging or computed tomography imaging.

If MultiStem is safe and there is a signal of efficacy, a late stage phase IIb-III trial is planned.

The present article discusses the evolution of stroke care in Brazil over the last decade.

We describe the main characteristics of stroke care before 2008; a pilot study in a Southern Brazilian city between 2008 and 2010, the Brazilian Stroke Project initiative; and the 2012 National Stroke Policy Act.

The National Stroke Project was followed by a major increased on the number of stroke center in the country. The key elements of the 2012 National Stroke Policy Act included: definition of the requirements and levels of stroke centers; improved reimbursement for stroke care; promotion of stroke telemedicine; definition of the Line of Stroke Care (to integrate available resources and other health programs); increased funding for stroke rehabilitation; funding for training of healthcare professionals and initiatives to increase awareness about stroke within the population.

The evolution of stroke care in Brazil over the last decade is a pathway that exemplifies the challenges that middle-income countries have to face in order to improve stroke prevention, treatment and rehabilitation. The reported Brazilian experience can be extrapolated to understand the past, present, and future of stroke care in middle-income countries.

We aimed to evaluate the early outcomes and safety of stroke thrombolysis in a South African setting.

We conducted a prospective observational study of all stroke patients receiving tPA for thrombolysis over the period January 2000 to February 2011. The primary outcome measure was the proportion of patients achieving significant early neurological recovery defined as an improvement of four or more points on the NIHSS score at discharge. The safety endpoint was the rate of symptomatic intracranial haemorrhage (SICH) and death.

Forty-two patients received thrombolysis over the study period. Sixty-seven percent achieved significant neurological improvement. The majority of patients (53.8%) were discharged home, and by the time of discharge 17 (40.5%) were functionally independent. SICH occurred in 2 (4.8%) patients with an overall mortality rate of 7.1%.

Our findings indicate that the use of thrombolysis in routine clinical practice in a South African setting has similar safety and early efficacy outcomes to developed and other developing countries.

To investigate the recovery mechanism using functional magnetic resonance imaging.

Forty-seven poststroke hemiparetic patients were hospitalized to receive 12 sessions of 40-min low-frequency repetitive transcranial magnetic stimulation over the nonlesional hemisphere and daily occupational therapy for 15 days. Motor function was evaluated with the Fugl–Meyer Assessment and Wolf Motor Function Test. The functional magnetic resonance imaging with motor tasks was performed at admission and discharge. The laterality index of activated voxel number in Brodmann areas 4 and 6 on functional magnetic resonance imaging was calculated (laterality index range of −1 to +1). Patients were divided into two groups based on functional magnetic resonance imaging findings before the intervention: group 1: patients who showed bilateral activation (n = 27); group 2: patients with unilateral activation (n = 20).

Treatment resulted in improvement in Fugl–Meyer Assessment and Wolf Motor Function Test in the two groups (P < 0·01). The treatment also resulted in a significant increase in laterality index in group 1 (P < 0·05), suggesting a shift in activated voxels to the lesional hemisphere. Patients of group 2 showed a significant increase in lesional hemisphere activation (P < 0·05).

The results of serial functional magnetic resonance imaging indicated that our proposed treatment can induce functional cortical reorganization, leading to motor functional recovery of the affected upper limb. Especially, it seems that neural activation in the lesional hemisphere plays an important role in such recovery in poststroke hemiparetic patients.

To investigate whether induced hypertension improves the functional outcome in patients with delayed cerebral ischemia after SAH.

The HIMALAIA trial is a multicenter, singe-blinded, randomized controlled trial in patients with DCI after a recent SAH. Eligible patients will be randomized to either induced hypertension (n = 120) or to no induced hypertension (n = 120). In selected centers, the efficacy of induced hypertension in augmenting cerebral blood flow will be measured by means of cerebral perfusion computerized tomography scanning. Follow-up assessments will be performed at 3 and 12 months after randomization by trial nurses who are blinded to the treatment allocation and management. We will include patients during five years.

The primary outcome is the proportion of subarachnoid hemorrhage patients with delayed cerebral ischemia with poor outcome three-months after randomization, defined as a modified Rankin scale of more than 3. Secondary outcome measures are related to treatment failure, functional outcome, adverse events, and cerebral hemodynamics. The HIMALAIA trial is registered at clinicaltrials.gov under identifier NCT01613235.

We prospectively recruited patients with acute stroke, diagnosed and subtyped by a stroke physician using clinical features and brain magnetic resonance imaging. A neuroradiologist rated basal ganglia and centrum semiovale enlarged perivascular spaces on a five-point scale, white matter lesions, recent and old infarcts, and cerebral atrophy. We assessed associations between basal ganglia-, centrum semiovale- and total (combined basal ganglia and centrum semiovale) enlarged perivascular spaces, stroke subtype, white matter lesions, atrophy, and vascular risk factors.

Among 298 patients (mean age 68 years), after adjusting for vascular risk factors and white matter lesions, basal ganglia–enlarged perivascular spaces were associated with increasing age (P = 0·001), centrum semiovale–enlarged perivascular spaces (P < 0·001), cerebral atrophy (P = 0·03), and lacunar stroke subtype (P = 0·04). Centrum semiovale–enlarged perivascular spaces were associated mainly with basal ganglia–enlarged perivascular spaces. Total enlarged perivascular spaces were associated with increasing age (P = 0·01), deep white matter lesions (P = 0·005), and previous stroke (P = 0·006).

Enlarged perivascular spaces are associated with age, lacunar stroke subtype and white matter lesions and should be considered as another magnetic resonance imaging marker of cerebral small vessel disease. Further evaluation of enlarged perivascular spaces in studies of ageing, stroke, and dementia is needed to determine their pathophysiological importance.

The study aims to assess the effect of high-dose paracetamol in patients with acute stroke and a body temperature of 36·5°C or above on functional outcome.

The Paracetamol (Acetaminophen) In Stroke 2 trial is a multicenter, randomized, double-blind, placebo-controlled clinical trial. We use a power of 85% to detect a significant difference in the scores on the modified Rankin Scale of the paracetamol group compared with the placebo group at a level of significance of 0·05 and assume a treatment effect of 7%. Fifteen-hundred patients with acute ischemic stroke or intracerebral hemorrhage and a body temperature of 36·5°C or above will be included within 12 h of symptom onset. Patients will be treated with paracetamol in a daily dose of six-grams or matching placebo for three consecutive days. The Paracetamol (Acetaminophen) In Stroke 2 trial has been registered as NTR2365 in The Netherlands Trial Register.

The primary outcome will be improvement on the modified Rankin Scale at three-months as analyzed by ordinal logistic regression.

If high-dose paracetamol will be proven effective, a simple, safe, and extremely cheap therapy will be available for many patients with acute stroke worldwide.

We aimed to assess the effects of adding clopidogrel to aspirin on the occurrence of stroke and major haemorrhage in patients with vascular disease.

Meta-analysis of published randomized trials comparing the combination of clopidogrel and aspirin vs. aspirin alone that reported stroke and major bleeding.

Thirteen randomized trials were included with a total of 90 433 participants (mean age 63 years; 63% male) with a mean follow-up of 1·0 years and 2011 strokes. Stroke was reduced 19% by dual antiplatelet therapy (odds ratio = 0·81, 95% confidence interval 0·74–0·89) with no evidence of heterogeneity of effect across different trial populations (I² index = 5%, P = 0·4 for heterogeneity). Dual antiplatelet therapy reduced ischemic stroke by 23% (odds ratio = 0·77; 95% confidence interval 0·70–0·85); there was a nonsignificant 12% increase in intracerebral haemorrhage (odds ratio = 1·12, 95% confidence interval 0·86–1·46). Among 1930 participants with recent (<30 days) brain ischemia from four trials, stroke was reduced by 33% (odds ratio = 0·67, 95% confidence interval 0·46–0·97) by dual antiplatelet therapy vs. aspirin alone. The risk of major bleeding was increased by 40% (odds ratio = 1·40, 95% confidence interval 1·26–1·55) by dual antiplatelet therapy.

This meta-analysis demonstrates a substantial relative risk reduction in stroke by clopidogrel plus aspirin vs. aspirin alone that is consistent across different trial cohorts. Major haemorrhage is increased by dual antiplatelet therapy.

Three hundred and ten consecutive patients aged 50 years and older with a first episode of acute ischemic stroke were prospectively evaluated. All patients were admitted to the hospital within 24 h of the onset of stroke symptoms. The type of acute ischemic stroke was classified according to the Trial of Org 10172 in Acute Stroke Treatment classification. Blood samples were taken for measurement of brain natriuretic peptide levels at admission. Aortic stiffness indices, aortic strain and distensibility, were calculated from the aortic diameters measured by transthoracic echocardiography. The patients were followed for one-year or until death, whichever came first. Death occurred in 51 (16·5%) patients. On multivariate logistic regression analysis, National Institutes of Health Stroke Scale score >13, diabetes, brain natriuretic peptide >235 pg/mL, aortic distensibility, and aortic strain were associated with all-cause mortality. The optimal cutoff level of brain natriuretic peptide to distinguish the deceased group from the survival group was 235 pg/mL (sensitivity 71·0% and specificity 63·0%) and to distinguish cardioembolic stroke from noncardioembolic stroke was 155 pg/mL (sensitivity 81% and specificity 63%).

Aortic stiffness and brain natriuretic peptide predict mortality in patients with first-ever acute ischemic stroke. Brain natriuretic peptide also differentiates cardioembolic stroke from noncardioembolic stroke.

The aim of this study was to systematically review randomized controlled trials that compare rehabilitation to standard care after stroke in China.

We searched 24 databases including Wanfangdata (China), MEDLINE, EMBASE, CENTRAL, Cochrane Stroke Group Register, and Cochrane Central Register of Controlled trials. The primary outcome of interest was activities of daily living (Barthel Index), and the secondary outcome was disability (Fugl-Meyer Score). Random-effect meta-analysis was performed.

Thirty-seven randomized controlled trials consisting of 5916 patients met inclusion criteria. Mean age reported in each study range from 47·2 to 72·5 years, 52·6% were male and 23·8% had a haemorrhagic stroke. Rehabilitation interventions varied between studies, but all included additional exercise therapy. Control patients had no formal rehabilitation. Patients who received rehabilitation showed marked improvements in Barthel Index (standardized mean difference: 1·04, 95% confidence interval: 0·88–1·21, P < 0·001, I² = 85·9%) and Fugl-Meyer Score (standardized mean difference: 1·10, 95% confidence interval: 0·82–1·38, P < 0·001, I² = 94·3%) compared with controls. However, reporting quality was low, and time to start of rehabilitation was often unclear.

These data provide some evidence that rehabilitation poststroke is more effective than no rehabilitation, improving activities of daily living and reducing disability. Although results are limited by low reporting quality and study heterogeneity, conducting research in countries in which rehabilitation is not standard care provides an opportunity to advance our understanding and should be encouraged.

We included 985 consecutive acute ischemic stroke patients treated with intravenous thrombolysis at the Helsinki University Central Hospital during 1995–2008. Body temperature, blood leukocyte count, and C-reactive protein levels were analyzed on arrival and at day one. Clinical improvement was defined as National Institutes of Health Stroke Scale score decrease of ≥4 points or a score of 0 at 24 h. Functional outcome was assessed at three-months with the modified Rankin Scale dichotomized at 0–2 (good) vs. 3–6 (poor). Associations were tested with multivariable logistic regression analysis.

Of the baseline variables, lower C-reactive protein independently predicted clinical improvement at 24 h (odds ratio 0·94 per 5 mg/L; 95% confidence interval 0·89–1·00; P = 0·03), whereas higher leukocyte count (odds ratio 1·10 per E9/L; 1·03–1·17; P < 0·01) and C-reactive protein (odds ratio 1·07 per 5 mg/L; 1·01–1·14; P = 0·02) were associated with poor three-month outcome. When body temperature increased over the first 24 h, clinical improvement after thrombolysis was unlikely (odds ratio 0·66 per °C; 0·45–0·95; P = 0·03) and poor outcome more common (odds ratio 1·63 per °C; 1·24–2·14; P < 0·001). Elevated leukocytes at baseline increased the risk of symptomatic intracerebral hemorrhage (odds ratio 1·07 per E9/L; 1·00–1·13; P = 0·04).

A lower level of systemic inflammation at time of thrombolysis may be associated with clinical improvement and good outcome at three-months. Increase in body temperature during the first 24 h associates with lack of clinical improvement and worse patient outcome.

We hypothesized that patients with posterior circulation stroke receive delayed thrombolytic treatment in comparison to anterior circulation stroke. We investigated the differences in times to evaluation or treatment between patients with anterior circulation ischaemic stroke and posterior circulation stroke in our aim to understand the barriers that might have caused these delays.

A cross-sectional study was conducted using consecutive patients presenting to our tertiary academic centre with acute ischaemic stroke who were treated with intravenous tissue plasminogen activator within 4·5 h from symptom onset. We compared demographics, stroke severity, symptoms and signs, and time intervals among onset, emergency department arrival, emergency department physician evaluation, neurologist evaluation, brain imaging, and tissue plasminogen activator treatment in patients with anterior circulation stroke and posterior circulation stroke.

Among 252 patients treated with intravenous tissue plasminogen activator, 12% had posterior circulation stroke. Patients with posterior circulation stroke had significantly lower median baseline the National Institutes of Health and Stroke Scale (NIHSS) score (P = 0·01), higher frequency of nausea (P < 0·01), vomiting (P < 0·01), dizziness (P < 0·01), and lower frequency of aphasia (P = 0·002) or neglect (P = 0·048). The emergency department physician evaluation-to-neurologist evaluation and door-to-needle intervals were significantly longer for posterior circulation stroke patients compared with anterior circulation stroke patients. The neurologist-to-needle time, however, was similar in the two groups. The presence of nausea and vomiting was associated with a longer time from emergency department evaluation to neurology evaluation and had a significant association with delayed treatment.

Posterior circulation stroke patients had a delay in neurology evaluation after initial emergency department evaluation and a delay in intravenous tissue plasminogen activator administration compared with anterior circulation stroke patients. There may be difficulties in rapidly recognizing the symptoms of posterior circulation stroke, in contrast to anterior circulation stroke, in the emergency department.

Magnetic resonance imaging (1.5t) with intracranial magnetic resonance angiography data was collected on a convenience sample between July 2008 and January 2009. All patients were independently assessed for circle of Willis variants by two researchers and categorized into two groups: those with a complete circle of Willis and those with an incomplete circle of Willis (absent vessels). The complete group was sub-divided into a classical group (entirely normal circle of Willis) and a hypoplastic group (hypoplasia but no absent vessels). White matter disease assessment was conducted for these groups, by two researchers blind to magnetic resonance angiography findings, on all patients over 50 years old.

The circle of Willis was characterized in 163 patients, while 90 (>50 years) underwent white matter disease assessment. The kappa inter-rater reliability between both circle of Willis assessors and between both white matter disease assessors was 0·57 and 0·63, respectively. The prevalence of circle of Willis variants strongly correlated with the seminal paper by Riggs and Rupp. Independent of age and gender, those with an incomplete circle of Willis (n = 68) exhibited 58% more white matter disease than those with a complete circle of Willis (n = 22) (white matter disease score 6·52 vs. 4·11, respectively, P = 0·03). Patients with absent anterior vessels exhibited more frontal white matter disease than those with intact anterior vessels (3·7 vs. 1·72, P < 0·001). Patients with absent posterior vessels exhibited more occipital white matter disease than those with intact posterior vessels (2·52 vs. 1·34, P = 0·014).

These data suggest that congenital absence of anastomotic capacity correlates with incident white matter disease, thus alluding to a hypoperfusion mechanism in the development of white matter disease.

We compared perfusion in the acute stage after perimesencephalic hemorrhage and aneurysmal subarachnoid hemorrhage.

We included 45 perimesencephalic hemorrhage patients and 45 aneurysmal subarachnoid hemorrhage patients, who were matched on clinical condition at admission and underwent computerized tomographic scanning <72 h after subarachnoid hemorrhage. Cerebral blood flow was assessed in 12 predefined regions of interest. Differences in cerebral blood flow values with corresponding 95% confidence intervals were calculated. Sub-group analyses were performed stratified on comparable amounts of blood and location of blood (posterior circulation aneurysms and additionally in infratentorial and supratentorial aneurysms).

Cerebral blood flow was higher in perimesencephalic hemorrhage patients (mean: 63·8) than in aneurysmal sub-arachnoid hemorrhage patients (mean: 55·9; difference of means: −7·9 [95% confidence interval: −10·7 to −5·2]) and also in the sub-group with comparable amounts of blood (mean cerebral blood flow: 56·4; difference of means: −7·4 [95% confidence interval: −10·4 to −4·3]). Cerebral blood flow was comparable with perimesencephalic hemorrhage patients for the sub-group with posterior circulation aneurysms (difference of means: −0·7 [95% confidence interval: −5·2 to 3·8]); however, differences diverged after stratifying posterior circulation aneurysms into supratentorial (difference of means −3·9 [95% confidence interval: −9·3 to 1·4]) and infratentorial aneurysms (difference of means 3·0 [95% confidence interval: −2·8 to 8·8]).

Perimesencephalic hemorrhage patients have a higher cerebral blood flow than aneurysmal subarachnoid hemorrhage patients. The findings of this study further support a venous origin of bleeding in perimesencephalic hemorrhage patients. Future studies should further elaborate on cerebral blood flow in posterior circulation aneurysms.

This study is part of a two-year prospective community-based registry of all cerebrovascular events in the district of Udine (153 312 inhabitants), Friuli-Venezia Giulia region, northeast of Italy, between 1 April 2007 and 31 March 2009. Overlapping sources for case finding were used, combining hot and cold pursuit.

We identified 784 stroke cases, 640 (81·6%) incident. The crude overall annual incidence rate per 100 000 residents was 256 (95% confidence interval 241–271) for all strokes and 209 (95% confidence interval 195–223) for first-ever strokes. Incidence rate for first-ever strokes was 181 (95% confidence interval 155–211) after adjustment to the 2007 Italian population and 104 (95% confidence interval 88–122) compared with the European standard population. Incidence rates for first-ever strokes was 215 (196–235) for women, 202 (183–223) for men. Crude annual incidence rates per 100 000 population were 167 (153–178) for ischemic stroke, 31 (26–37) for intracerebral hemorrhage, 8·1 (5·7–11·4) for sub-arachnoid hemorrage, and 4·6 (2·8–7·1) for undetermined stroke. Overall case fatality rates for first-ever stroke were 20·6% at 28 days and 30·2% at 180 days.

Our study shows incidence rates higher than previously reported in our region but not supporting the view of higher incidence rates in Northern than in Southern Italy. Results contribute to time-trends analysis on epidemiology, useful for dimensioning services in Italy and show the persistence of a gap between the outcome of stroke in Italy and that of the best performing European countries, urging to adopt better stroke management plans.

The Stroke Hyperglycemia Insulin Network Effort trial aims to determine the safety and efficacy of standard vs. intensive glucose control with insulin in hyperglycemic acute ischemic stroke patients.

This is a randomized, blinded, multicenter, phase III trial of approximately 1400 hyperglycemic patients who receive either standard sliding scale subcutaneous insulin (blood glucose range 80–179 mg/dL, 4·44-9·93 mmol/L) or continuous intravenous insulin (target blood glucose 80–130 mg/dL, 4·44-7·21 mmol/L) for up to 72 h, starting within 12 h of stroke symptom onset. The acute treatment phase is single blind (for the patients), but the final outcome assessment is double blind. The study is powered to detect a 7% absolute difference in favorable outcome at 90 days.

The primary outcome is a baseline severity adjusted 90-day modified Rankin Scale score, defined as 0, 0–1, or 0–2, if the baseline National Institutes of Health Stroke Scale score is 3–7, 8–14, or 15–22, respectively. The primary safety outcome is the rate of severe hypoglycemia (<40 mg/dL, <2·22 mmol/L).

This trial will provide important novel information about preferred management of acute ischemic stroke patients with hyperglycemia. It will determine the potential benefits and risks of intensive glucose control during acute stroke.

We described the representation of those with aphasia in acute stroke clinical research, the level of inclusion across international trial sites, and whether there have been improvements in the inclusion of this population in recent clinical trials.

We conducted a retrospective analysis of clinical trial data from the Virtual International Stroke Trials Archive (VISTA), defining aphasia using the Best Language (item 9) domain of the National Institutes of Health Stroke Scale. We used proportional odds modeling, adjusting for age, gender, ethnicity, stroke severity, medical history, hemisphere affected by stroke, and trial eligibility criteria, to examine the associations between year, location of enrollment, inclusion, and attrition of those with aphasia.

Data were available for 8904 patients from 10 trials; no trials listed aphasia as an exclusion criterion. At baseline, aphasia was present in 4039 (45·4%); severe/global aphasia was present in 2688 (30·2%). We observed no geographic or longitudinal disparity in the attrition of these patients at three-months. Centers in the Philippines recruited fewer people [P = 0·05, odds ratio = 0·5, 95% confidence interval (0·2, 1·0)], while centers in Central and South America included more people with severe/global aphasia [P = 0·0004, odds ratio = 2·4, 95% confidence interval (1·3, 4·3)], when compared with centers in the USA and Canada.

Acute stroke trials have demonstrated the feasibility of including people with aphasia in stroke research; we observed geographic variations that were not entirely explained by case mix or trial eligibility criteria. Similar levels of inclusion should be sought in nonemergency stroke trials to improve the applicability of research findings to this population.

This study aims to evaluate the value of clinically useful biomarkers (d-dimer and fibrinogen) for cerebral venous sinus thrombosis prediction.

Two-hundred and thirty-three suspected cerebral venous sinus thrombosis patients were enrolled in this prospective study. Thirty-four cases confirmed as cerebral venous sinus thrombosis using imaging modalities, whereas the other 199 cases served as mimic controls. Plasma samples of 34 healthy controls were further collected from age- and gender-matched volunteers. d-dimer and fibrinogen levels of all patients and controls were measured before imaging and treatment. The dynamic d-dimer and fibrinogen levels in cerebral venous sinus thrombosis cases after anticoagulation were monitored for up to 180 consecutive days.

At admission before treatment the average d-dimer and fibrinogen levels in cerebral venous sinus thrombosis group were 968·9 ± 160·1 μg/l and 6·9 ± 1·3 g/l, both of which were significantly elevated when compared with that of the controls. In cerebral venous sinus thrombosis patients, 94·1% had d-dimer elevation, 73·5% had fibrinogen elevation, and 67·6% had both elevated d-dimer and fibrinogen. During acute phase, the sensitivity and specificity of predicting cerebral venous sinus thrombosis using only d-dimer were 94·1% and 97·5%, whereas that of d-dimer in combination with fibrinogen were 67·6% and 98·9%. After administering anticoagulation, d-dimer levels gradually recovered; however, fibrinogen levels fluctuated with 33·3% of the patients still exhibiting elevated values up until 180 days.

d-dimer may serve as an important screening tool to determine the urgency of obtaining magnetic resonance imaging/magnetic resonance venography or digital subtraction angiography in patients presenting with clinical symptoms that are suspected of cerebral venous sinus thrombosis. Furthermore, d-dimer in combination with fibrinogen may increase the predictive value of acute cerebral venous sinus thrombosis.

To test the hypothesis that the efficacy of NeuroAiD compared with placebo in improving functional outcome and reducing neurological deficit in patients with cerebral infarction of intermediate severity varies between sub-groups of patients randomized in the main Chinese Medicine Neuroaid Efficacy on Stroke study when categorized according to baseline imaging characteristics.

This is a retrospective cohort sub-group analysis of patients who participated in the main Chinese Medicine Neuroaid Efficacy on Stroke study, a multicenter, double-blind, placebo-controlled trial that recruited 1100 patients within 72 h of ischemic stroke onset with National Institutes of Health Stroke Scale 6–14 and were randomized to either NeuroAiD or placebo taken four capsules three times daily for three months. Review of the baseline images to classify the acute stroke lesions in terms of size, location, and extent of involvement will be performed retrospectively by two readers who will remain blinded as to treatment allocation and outcomes of the subjects.

The primary efficacy end-point in the main Chinese Medicine Neuroaid Efficacy on Stroke study is the modified Rankin Scale grades at three-months. Secondary efficacy end-points are the National Institutes of Health Stroke Scale score at three-months; difference of National Institutes of Health Stroke Scale scores between baseline and 10 days and between baseline and three-months; difference of National Institutes of Health Stroke Scale sub-scores between baseline and 10 days and between baseline and three-months; modified Rankin Scale at 10 days, one-month, and three-months; Barthel index at three-months; and Mini Mental State Examination at 10 days and three-months. Analysis of these primary and secondary end-points will be performed for sub-groups defined in this study after review of the baseline brain imaging: nonlacunar and lacunar, cortical and sub-cortical, hemispheric vs. brainstem, Alberta Stroke Program Early CT score <7 and 7–10, and score <8 and 8–10.

A systematic search was performed using PubMed and Central Register of Controlled Trials databases for all randomized controlled trials, which compare warfarin with antiplatelet therapy given for at least one-month in heart failure patients with sinus rhythm and report at least one of the following outcomes: ischemic stroke, death, myocardial infarction, hospitalization due to worsening heart failure, intracranial hemorrhage, and major hemorrhage. Four randomized controlled trials involving adjusted-dose warfarin (4187 subjects) were included. When compared with antiplatelet therapy, warfarin reduced ischemic stroke by 0·74% per year (RR 0·49; 95% CI: 0·32–0·73: P = 0·0006; Number needed to treat = 135) but increased major hemorrhage by 0·99% per year (RR 2·15; 95% CI: 1·55–2·99: P < 0·00001; Number needed to harm = 101). Warfarin did not significantly affect the risk of death, myocardial infarction, hospitalization due to heart failure or intracranial hemorrhage as compared with antiplatelet therapy.

Warfarin as compared with antiplatelet therapy reduces risk of ischemic stroke, does not significantly affect death, myocardial infarction, hospitalization due to heart failure or intracranial hemorrhage and increases major hemorrhage in heart failure patients who are in sinus rhythm.

We sought to analyze frequency, patient characteristics, and specific therapies among emergently transferred patients within the telemedical Stroke East Saxony Network.

We reviewed consecutive patients who were transferred emergently from remote spoke sites to hub sites. Certified stroke neurologists performed teleconsultations 24/7, with access to high-speed videoconferencing and transfer of brain images. Emergent transfers were initiated when considered necessary by the stroke neurologist.

In 2009 and 2010, we conducted 1413 teleconsultations and subsequently recommended transfer in 339 (24%) patients [mean age 64 ± 14 years, 54% males, median National Institutes of Health Stroke Scale score 5 (interquartile range, IQR 12). The mean teleconsultation-to-arrival time was 1·7 ± 0·8 h (median 1·6 h). Sixty-eight (20%) transferred patients had a nonstroke diagnosis. The remaining 271 (80%) patients had stroke diagnoses [ischemic stroke, 114 (34%); transient ischemic attack, 8 (2%); and intracranial haemorrhage, 149 (44%)]. Forty (35%) ischemic stroke patients received tissue plasminogen activator at spoke sites (‘drip and ship’). Of the 240 stroke patients emergently transferred to the main hub site, 119 (49·6%) received at least one specific stroke therapy.

A remarkable number of stroke patients can be transferred within a telemedical network to enable the delivery of specific stroke therapies that require advanced multispecialty expertise. Whether associated logistic efforts and costs have an impact on patients' clinical outcomes needs to be evaluated.

To evaluate the cardiovascular health status of the inhabitants of Atahualpa (a rural village in coastal Ecuador) and to determine the prevalence and incidence of stroke and ischemic heart disease in the region.

Three-phase epidemiologic survey. During phase I, Atahualpa residents aged ≥40 years will be screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In phase II, neurologists and cardiologists will examine suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess the prevalence and incidence of these conditions. In phase III, patients with a diagnosis of stroke and ischemic heart disease will undergo complementary tests for achieving a more specific diagnosis.

Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective in improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations.

We sought to identify a base level of community stroke symptom knowledge associated with stroke recognition when symptoms occur, an immediate ambulance call, and ‘stroke recognition and immediately calling an ambulance’ as a single sequence of events.

For six-months in 2004–2005, we identified all patients with stroke living in a defined region of Melbourne and who were transported by ambulance to one of the three hospitals. The person who called the ambulance (caller) was interviewed.

One hundred ninety-eight patients were identified and 150 callers interviewed. Symptoms reported most frequently were limb weakness (67%), speech problems (57%), and facial weakness (24%). Reporting at least two of the symptoms – facial weakness, limb weakness, or speech problems (62% of callers) – was associated with stroke recognition (P = 0·004), immediately calling an ambulance (P = 0·065), and both ‘stroke recognition and immediately calling an ambulance’ (P = 0·053).

Knowing at least two of the symptoms – facial weakness, limb weakness, and speech problems – appears to be an appropriate indicator of stroke symptom knowledge as it is associated with stroke recognition and appropriate action. Recognizing stroke symptoms and immediately calling an ambulance increase the potential to reduce prehospital time delays and improve eligibility of acute stroke patients for rapid treatment.

We performed a multicenter, randomized, controlled, open-label phase II trial with blinded outcome assessment. Patients with TIA or minor ischemic stroke in the previous six months and impaired glucose tolerance (2-hour post-load glucose levels of 7.8–11.0 mmol/l) were randomized to metformin, in a daily dose of 2 g, or no metformin, for three months. Primary outcome measures were safety and feasibility of metformin, and the adjusted difference in 2-hour post-load glucose levels at three months. This trial is registered as an International Standard Randomized Controlled Trial Number 54960762.

Forty patients were enrolled; 19 patients were randomly assigned metformin. Nine patients in the metformin group had side effects, mostly gastrointestinal, leading to permanent discontinuation in four patients after 3–10 weeks. Treatment with metformin was associated with a significant reduction in 2-hour post-load glucose levels of 0·97 mmol/l (95% CI 0·11–1·83) in the on-treatment analysis, but not in the intention-to-treat analysis (0·71 mmol/l; 95% CI −0·36 to 1·78).

Treatment with metformin in patients with TIA or minor ischemic stroke and impaired glucose tolerance is safe, but leads to minor side effects. If tolerated, it may lead to a significant reduction in post-load glucose levels. This suggests that the role of metformin as potential therapeutic agent for secondary stroke prevention should be further explored.

The objective is to compare the efficacy of carotid endarterectomy + optimal medical therapy versus optimal medical therapy alone in patients with asymptomatic (70–79%) extracranial carotid stenosis.

The Aggressive Medical Treatment Evaluation for Asymptomatic Carotid Artery Stenosis study is a prospective, randomized, parallel, two-arm, multicenter trial. Primary end-points will be analyzed using standard time-to-event statistical modeling with adjustment for major baseline covariates. The primary analysis is on an intent-to-treat basis.

The primary outcome is nonfatal stroke, nonfatal myocardial infarction, and death during follow-up of up to five-years, and the secondary outcome includes death from any cause and stroke.

The aims of this study are to assess, in a sample of registrants participating in a three-month follow-up survey, retention of knowledge of risk factors and health conditions associated with hypertension, and whether those who were advised to see their doctor sought treatment or performed other health promotion actions.

Various organizations (mainly pharmacies) were recruited to offer a ‘free’ standardized blood pressure check and educational resources for one-week/year between 2008 and 2010. Data collection was done thru registration log and detailed questionnaires for a sample of registrants at baseline and three-months. Descriptive statistics were used for comparison of baseline and three-month data.

There were 59 817 registrants over three-years. A total of 2044/2283 (90%) registrants completed a baseline survey (66% female, 50% aged >55 years); 43% had blood pressure ≥140/90 mmHg whereby 32% were unaware of their blood pressure status. Follow-up surveys were obtained from 510/805 (63%) baseline participants who provided consent. At three-months, improved knowledge was found for 9 of 11 risk factors for hypertension (e.g. lack of exercise baseline 73%; three-months 85%, P < 0·001). Knowledge for all the health conditions assessed that are associated with hypertension improved (e.g. stroke baseline 72%; three-months 87%, P < 0·001, heart attack baseline 69%; three-months 84%, P < 0·001). All respondents reported at least one health promotion action. Among 141/510 advised to visit their doctor, 114 (81%) did.

Know Your Numbers is a successful health promotion program and encourages people to be reviewed by their doctor.

The study aims to evaluate whether homocysteine-lowering therapy with folic acid and vitamins B₆ and B₁₂ reduces recurrent stroke events and other combined incidence of recurrent vascular events and vascular death in ischemic stroke patients of low folate regions.

This is a multicenter, randomized, double-blinded, placebo-controlled trial. Patients (n = 8000, α = 0·05, β = 0·10) within one-month of ischemic stroke (large-artery atherosclerosis or small-vessel occlusion) or hypertensive intracerebral haemorrhage with plasma homocysteine level ≥15 μmol/l will be enrolled. Eligible patients will be randomized by a web-based, random allocation system to receive multivitamins (folic acid 0·8 mg, vitamin B₆ 10 mg, and vitamin B₁₂ 500 μg) or matching placebo daily with a median follow-up of three-years.

Patients will be evaluated at six monthly intervals. The primary outcome event is the composite event ‘stroke, myocardial infarction, or death from any vascular cause’, whichever occurs first. Secondary outcome measures include nonvascular death, transient ischemic attack, depression, dementia, unstable angina, revascularization procedures of the coronary, and cerebral and peripheral circulations.

This is the first multicenter randomized trial of secondary prevention for ischemic stroke in a Chinese population with a higher homocysteine level but without folate food fortification.

The study aims to investigate the association in stroke patients between body mass index and risk of death and readmission for recurrent stroke.

An administrative Danish quality-control registry designed to collect a predefined dataset on all hospitalized stroke patients in Denmark 2000–2010 includes 45 615 acute first-ever stroke patients with information on body mass index in 29 326. Data include age, gender, civil status, stroke severity, computed tomography, and cardiovascular risk factors. Patients were followed up to 9·8 years (median 2·6 years). We used Cox regression models to compare risk of death and readmission for recurrent stroke in the four body mass index groups: underweight (body mass index < 18·5), normal weight (body mass index 18·5–24·9), overweight (body mass index 25·0–29·9), obese (body mass index ≥ 30·0).

Mean age 72·3 years, 48% women. Mean body mass index 23·0. Within follow-up, 7902 (26·9%) patients had died; 2437 (8·3%) were readmitted because of recurrent stroke. Mortality was significantly lower in overweight (hazard ratio 0·72; confidence interval 0·68–0·78) and obese (hazard ratio 0·80; confidence interval 0·73–0·88) patients while significantly higher in underweight patients (hazard ratio 1·66; confidence interval 1·49–1·84) compared with normal weight patients. Risk of readmission for recurrent stroke was significantly lower in obese than in normal weight patients (hazard ratio 0·84; confidence interval 0·72–0·92).

Obesity was not only associated with reduced mortality relative to normal weight patients. Compared with normal weight, risk of readmission for recurrent stroke was also lower in obese stroke patients.

We investigated whether there are differences in long-term mortality among stroke patients with coexisting potential causes.

We evaluated the long-term all-cause mortality and stroke or cardiovascular mortality of ischemic stroke patients with multiple potential stroke mechanisms, large artery atherosclerosis, cardioembolism, small vessel occlusion, and negative evaluation admitted to a single center between January 1996 and December 2008. Mortality data were obtained from a National Death Certificate system.

Total 3533 patients were included in this study: 286 multiple potential mechanisms (138 large artery atherosclerosis + cardioembolism, 105 small vessel occlusion + large artery atherosclerosis, 43 small vessel occlusion + cardioembolism), 1045 large artery atherosclerosis, 701 cardioembolism, 606 small vessel occlusion, and 895 negative evaluation. During a mean follow-up of 3·9 years, as referenced to small vessel occlusion mortality rate, the adjusted mortality hazard ratio was 4·387 (95% confidence interval 3·157–6·096) for large artery atherosclerosis + cardioembolism group, 3·903 (95% confidence interval 3·032–5·024) for cardioembolism group, and 2·121 (95% confidence interval 1·655–2·717) for large artery atherosclerosis. The risk of long-term ischemic stroke mortality or cardiovascular mortality also showed comparable findings: highest in the large artery atherosclerosis + cardioembolism, followed by cardioembolism, and large artery atherosclerosis groups. However, the outcome of small vessel occlusion + large artery atherosclerosis or small vessel occlusion + cardioembolism group was not significantly different from that of small vessel occlusion.

Coexisting potential causes of ischemic stroke impact on long-term mortality. Identification of coexisting potential causes may help to predict stroke outcomes and to guide planning secondary prevention strategies.

We undertook to examine outcomes among Asians by comparing a propensity-matched cohort of thrombolyzed patients from a tertiary center in Singapore with nonthrombolyzed Asian comparators collated from Virtual International Stroke Trials Archives (control).

We identified propensity scores-matched patients between thrombolyzed and control Asian patients lodged in the Virtual International Stroke Trials Archives by employing propensity scores method. We compared matched patients for their distributions of three-month functional (modified Rankin scores) and neurological outcomes (National Institute of Health Stroke Scale) by employing Cochran–Mantel–Haenszel test and proportional odds logistic regression analysis. We report odds ratio and 95% confidence interval for improved outcomes on day 90.

Virtual International Stroke Trials Archives and National University Hospital, Singapore, contributed 517 and 133 patients of Asian race-ethnicity (n = 650), respectively. After propensity matching, sample size reduced to 237 patients; 104 were from Virtual International Stroke Trials Archives. Age (59·7 vs. 61·5 years, P = 0·2) and mean baseline National Institute of Health Stroke Scale scores were similar (14) between thrombolyzed and control. The odds ratio for shift toward improved modified Rankin scores and National Institute of Health Stroke Scale distributions after tissue plasminogen activator therapy were 2·8 (95% confidence interval 1·8-4·5, P < 0·0001, n = 233; Cochran–Mantel–Haenszel P < 0·0001) and 2·8 (95% confidence interval 1·7–4·7, P = 0·0008, n = 201; Cochran–Mantel–Haenszel P = 0·0001).

Our data indicate that Asian patients derive benefit from thrombolytic therapy.

The study aims to test the efficacy and safety of MRI-guided thrombolysis with tissue plasminogen activator (rtPA) in ischemic stroke patients with unknown time of symptom onset, e.g., waking up with stroke symptoms. We hypothesize that stroke patients with unknown time of symptom onset with a DWI-FLAIR-mismatch pattern on MRI will have improved outcome when treated with rtPA compared to placebo.

WAKE-UP is an investigator initiated, European, multicentre, randomized, double-blind, placebo-controlled clinical trial. Patients with unknown time of symptom onset who fulfil clinical inclusion criteria (disabling neurological deficit, no contraindications against thrombolysis) will be studied by MRI. Patients with MRI findings of a DWI-FLAIR-mismatch will be randomised to either treatment with rtPA or placebo.

The primary efficacy endpoint will be favourable outcome defined by modified Rankin Scale 0–1 at day 90. The primary safety outcome measures will be mortality and death or dependency defined by modified Rankin Scale 4–6 at 90 days.

If positive, WAKE-UP is expected to change clinical practice making effective and safe treatment available for a large group of acute stroke patients currently excluded from specific acute therapy.

Echoplanar Imaging Thrombolytic Evaluation Trial was a trial of 101 ischemic stroke patients randomized to intravenous tissue plasminogen activator or placebo, and Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution was a prospective cohort of 74 ischemic stroke patients treated with intravenous tissue plasminogen activator at three to six hours following symptom onset. Patients underwent multimodal magnetic resonance imaging before treatment, at three to five days and three-months after stroke in Echoplanar Imaging Thrombolytic Evaluation Trial; before treatment, three to six hours after treatment and one-month after stroke in Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution. Patients were assessed with the National Institutes of Health Stroke Scale and the modified Rankin scale before treatment and at three-months after stroke. Patients were categorized into definite atrial fibrillation (present on initial examination), probable atrial fibrillation (history but no atrial fibrillation on initial examination), and no atrial fibrillation. Perfusion data were reprocessed with automated magnetic resonance imaging analysis software (RAPID, Stanford University, Stanford, CA, USA). Hypoperfusion volumes were defined using time to maximum delays in two-second increments from >4 to >8 s. Hemorrhagic transformation was classified according to the European Cooperative Acute Stroke Studies criteria.

Of the 175 patients, 28 had definite atrial fibrillation, 30 probable atrial fibrillation, 111 no atrial fibrillation, and six were excluded due to insufficient imaging data. At baseline, patients with definite atrial fibrillation had more severe hypoperfusion (median time to maximum >8 s, volume 48 vs. 29 ml, P = 0·02) compared with patients with no atrial fibrillation. At outcome, patients with definite atrial fibrillation had greater infarct growth (median volume 47 vs. 8 ml, P = 0·001), larger infarcts (median volume 75 vs. 23 ml, P = 0·001), more frequent parenchymal hematoma grade hemorrhagic transformation (30% vs. 10%, P = 0·03), worse functional outcomes (median modified Rankin scale score 4 vs. 3, P = 0·03), and higher mortality (36% vs. 16%, P = 0·03) compared with patients with no atrial fibrillation. Definite atrial fibrillation was independently associated with increased parenchymal hematoma (odds ratio = 6·05, 95% confidence interval 1·60–22·83) but not poor functional outcome (modified Rankin scale 3–6, odds ratio = 0·99, 95% confidence interval 0·35–2·80) or mortality (odds ratio = 2·54, 95% confidence interval 0·86–7·49) three-months following stroke, after adjusting for other baseline imbalances.

Atrial fibrillation is associated with greater volumes of more severe baseline hypoperfusion, leading to higher infarct growth, more frequent severe hemorrhagic transformation and worse stroke outcomes.

From the Dutch hospital discharge register (nationwide coverage), we identified 9403 patients admitted with subarachnoid hemorrhage in the Netherlands between 1997 and 2006. Changes in risk of death within this time frame and influence of age and gender were quantified with Poisson regression.

The overall 30-day risk of death was 34·0% (95% confidence interval 33·1↔35·0%). After adjustment for age and gender, the annual decrease was 1·6% (95% confidence interval 0·5↔2·6%), which confers to a decrease of 13·4% (95% confidence interval4·8↔21·2%) in the study period. The one-year risk of death decreased 2·0% per year (95% confidence interval1·1↔2·9%). The decrease in risk of death was mainly found in the period 2003–2005, was not found for patients ≥65 years and was statistically significant for men, but not for women.

The decrease in risk of death for patients admitted in the Netherlands with subarachnoid hemorrhage is overall considerable, but unevenly distributed over age and gender. Further research should focus on reasons for improved survival (improved diagnostics, improved treatment) and reasons why improvement has not occurred for women and for patients in older age categories.

We identified 107 consecutive spontaneous subarachnoid hemorrhage cases. Of these cases, 31 (29%) patients were admitted directly and 76 (71%) were transferred from general hospitals. Univariate and multivariate analyses evaluated differences in mortality, complications, discharge disposition, and in-hospital length of stay.

Differences in baseline parameters (age, gender, admission Glasgow Coma Scale, Fisher grade, admission Hunt and Hess grade) were not statistically significant between direct-admit and transfer patients at our institution. Transferred patients developed vasospasm more frequently (58% vs. 32%; P < 0·05) and had a longer delay time to surgery (3·9-days vs. 2·4-days: P < 0·05). Multivariate analysis showed that the likelihood of vasospasm was significantly higher for transfer patients (OR 3·46, CI: 1·2–10·3, P = 0·03). In addition, longer in-hospital stays and higher odds of non-routine discharge were observed in transferred patients (P < 0·01). No differences in outcome could be identified for surgical vs. endovascular treatment rates between direct-admit and transfer patients. An association, but no causative link, can be made between the effect of transfer and the outcomes of SAH patients due to the retrospective nature of our study.

Spontaneous subarachnoid hemorrhage patients admitted directly to our comprehensive stroke center showed less complications compared to those transferred from general hospitals. This improvement was independent of time to treatment. Additional research in multiple centers using prospective analysis should be conducted to confirm that preferential direct transport to a comprehensive stroke center would likely yield considerable improvements in public health.

We examined the efficacy and safety of dual antiplatelets in patients with transient ischemic attack or minor stroke, defined as National Institute of Health Stroke Scale scores 0–3, in a subgroup analysis of Clopidogrel plus aspirin versus Aspirin alone for Reducing embolization in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR) study. Microembolic signals on transcranial Doppler monitoring was used as surrogate marker for recurrent stroke risk. Patients with ≥1 microembolic signals at baseline were randomized to receive dual therapy (aspirin 75–160 mg daily and clopidogrel 300 mg day 1 then 75 mg daily) or monotherapy (aspirin 75–160 mg daily) for seven-days.

Sixty-five of 100 patients recruited had transient ischemic attack or minor stroke: 30 received dual therapy and 35 received monotherapy. Mean onset-to-randomization was 2·3 days in dual therapy group and 3·2 days in monotherapy group (P = 0·03). At day 7, the proportion of patients with ≥1 microembolic signals was 9 of 29 patients in dual therapy group and 18 of 34 patients in monotherapy group (adjusted relative risk reduction 41·4%, 95% CI 29·8–51·1, P < 0·001). The median number of microembolic signals on day 7 was 0 in dual therapy group and 1·0 in monotherapy group (P = 0·046). No patients had intracranial or severe systemic hemorrhage.

Early dual therapy with clopidogrel and aspirin reduces microembolic signals in patients with minor ischemic stroke or transient ischemic attack, without causing significant bleeding complications.

The study aims to determine the association between inflammatory markers and cognitive impairment.

Ischemic stroke patients with baseline neuropsychological assessments at three-months poststroke were followed up with annual neuropsychological assessments for up to five-years. Inflammatory markers (C-reactive protein, interleukin 1β, interleukin 6, interleukin 8, interleukin 10, interleukin 12, and tumor necrosis factor-α) were assayed, and logistic regression analyses were performed to determine associations between inflammatory markers and both baseline cognitive status and subsequent cognitive decline.

There were 243 ischemic stroke patients in the study. In multivariable ordinal logistic regression analysis, age, education, ethnicity, stroke subtype, and interleukin 8 (OR 1·23 CI 1·05–1·44) levels were independently associated with baseline cognitive status. In multivariable logistic regression analyses, age, gender, recurrent strokes, and interleukin 12 (OR 25·02 CI 3·73 to 168·03) were independent predictors of subsequent cognitive decline.

Following ischemic stroke, higher serum interleukin 8 is independently associated with baseline cognitive impairment while higher serum interleukin 12 is associated with subsequent cognitive decline.

The study aims to establish paths to care and outcomes for patients referred by general practitioners and emergency departments to an Australian acute access transient ischemic attack service.

This is a prospective audit. Primary outcomes were time from event to referral, from referral to clinic appointment, and from event to appointment. ABCD2 score was calculated for each event. Time from event was modeled using Cox proportional hazards regression.

There were 231 clinic attendees (general practitioner: 127; emergency department: 104). Mean time from event to referral was 9·2 days (SD 23·7, median 2), from referral to being seen in the clinic was 13·6 days (SD 19·0, median 7), and from event to being seen in the clinic was 17·2 days (SD 27·1, median 10). Of low-risk patients, 38·5% were seen within seven-days of event. Of high-risk patients, 36·7% were seen within one-day. ABCD2 score was not a significant predictor of any time interval from event to clinic attendance. There were no completed strokes prior to clinic attendance.

Times from event to clinic assessment were in excess of current recommendations and risk stratification was suboptimal, though short-term outcomes were good. Improvements in referral mechanisms may enhance risk-stratification and triage.

We evaluated whether anaemia on admission was associated with greater intracerebral haemorrhage severity and worse outcome.

Consecutive patients with spontaneous intracerebral haemorrhage were analyzed from the Registry of the Canadian Stroke Network. Admission haemoglobin was related to stroke severity (using the Canadian Neurological Scale), modified Rankin score at discharge, and one-year mortality. Adjustment was made for potential confounders including age, gender, medical history, warfarin use, glucose, creatinine, blood pressure, and intraventricular haemorrhage.

Two thousand four hundred six patients with intracerebral haemorrhage were studied of whom 23% had anaemia (haemoglobin <120 g/l) on admission, including 4% with haemoglobin <100 g/l. Patients with anaemia were more likely to have severe neurological deficits at presentation [haemoglobin ≤100 g/l, adjusted odds ratio 4·04 (95% confidence interval 2·39, 6·84); haemoglobin 101–120 g/l, adjusted odds ratio 1·93 (95% confidence interval 1·43, 2·59), both P < 0·0001]. In nonanticoagulated patients, severe anaemia was also associated with poor outcome (modified Rankin score 4–6) at discharge [haemoglobin ≤100 g/l, adjusted odds ratio 2·42 (95% confidence interval 1·07–5·47), P = 0·034] and increased mortality at one-year [haemoglobin ≤100 g/l, adjusted hazard ratio 1·73 (95% confidence interval 1·22–2·45), P = 0·002].

Anaemia on admission is associated with greater intracerebral haemorrhage severity and worse outcomes. The utility of transfusion remains unclear in this setting.

The aim of this study was to determine if a four-month treadmill and overground walking program is more effective than a two-month program, compared with control, at improving walking in community-dwelling people with stroke who walk slowly.

A three-arm randomized trial with concealed allocation, assessor blinding, and intention-to-treat analysis involving 102 people with stroke living in the community who walked slowly was undertaken. Experimental group 1 undertook 30 min of treadmill and overground walking thrice per week for four-months, experimental group 2 undertook training for two-months, while the control group had no intervention. The primary outcome was walking measured as the distance covered during the six-min walk test. Other outcomes were walking speed, step length and cadence, health status, community participation, self-efficacy and falls.

By two-months, the experimental groups, who were both undergoing training, had improved their six-min walk distance compared with the control group. The four-month training group continued training beyond two-months and improved further so that by four months they walked 38 m (95% confidence interval 15–60) more than the control group and 29 m (95% confidence interval 4–53) more than the two-month training group. However, by 12 months, well after the cessation of training, both experimental groups had returned to near baseline levels, and there was no difference between the groups.

Four months of treadmill training results in better walking. However, these effects disappear once training ceases. Therefore, training should be ongoing.

The study aims to evaluate the clinical and cost-effectiveness of a purposely developed system of care for stroke patients and their carers living in the community.

This is a cluster randomized, controlled trial. The trial aimed to recruit 800 patients (and their carers, if appropriate) in 32 stroke services across the United Kingdom. The system of care is delivered by health professionals undertaking a community-based liaison or coordinating role for stroke patients (termed ‘stroke care coordinators’). Stroke care coordinators in stroke services randomized to the intervention group were trained to deliver the system of care, while those randomised to the control group continued to deliver current practice.

The primary outcome is patient emotional health measured using the General Health Questionnaire 12 at six-months after recruitment. Secondary outcomes include cost-effectiveness, patient functional health and carer emotional health, with final follow-up at 12 months.

Thirty-two stroke services were randomized and 800 patients and 208 carers were recruited from 29 services. Follow-up is ongoing, and trial results are expected in early 2013.

To determine if perfusion or angiographic imaging with computed tomography or magnetic resonance help identify patients who are more likely to benefit from recombinant tissue Plasminogen Activator in the context of a large multicenter randomized trial of recombinant tissue Plasminogen Activator given within six-hours of onset of acute ischemic stroke, the Third International Stroke Trial.

Third International Stroke Trial is a prospective multicenter randomized controlled trial testing recombinant tissue Plasminogen Activator (0·9 mg/kg, maximum dose 90 mg) started up to six-hours after onset of acute ischemic stroke, in patients with no clear indication for or contraindication to recombinant tissue Plasminogen Activator. Brain imaging (computed tomography or magnetic resonance) was mandatory pre-randomization to exclude hemorrhage. Scans were read centrally, blinded to treatment and clinical information. In centers 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.

The primary outcome in Third International Stroke Trial is alive and independent (Oxford Handicap Score 0–2) at 6 months; secondary outcomes are symptomatic and fatal intracranial hemorrhage, early and late death. The perfusion and angiography study additionally will examine interactions between recombinant tissue Plasminogen Activator and clinical outcomes, infarct growth and recanalization in the presence or absence of perfusion lesions and/or arterial occlusion at presentation. The study is registered ISRCTN25765518.

Our objectives were to investigate factors associated with elevated leucocyte count and whether there is correlation between leucocyte count and short- and long-term outcomes.

Of our database of 1008 consecutive patients aged 15 to 49, we included those with leucocyte count measured within the first two days from stroke onset. Outcomes were three-month and long-term disability, death, and vascular events. Linear regression was used to explore baseline variables associated with leucocyte count. Logistic regression and Cox proportional models studied the association between leucocyte count and clinical outcomes.

In our study cohort of 797 patients (61·7% males; mean age 41·4 years), mean leucocyte count was high: 8·8 ± 3·1 × 10⁹ cells/L (Reference range: 3·4–8·2 × 10⁹ cells/L). Higher leucocyte levels were associated with dyslipidaemia, smoking, peripheral arterial disease, stroke severity, and lesion size. After adjustment for age, gender, relevant risk factors, both continuous leucocyte count and the highest quartile of leucocyte count were independently associated with unfavourable three-month outcome. Regarding events in the long-term (follow-up 8·1 ± 4·2 years in survivors), no association between leucocyte count and the event risks appeared.

Among young stroke patients, high leucocyte count was a common finding. It was associated with vascular disease and its risk factors as well as severity of stroke, but it was also independently associated with unfavourable three-month outcome in these patients. There was no association with the long-term outcome.

To synthesize the data surrounding stroke in South Africa and calculate disability adjusted life years attributable to stroke in South Africa in 2008.

We undertook a systematic review to identify studies on the prevalence and mortality of stroke in South Africa. We used the DisMod program to calculate missing epidemiological parameters, in particular incidence and duration. Using these values, we calculated the burden of disease in years of life lost (YLL), years lived with disability (YLD) and disability adjusted life years (DALY).

Data on prevalence and mortality of stroke in South Africa are scarce. We estimate there are 75 000 strokes in South Africa each year, with 25 000 of these fatal within the first month. The burden of disease due to stroke in South Africa was 564 000 DALYs. Of this, 17% is contributed by YLD (14–20% in sensitivity analysis).

This study provides information on prevalence, incidence and disease burden of stroke at the national level in South Africa. The results of this analysis will enable further work on priority setting and health service planning for primary and secondary prevention of stroke in South Africa.

Questionnaires covering availability of endovascular treatments for stroke, e.g. intra-arterial thrombolysis and mechanical thrombectomy, were emailed to all British Association of Stroke Physicians members in October 2010. Where more than one response was received from the same hospital, the data were only entered once. If there was a discrepancy between different respondents for the same hospital, details were cross-checked with the respondents to ensure accuracy.

Responses were received from 58 hospitals in England, Scotland, Wales, and Northern Ireland. Intra-arterial thrombolysis and/or mechanical thrombectomy were available in 23 hospitals. Of these, three had not performed any procedures in 2010. Twenty centres had conducted a mean (range) of eight (2–20) procedures during the 10-month period. Thirty-five hospitals were not offering endovascular treatments. Sixteen of these were not referring patients to centres which could provide interventional treatments. Hospitals offering endovascular treatments had a mean (range) of 5·2 (2–12) stroke physicians, 2·3 (0–4) interventional neuroradiologists, and 3·6 (0–9) noninterventional neuroradiologists. Only two hospitals providing interventions had four or more interventional neuroradiologists.

Only a small number of hospitals in the United Kingdom provide interventional treatments for stroke. Almost 50% of hospitals not providing interventions had no processes in place for referral to providers.

We undertook a meta-analysis of randomized controlled trials comparing the efficacy and safety of intra-arterial thrombolysis with either standard treatment or intravenous thrombolysis following acute ischemic stroke. Primary outcomes included poor functional outcomes (modified Rankin Scale 3–6), mortality, and symptomatic intracranial hemorrhage. Study quality was assessed, and outcomes were stratified by comparison treatment received.

Four trials (n = 351) comparing intra-arterial thrombolysis with standard treatment were identified. Intra-arterial thrombolysis reduced the risk of poor functional outcomes (modified Rankin Scale 3–6) [relative risk (RR) = 0·80; 95% confidence interval = 0·67–0·95; P = 0·01]. Mortality was not increased (RR = 0·82; 95% confidence interval = 0·56–1·21; P = 0·32); however, risk of symptomatic intracranial hemorrhage was nearly four times more likely (RR = 3·90; 95% confidence interval = 1·41–10·76; P = 0·006). Two trials (n = 81) comparing intra-arterial thrombolysis with intravenous thrombolysis were identified. Intra-arterial thrombolysis was not found to reduce poor functional outcomes (modified Rankin Scale 3–6) (RR = 0·68; 95% confidence interval = 0·46–1·00; P = 0·05). Mortality was not increased (RR = 1·12; 95% confidence interval = 0·47–2·68; P = 0·79); neither was symptomatic intracranial hemorrhage (RR = 1·13; 95% confidence interval = 0·32–3·99; P = 0·85). Differences in time from symptom onset-to-treatment and type of thrombolytic administered were found across the trials.

This analysis finds a modest benefit of intra-arterial thrombolysis over standard treatment, although it does not find a clear benefit of intra-arterial thrombolysis over intravenous thrombolysis in acute ischemic stroke patients. However, few trials, small sample sizes, and indirectness limit the strength of evidence.

A population-based sample of 38 949 rural Chinese adults, aged ≥35 years and free from stroke at baseline, were followed from 2004–2006 to 2010. Stroke was defined by the World Health Organization diagnosis criteria.

The age-standardized incidence rates per 100 000 person-years of overall, first ever stroke was 601·9 (95% confidence interval, 528·3 to 675·5), and mortality rate was 276·7 (95% confidence interval, 251·6 to 301·9). The age-standardized incidence rate was higher in men (775·9 per 100 000 person-years) than in women (435·6 per 100 000 person-years). Among 858 first ever stroke events, 56·3% were ischemic strokes, 40·6% were hemorrhagic strokes, and 3·1% were undetermined strokes. Hypertension and lipid disorder were common modifiable risk factors in the ischemic stroke and hemorrhagic stroke groups.

The annual incidence of stroke and resulting mortality has increased at an accelerated rate. Furthermore, the incidence of stroke in rural China was higher than that found in urban China and Western countries. Hypertension and lipid disorder were important modifiable risk factors. The primary sub-type of stroke observed in rural China was ischemic stroke. These findings underscored the need for more aggressive efforts to control the risk factors of stroke and other cardiovascular diseases in rural areas.

To assess etiological mechanisms, frequency, and predictors of symptom progression, as well as its impact on prognosis.

Anterior choroidal artery infarct patients were prospectively identified via predefined infarct locations with ischemic lesions ≥1·5 cm vertical diameter in cerebral imaging. Definition of neurological progression was ≥2 National Institutes of Health Stroke Scale points in motor function or ≥4 in total National Institutes of Health Stroke Scale. Stroke etiology was determined according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. We assessed demographical data, risk factors, and acute phase parameters in order to find predictors of neurological progression.

Thirty patients fulfilled the inclusion criteria. Eighteen patients (60%) had neurological progression during days 1–3. Despite similar stroke severity at admission (median National Institutes of Health Stroke Scale in progressive infarcts 4·5 versus 4; P = 0·72), patients with progression had more severe deficits at day 3 (median National Institutes of Health Stroke Scale 9 vs. 3·5; P = 0·04) and worse three-month outcome. Only 31% of patients with progression scored <2 in the modified Rankin Scale compared with 89% without progression (P = 0·01) after three-months. No statistically significant differences regarding possible predictors of progression were found. Magnetic resonance imaging findings and etiological assessment suggest overlapping mechanisms of small and large vessel disease.

Neurological deterioration is frequent in anterior choroidal artery infarcts and is associated with worse outcome. While mechanisms of small and large vessel disease seem to overlap in anterior choroidal artery infarction, we were not able to identify predictors of neurological progression.

We selected 500 patients treated by intravenous alteplase and 500 controls from Virtual International Stroke Trials Archive, matching modified Rankin score outcomes to those from pooled randomized controlled trial 4·5–6 h data. We ranked patients by prognostic score. We chose limits to optimize our sample for a net treatment benefit significant at P = 0·01 by Cochran–Mantel–Haenszel test and by ordinal regression. For validation, we had these applied to the pooled randomized controlled trial data for 4·5–6 h, testing for net benefit by Cochran–Mantel–Haenszel test, ordinal regression, and also by dichotomized outcomes: modified Rankin score 0–1, mortality and parenchymal hemorrhage type 2 bleeds. All analyses were adjusted for age and National Institutes of Health Stroke Scale.

In the training dataset, limits of 56–95 on a prognostic score retained 714 patients in whom there was net benefit significant at P = 0·01. When applied to the 1120 patients in the pooled randomized controlled trial 4·5–6 h dataset, score limits of 56–95 retained 711 patients and gave odds ratio for improved modified Rankin score distribution of 1·13, 95% confidence interval 0·87–1·47, Cochran–Mantel–Haenszel P = 0·89. More patients achieved modified Rankin score 0–1 (odds ratio 1·44, 1·02–2·05, P = 0·04) but mortality and parenchymal hemorrhage type 2 bleeds were increased: odds ratio 1·56, 1·01–2·40, P = 0·04; odds ratio 15·6, 3·7–65·8, P = 0·0002, respectively.

Selection of patients between 4·5 and 6 h based on simple clinical measures failed to deliver a population in whom the alteplase effect would be safe and effective.

Identifying risk factors for delayed stroke upon cervical artery dissection.

Cervical artery dissection patients from the multicenter Cervical Artery Dissection and Ischemic Stroke Patients study were classified as patients without stroke (n = 339), with stroke preceded by nonstroke symptoms (delayed stroke, n = 244), and with stroke at onset (n = 382). Demographics, clinical, and vascular findings were compared between the three groups.

Patients with delayed stroke were more likely to present with occlusive cervical artery dissection (P < 0·001), multiple cervical artery dissection (P = 0·031), and vertebral artery dissection (P < 0·001) than patients without stroke. No differences were observed in age, smoking, arterial hypertension, hypercholesterolemia, migraine, body mass index, infections during the last week, and trauma during the last month, but patients with delayed stroke had less often transient ischemic attack (P < 0·001) and local signs (Horner syndrome and cranial nerve palsy; P < 0·001).

Occlusive cervical artery dissection, multiple cervical artery dissection, and vertebral artery dissection were associated with an increased risk for delayed stroke. No other risk factors for delayed stroke were identified. Immediate cervical imaging of cervical artery dissection patients without ischemic stroke is needed to identify patients at increased risk for delayed ischemia.

The authors investigated whether excessive working conditions would associate with increased risk of haemorrhagic stroke.

A nationwide matched case-control study database, which contains 940 cases of incident haemorrhagic stroke (498 intracerebral haemorrhages and 442 sub-arachnoid haemorrhages) with 1880 gender- and age- (±5-year) matched controls, was analysed. Work-related information based on the regular job situation, including type of occupation, regular working time, duration of strenuous activity during regular work and shift work, was gathered through face-to-face interviews. Conditional logistic regression analyses were used for the multivariable analyses.

Compared with white-collar workers, blue-collar workers had a higher risk for haemorrhagic stroke (odds ratio, 1·33 [95% confidence interval, 1·06–1·66]). Longer regular working time was associated with increased risk of haemorrhagic stroke [odds ratio, 1·38 (95% confidence interval, 1·05–1·81) for 8–12 h/day; odds ratio, 1·95 (95% confidence interval, 1·33–2·86) for ≥13 h/day; compared with ≤4 h/day]. Exposure to ≥8 h/week of strenuous activity also associated haemorrhagic stroke risk [odds ratio, 1·61 (95% confidence interval, 1·26–2·05); compared with no strenuous activity]. Shift work was not associated with haemorrhagic stroke (P = 0·98). Positive associations between working condition indices and haemorrhagic stroke risk were consistent regardless of haemorrhagic stroke sub-types and current employment status.

Blue-collar occupation, longer regular working time and extended duration of strenuous activity during work may relate to an increased risk of haemorrhagic stroke.

To investigate the effect of dementia on access to diagnostic procedures in ischaemic stroke patients.

All cases of ischaemic stroke from 2006 to 2010 were identified from the population-based Stroke Registry of Dijon, France. Patients' characteristics were recorded, as was the use of brain computed tomography scans, brain magnetic resonance imaging, electrocardiogram, echocardiography, and Doppler ultrasonography of the cervical arteries. Dementia was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Logistic regression models were used to evaluate the associations between dementia and the use of the diagnostic procedures.

Of the 907 patients recorded, 104 were excluded because of death and inability to test cognition. Among the remaining 803 patients, 149 (18·5%) had dementia. Almost all of the patients underwent a brain computed tomography scan and an electrocardiogram during their stay. In contrast, the use of both Doppler ultrasonography of the cervical arteries (79·2% versus 90·2%, P < 0·001), echocardiography (32·9% versus 43·6%, P = 0·02), and brain magnetic resonance imaging (21·5% versus 34·4%, P < 0·001) were significantly lower in stroke patients with dementia than in those without. In multivariate logistic regression, dementia was associated with a lower use of both Doppler ultrasonography (odds ratio = 0·49; 95% confidence interval: 0·29–0·81, P = 0·005), echocardiography (odds ratio = 0·57; 95% confidence interval: 0·37–0·89, P = 0·012), brain magnetic resonance imaging (odds ratio = 0·55; 95% confidence interval: 0·34–0·89, P = 0·015), and a comprehensive assessment (odds ratio = 0·62; 95% confidence interval: 0·40–0·96, P = 0·033).

Demented patients were less likely to undergo diagnostic procedures after ischaemic stroke. Further studies are needed to determine whether this lower utilization could account for the reported excess in recurrent events in these patients.

Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0–1), good (mRS: 0–2), and poor (mRS: 3–6).

Over 7·5 years, 30 (4·2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0·63, 95% CI 0·50–0·79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1·02, 95% CI 1·01–1·03), lower NIHSS (OR 1·11, 95% CI 1·03–1·18), a higher proportion of stroke mimics (OR 17·61, 95% CI 6·20–50·02) and shorter hospital stay (OR 1·32, 95% CI 1·09–1·61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1·37, 95% CI 1·06–1·78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1·61, 95% CI 0·69–3·73).

The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out of six refusal patients (16·6%) had a stroke mimic.

We aimed to identify the top 10 research priorities relating to life after stroke, as agreed by stroke survivors, caregivers, and health professionals.

Key stages involved establishing a priority setting partnership; gathering treatment uncertainties from stroke survivors, caregivers, and health professionals relating to life after stroke (using surveys administered by e-mail, post, and at face-to-face meetings); checking submitted treatment uncertainties to ensure that they were clear, unanswered questions about the effects of a treatment/intervention; interim prioritization to identify the highest priority questions (objectively identified from ranking of personal priorities by original survey respondents); and a final consensus meeting to reach agreement on the top 10 research priorities.

We gathered 548 research questions that were refined into 226 unique unanswered treatment uncertainties. Ninety-seven respondents completed the interim prioritization process, objectively identifying 24 shared priority treatment uncertainties. A representative group of 28 stroke survivors, caregivers, and health professionals attended a final meeting, reaching consensus on the top 10 research priorities relating to life after stroke.

Six of the agreed top 10 research priorities related to specific stroke-related impairments, including cognition, aphasia, vision, upper limb, mobility, and fatigue. Three related to more social aspects of ‘living with stroke’ including coming to terms with long-term consequences, confidence, and helping stroke survivors and their families ‘cope’ with speech problems. One related to the secondary consequences of stroke and subsequent stroke prevention.

The top 10 research priorities relating to life after stroke have been identified using a rigorous and person-centered approach. These should be used to inform the prioritization and funding of future research relating to life after stroke.

Consecutive patients with a discharge diagnosis of possible or definite transient ischaemic event who underwent computed tomography perfusion were included in this study. The presence of an ischaemic lesion was assessed on noncontrast computed tomography, automatically deconvolved CTP_TMax (Time till the residue function reaches its maximum), and when available on diffusion-weighted imaging and PWI_TMax maps.

Thirty-four patients were included and 17 underwent magnetic resonance imaging. Median delay between onset and computed tomography perfusion was 4·4 h (Interquartile range [IQR]: 1·9–9·6), and between computed tomography perfusion and magnetic resonance imaging was 11 h (Interquartile range: 3·8–22). Noncontrast computed tomography was negative in all cases, while CTP_TMax identified an ischaemic lesion in 12/34 patients (35%). In the subgroup of patients with multimodal magnetic resonance imaging, an ischaemic lesion was found in six (35%) patients using CTP_TMax versus nine (53%) on magnetic resonance imaging (five diffusion-weighted imaging, nine perfusion-weighted imaging). The additional yield of CTP_TMax over computed tomography angiography was significant in the evaluation of transient ischaemic attack (12 vs. 3, McNemar, P = 0·004).

CTP_TMax found an ischaemic lesion in one-third of acute transient ischaemic attack patients. Computed tomography perfusion may be an acceptable substitute when magnetic resonance imaging is unavailable or contraindicated, and has additional yield over computed tomography angiography. Further studies evaluating the outcome of patients with computed tomography perfusion lesions in transient ischaemic attack are justified at this time.

The aim of this study was to examine the gender-specific association between childhood parental divorce and later incidence of stroke, while controlling for age, race ethnicity, socioeconomic status, health behaviors, diabetes, social support, marital status, mental health, and health care utilization.

Secondary analysis of the population-based Behavioral Risk Factor Surveillance System survey; logistic regression analyses were conducted. The final sample included 4074 males and 5886 females. Respondents were excluded if they had experienced parental addictions to drugs or alcohol, any form of childhood abuse (physical, sexual, or emotional), or witnessed domestic violence.

A threefold risk of stroke was found for males who had experienced parental divorce before the age of 18 in comparison with males whose parents had not divorced [age- and race ethnicity-adjusted model odds ratio (OR) = 2·99, 95% confidence interval (CI) = 1·79, 4·98; fully adjusted model OR = 3·01, 95% CI = 1·68, 5·39]. Parental divorce was not significantly associated with stroke among women (fully adjusted OR = 1·64, 95% CI = 0·89, 3·02).

There is a robust association between parental divorce and stroke among males, even after adjustment for many known risk factors and the exclusion of respondents who had experienced parental addictions or family violence. Further research is needed to investigate plausible pathways linking parental divorce and stroke in males.

The primary aim is to determine the effectiveness of an individualized management program on risk factor management for patients discharged from hospital after stroke.

Multicentre, cluster-randomized, controlled trial, with clusters by general practice. Participants are randomized to receive intervention or control after a baseline assessment undertaken after discharge from hospital. The general practice they attend is marked as an intervention or control accordingly. All subsequent participants attending those practices are automatically assigned as intervention or control. Baseline and all outcome assessments, including an analysis of risk factors, are undertaken by assessors blinded to patient randomization.

Based on the results of blinded assessments, the individualized management program group will receive targeted advice on how to manage their risk factors using a standardized, evidence-based template to communicate ‘ideal’ management with their general practitioner. In addition, patients randomized to the individualized management program group will receive counselling and education about stroke risk factor management by an intervention study nurse. Individualized management programs will be reviewed at three-months, six-months, 12 months, and 18 months after stroke, at which times they will be modified if appropriate. Stroke risk management will be evaluated using changes in the Framingham cardiovascular risk score. Analysis will be on an intention-to-treat basis using analysis of covariance or generalized linear model to adjust for baseline risk score and other relevant confounding factors.

Ischaemic stroke patients from phase 3 of the Registry of the Canadian Stroke Network data (July 2003–March 2008) were included. Lacunar stroke was defined as a lacunar syndrome supported by computed tomography brain showing a subcortical hypodense lesion with a diameter <20 mm. Clinical syndromes were used to define other stroke sub-types. The outcomes were mortality at 90 days, modified Rankin Scale score 0–2 at discharge, occurrence of intracranial haemorrhage as a complication of stroke in-hospital, and discharge disposition to home.

A total of 11 503 patients of ischaemic stroke were included from the Registry of the Canadian Stroke Network 3 between July 2003 and March 2008. Lacunar strokes formed 19·1% of the total strokes. The total number of patients who received tissue plasminogen activator was 1630 (14·2%). A significant association was found between tissue plasminogen activator treatment and outcomes after controlling Oxfordshire Community Stroke Project types – for modified Rankin Scale at discharge and discharge to home, but not for mortality. A thrombolysis-by-Oxfordshire Community Stroke Project stroke sub-type interaction was observed due to lack of benefit among the posterior circulation stroke sub-types. Patients with lacunar strokes, partial anterior circulation stroke, and total anterior circulation strokes all benefited approximately equally from thrombolysis.

Thrombolysis is associated with clinically improved outcome among patients with lacunar stroke syndromes.

We prospectively enrolled 634 Chinese stroke patients. Aspirin was administrated to every patient from the first day of admission. Whole blood samples were collected for platelet aggregation testing after aspirin was administered for 7–10 days. A follow-up period of 12–24 months was performed to record vascular events and hemorrhagic side effects.

Aspirin resistance (AR) was detected in 129 patients (20·4%), aspirin semi-resistance (ASR) in 28 patients (4·4%) and aspirin sensitivity (AS) in 477 patients (75·2%). Logistic regression analysis found that diabetes and high levels of low density lipoprotein cholesterol (LDL) were independent risk factors for ASR and AR. During a median follow-up period of 19·4 months, the prevalence of recurrent stroke, death from all causes, myocardial infarction and vascular events overall were higher in patients with AR + ASR than in patients with AS. Cox regression analysis found that diabetes and AR were independent risk factors for vascular events.

Aspirin resistance is common in Chinese patient taking antiplatelet medications. Diabetes and high LDL may induce platelet activation and thrombosis and increase the occurrence of aspirin resistance. Patients who are detected to be aspirin resistant are at a greater risk of clinically important vascular events.

Stroke-free participants (n = 22 847) aged > 50 years in the Health and Retirement Study (1992–2008) were analyzed. Childhood and adulthood socioeconomic status were assessed using parental and participant's education attainments. Incident stroke was defined as self-reported first incident stroke.

Of the study sample, 2298 subjects experienced first incident stroke (10·06%). Cox's regression models indicate that subjects with low childhood socioeconomic status had 1·36 times higher risk (95% confidence interval: 1·18–1·57) of first incident stroke than those with high childhood socioeconomic status. There was an 8% reduction of this association after adjustment for adulthood socioeconomic status. Adults with diabetes mellitus had the highest hazard ratio (1·91, 95% confidence interval: 1·63–2·23) for incident stroke, followed by heart disease (1·69, 1·48–1·93), and then hypertension (1·56, 1·40–1·75). Significant interaction effect of childhood socioeconomic status and diabetes mellitus, and combined effects of socioeconomic status and chronic conditions on risk of incident stroke were observed.

Both low socioeconomic status in childhood and adulthood socioeconomic status predict the risk of stroke. There are significantly combined effects of socioeconomic status and chronic conditions on the risk of stroke. Improving socioeconomic status across the life span and aggressive control of chronic conditions may play pivotal roles in the prevention of stroke development.

We investigated whether survival of subjects with warfarin-associated intracerebral haemorrhage had improved after implementation of reversal of warfarin anticoagulation with prothrombin complex concentrate.

We identified all subjects with warfarin-associated intracerebral haemorrhage during 1993–2008 among the population of Northern Ostrobothnia, Finland. From 2004 onwards, prothrombin complex concentrate was used in Oulu University Hospital, the only hospital treating intracerebral haemorrhage subjects in the region, to counteract the effect of warfarin in subjects with warfarin-associated intracerebral haemorrhage. We compared the outcomes of subjects admitted during 1993–2003 and 2004–2008 and those treated and not treated with prothrombin complex concentrate. We also explored the predictors for one-year survival of the warfarin-associated intracerebral haemorrhage subjects.

We identified altogether 181 subjects who had intracerebral haemorrhage while on warfarin. One-year survival was significantly (P = 0·031) higher for the 60 subjects admitted during 2004–2008 (43·3%) than for the 121 admitted before 2004 (30·6%). In multivariable analysis, prothrombin complex concentrate treatment reduced one-year case fatality (hazard ratio 0·52, 95% confidence interval 0·29–0·93). Thromboembolic complications did not occur more frequently among those treated with prothrombin complex concentrate.

The survival of warfarin-associated intracerebral haemorrhage subjects among the population of Northern Ostrobothnia has improved likely because of introduction of prothrombin complex concentrate.

Using the large population collected in the prospective International Paediatric Stroke Study, we analysed the characteristics, clinical presentations, imaging findings, and early outcomes of children with and without cardiac disorders.

Aetiological data were available for 667 children with arterial ischaemic stroke (ages 29 days to 19 years). Cardiac disorders were indentified in 204/667 (30·6%), congenital defects in 121/204 (59·3%), acquired in 40/204 (19·6%), and isolated patent foramen ovale in 31/204 (15·2%). Compared to other children with stroke, those with cardiac disorders were younger (median age 3·1 vs. 6·5 years; P < 0·001) and less likely to present with headache (25·6% vs. 44·6%; P < 0·001), but were similar in terms of gender and presentation with focal deficits, seizures, or recent infection. Analysis of imaging data identified significant differences (P = 0·005) in the vascular distribution (anterior vs. posterior circulation or both) between groups. Bilateral strokes and haemorrhagic conversion were more prevalent in the cardiac disorders group.

Cardiac disorders were identified in almost one-third of children with arterial ischaemic stroke. They had similar clinical presentations to those without cardiac disorders but differed in age and headache prevalence. Children with cardiac disorders more frequently had a ‘cardioembolic stroke pattern’ with a higher prevalence of bilateral strokes in both the anterior and posterior circulations, and a greater tendency to haemorrhagic transformation.

Our goal was to study the reproducibility of outcomes obtained in five rat models of middle cerebral artery (MCA) ligation in order to identify the optimal model for the preclinical studies.

In Part 1 of the experiments, systolic blood flow velocity (sBFV) and cerebral area at risk (AR) were determined immediately after the onset of brain ischemia induced in different ways in Wistar rats. After that, another set of experiments was performed (Part 2 of the experiments), now aimed at the assessment of the delayed outcome of five different models of cerebral ischemia designated as Versions 1–5.

The versions were: Version 1 – 40-minute left MCA (LMCA) occlusion with reperfusion; Version 2 – permanent LMCA ligation; Version 3 – permanent ligation of both LMCA and left common carotid artery (CCA); Version 4 – permanent LMCA and bilateral CCA (bCCA) ligation; Version 5 – permanent LMCA ligation and 40-minute bCCA occlusion. The infarct size (IS) was quantified using triphenyltetrazolium chloride staining. The severity of neurological deficit was assessed by the Garcia score. The extent of brain edema was determined by calculating the difference in volumes of affected and contralateral hemispheres.

Within a relatively big AR, Versions 1 and 2 resulted in a small IS [0·2 (0·0; 0·4)% and 0·3 (0·0; 0·7)%, respectively, P > 0·05]. Unlike that and comparable with AR, Version 3 resulted in a greater, albeit more variable IS [5·9 (2·1; 8·3)%, P < 0·0001 vs. Version 2]. Also comparable with AR, Versions 4 and 5 produced greatest values of IS [14·5 (11·4; 17·9)% and 11·3 (10·1; 14·2)%, respectively]; this parameter was most reproducible in Version 5. A significant decrease in neurological deficit score was found in Versions 4 and 5. Again, the reproducibility of the data on neurological outcome was higher in Version 5 versus Version 4.

Comparative analysis of several Versions of focal cerebral ischemia within a single study might be helpful in better understanding of the mechanisms underlying the development and aftermath of stroke. Permanent LMCA ligation plus transient bilateral CCA occlusion produced most consistent results and might be recommended for preclinical studies.

Patients suffering their first ever stroke were included in this randomized, evaluator-blinded, controlled trial with two parallel groups. Baseline examination included extensive assessment of exposure to vascular risk factors and cognitive assessments regarding memory, attention, and executive function. After discharge, patients were allocated to either intensive vascular risk factor intervention or care as usual. The primary end points were changes in trailmaking test A and 10-word test from baseline to 12 months follow-up.

One hundred ninety-five patients were randomized. The difference between groups in trail-making test A, adjusted for baseline measurements, was 3·8 s (95% confidence interval: −4·2 to 11·9; P = 0·35) in favor of the intervention group. The difference between groups in the 10-word recall test was 1·1 words (95% confidence interval: −0·5 to 2·7; P = 0·17) in favor of the intervention group. We did not observe any differences in the secondary outcomes of incident dementia or mild cognitive impairment.

We could not demonstrate cognitive effects of an intensive risk factor intervention at one-year poststroke. Longer follow-up and a more heterogeneous study sample might have lead to larger effects. More effective methods for managing the risk of further cognitive decline after stroke are needed.

We simulated the effect of multiple intervals of delay after the bolus on serum TPA concentrations using known pharmacokinetics parameters of TPA. The effect of different intervals of interruptions in the infusion of TPA was also determined. The effect of rebolusing with TPA on serum concentrations in the event of significant bolus to infusion delays or significant infusion interruption was also simulated.

Our data show that delays in starting the infusion may have significant effects on serum TPA concentrations. After the initial bolus, there is a rapid decrease in serum TPA concentrations unless the infusion is started immediately. Greater than 5 min delays in starting the infusion results in a slow gradual increase in serum TPA levels and levels stay well below the target concentrations for significant periods of time. Similarly, interruptions in the infusion of TPA lasting longer than 5 min can also significantly influence TPA levels. Rebolusing with TPA in these scenarios rapidly restores TPA levels to target concentrations.

Because of its short half life, TPA should be administered as a bolus followed by an immediate infusion. Bolus to infusion delays or interruptions in the infusion of TPA after the bolus may significantly impact serum TPA levels and may reduce the efficacy of thrombolysis. Protocols or administration regimens should be employed to prevent delays or interruptions in the infusion. When delays do occur, rebolusing of TPA may be needed to rapidly restore TPA to target levels.

(1) To demonstrate non-inferiority of SOLITAIRE compared with a legally marketed device, the MERCI Retrieval System®; (2) To demonstrate safety, feasibility, and efficacy of SOLITAIRE in subjects requiring mechanical thrombectomy diagnosed with acute ischaemic stroke.

Multicenter, randomized, prospective, controlled trial with blinded primary end-point ascertainment.

Key entry criteria include: age 22–85; National Institute of Health Stroke Scale (NIHSS) ≥8 and <30; clinical and imaging findings consistent with acute ischaemic stroke; patient ineligible or failed intravenous tissue plasminogen activator; accessible occlusion in M1 or M2 middle cerebral artery, internal carotid artery, basilar artery, or vertebral artery; and patient able to be treated within 8 h of onset. Sites first participate in a roll-in phase, treating two patients with the SOLITAIRE device, before proceeding to the randomized phase. In patients unresponsive to the initially assigned therapy, after the angiographic component of the primary end-point is ascertained (reperfusion with the initial assigned device), rescue therapy with other reperfusion techniques is permitted.

The primary efficacy end-point is successful recanalization with the assigned study device (no use of rescue therapy) and with no symptomatic intracranial haemorrhage. Successful recanalization is defined as achieving Thrombolysis In Myocardial Ischemia 2 or 3 flow in all treatable vessels. The primary safety end-point is the incidence of device-related and procedure-related serious adverse events. A major secondary efficacy end-point is time to achieve initial recanalization. Additional secondary end-points include clinical outcomes at 90 days and radiologic haemorrhagic transformation.

The objectives of the study were to: (1) develop methodology and calculate a secondary stroke process of care measure using available data in Saskatchewan, based on an appropriate hypertension therapy indicator recommendation from the CSS Performance Measurement Manual; (2) examine variation in secondary stroke prevention hypertensive care among the Saskatchewan Regional Health Authorities; and (3) investigate factors associated with receiving evidence-based hypertensive secondary stroke prevention.

This multi-year cross-sectional study was an analysis of deidentified health data derived from linkage of administrative health data. A select indicator from the CSS Performance Measurement Manual that measures adherence to a CSS Best Practice Guidelines concerning use of antihypertensive medications for secondary stroke prevention was calculated. Logistic regression was used to quantify the association of patient demographic and socioeconomic characteristics and geographic location of care with receipt of guideline-recommended hypertensive secondary stroke prevention. The target population was all Saskatchewan residents who were hospitalized in Saskatchewan for a stroke or TIA between April 1, 2001 and March 31, 2008.

The results of this study indicate that the management of hypertension for secondary stroke prevention is sub-optimal in Saskatchewan. Although there was some improvement over the time period, approximately 40% of patients were not taking antihypertensives at 90 days after discharge from acute care. The correlates, urban/non-urban, previous use of antihypertensive drugs and effect of age modified by sex, were found to be significantly associated with receiving hypertensive secondary stroke prevention, suggesting there are modifiable factors that contribute to variations in this form of secondary stroke care quality in Saskatchewan.

The results of this study suggest that there is a need for province-wide improvement to secondary stroke prevention in Saskatchewan, Canada.

In this study, the impact of baseline collaterals on early outcome and risk of symptomatic intracerebral hemorrhages after systemic thrombolysis in patients with proximal arterial occlusions within the anterior circulation were analyzed.

Collateralization scores were determined on the CT angiography source images (0 = absent; 1 ≤ 50%, 2 > 50% but <100%, and 3 = 100% collateral filling) of patients with distal intracranial carotid artery and/or M1 segment occlusions treated from 2008 to December 2011. A collateral score of 0 to 1 was designated as poor and 2 to 3 as good collateral vessel status. Outcome variables included in hospital mortality, favorable outcome at discharge (modified Rankin score ≤ 2), and rates of symptomatic intracerebral hemorrhage based on the European–Australasian Acute Stroke Study II definition.

Among 246 subjects (mean age of 74 years; median National Institutes of Health Stroke Scale N at admission 14), 205 patients (83%) had good collaterals, whereas 41 patients (17%) had poor collaterals, respectively. Patients with poor collaterals had significantly higher rates of in-hospital mortality (41% vs. 12%, P < 0·001), of symptomatic intracerebral hemorrhage (15% vs. 4·9%, P < 0·05) and had significantly lower rates of favorable early clinical outcome (0% vs. 28%, P < 0·001) compared with those with good collaterals. The grade of collateralization was independently associated with in-hospital mortality (P < 0·001), early clinical outcome (P < 0·01), and rates of symptomatic intracerebral hemorrhage (P < 0·01).

Patients with proximal arterial occlusions within the anterior circulation and poor baseline collaterals have a poor early functional outcome and high rates of symptomatic intracerebral hemorrhage after systemic thrombolysis. Since similar findings have also been reported after endovascular therapy, strategies to improve collateral blood flow should be assessed in this patient population.

The Locomotor Experience Applied Post-Stroke trial, a randomized controlled study of 408 subjects that tested the relative efficacy of two rehabilitation techniques on functional walking level at one-year poststroke, provided us the opportunity to prospectively assess the potential antineuroplastic effects of several classes of drug.

Subjects were randomized to receive one of the two rehabilitation therapies at two-months poststroke. Drugs taken were recorded at time of randomization. Outcome was assessed at one-year poststroke. Regression models were used to determine the amount of variance in success in improving functional walking level, gains in walking speed, and declines in lower extremity, upper extremity, and cognitive impairment accounted for by α1 noradrenergic blockers + α2 noradrenergic agonists, benzodiazepines, voltage-sensitive sodium channel anticonvulsants, and α2δ voltage-sensitive calcium channel blockers.

The maximum variance accounted for by any drug class was 1·66%. Drug effects were not statistically significant when using even our most lenient standard for correction for multiple comparisons.

Drugs in the classes we were able to assess do not appear to exert a clinically important effect on outcome over the period between two- and 12 months poststroke. However, the potential antineuroplastic effects of certain drugs remain an incompletely settled scientific question.

To determine whether a province-wide transient ischaemic attack Triaging algorithm and transient ischaemic attack hotline (the Alberta Stroke Prevention in transient ischaemic attacks and mild strokes intervention) can reduce the rate of stroke recurrence following transient ischaemic attack across the population of Alberta, Canada (population 3·7 million, 90-day rate of post-stroke transient ischaemic attack currently 9·5%). It also seeks to improve upon current transient ischaemic attack triaging rules by incorporating time from symptom onset as a predictive variable.

The transient ischaemic attack algorithm and hotline were developed with a broad consensus of clinicians, patients, policy-makers, and researchers and based on local adaptation of the work of others and research and insights developed within the province. Because neither patient-level nor region-level randomization was possible, we conducted a quasi-experimental design examining changes in the post-transient ischaemic attack rate of stroke recurrence before and after the 15-month implementation period using an interrupted time-series regression analysis. The design controls for changes in case-mix, co-interventions, and secular trends. A prospective transient ischaemic attack cohort will also be concurrently created with telephone follow-up at seven-days and 90 days as well as passive follow-up over the longer term using linkages to provincial healthcare administrative databases.

The primary outcome measure is the change in recurrence rate of stroke following transient ischaemic attack at seven-days and 90 days, comparing a period of two-years before vs. two-years after the intervention is implemented. All cases of recurrent stroke will be validated. Secondary outcomes include functional status, hospitalizations, morbidity, and mortality.

We are undertaking a rigorous evaluation of a population-based approach to improving quality of transient ischaemic attack care. Whether positive or negative, our work should provide important insights for all potential stakeholders.

The aim of this study was to examine the risk of ischemic and hemorrhagic stroke associated with the use of nonsteroidal anti-inflammatory drugs in healthy people.

By individual-level linkage of nationwide administrative registers in Denmark, information on hospital admissions, prescription claims, vital status, and cause of death were obtained. A cohort of healthy people without hospital admissions for five-years and no important prescription claims for two-years was selected. Case crossover and Cox proportional hazard models were used to analyze the relationship between nonsteroidal anti-inflammatory drug utilization and specific cerebrovascular risk (fatal or non-fatal ischemic or hemorrhagic stroke).

We selected 1 028 437 healthy individuals (median age 39 years). At least one nonsteroidal anti-inflammatory drug was claimed by 44·7% of the study population, and the drugs were generally used for a short period of time and in low doses. High-dose ibuprofen and diclofenac were associated with increased risk of ischemic stroke [hazard ratio 2·15 (95% confidence interval 1·66–2·79) and 2·37 (confidence interval 1·99–2·81), respectively]. Diclofenac was also associated with increased risk of hemorrhagic stroke and so was naproxen [hazard ratio 2·15 (confidence interval 1·35–3·42)].

In healthy individuals, use of commonly available nonsteroidal anti-inflammatory drugs such as ibuprofen, diclofenac, and naproxen was associated with increased risk of stroke.

The Hormones and Biomarkers Predicting Stroke Study is a case-control study of blood biomarkers assayed in 972 ischemic stroke cases and 972 controls, nested in the Women's Health Initiative Observational Study of 93 676 postmenopausal women followed for an average of eight-years. We evaluated additive predictive value of two commercially available biomarkers: C-reactive protein and lipoprotein-associated phospholipase A₂ to determine if they added to risk prediction by the Framingham Stroke Risk Score or by traditional risk factors, which included lipids and other variables not included in the Framingham Stroke Risk Score. As measures of additive predictive value, we used the C-statistic, net reclassification improvement, category-less net reclassification improvement, and integrated discrimination improvement index.

Addition of C-reactive protein to Framingham risk models or additional traditional risk factors overall modestly improved prediction of ischemic stroke and resulted in overall net reclassification improvement of 6·3%, (case net reclassification improvement = 3·9%, control net reclassification improvement = 2·4%). In particular, high-sensitivity C-reactive protein was useful in prediction of cardioembolic strokes (net reclassification improvement = 12·0%; 95% confidence interval 4·3–19·6%) and in strokes occurring in less than three-years (net reclassification improvement = 7·9%, 95% confidence interval 0·8–14·9%). Lipoprotein-associated phospholipase A₂ was useful in risk prediction of large artery strokes (net reclassification improvement = 19·8%, 95% confidence interval 7·4−32·1%) and in early strokes (net reclassification improvement = 5·8%, 95% confidence interval 0·4–11·2%).

C-reactive protein and lipoprotein-associated phospholipase A₂ can improve prediction of certain subtypes of ischemic stroke in older women, over the Framingham stroke risk model and traditional risk factors, and may help to guide surveillance and treatment of women at risk.

In a randomized trial conducted in New South Wales, Australia, a postcard was sent monthly to participants (n = 100) for five-months following hospital discharge after stroke (plus usual care) and compared with usual care (n = 101). Ethical approval was obtained to withhold information about the intervention and primary outcome from participants during the consent process.

No significant difference was seen in the proportion of participants with depression in the intervention group (1/88) vs. the control group (3/76) (relative risk 0·29, 95% confidence interval 0·03–2·71) at six-months. No significant differences were seen on Hospital Anxiety Depression Scale (HADS) depression and anxiety sub-scale scores, quality of life, or activities of daily living; however, many (47/100) responded positively to the postcards.

Although this simple postcard intervention did not significantly reduce the proportion of participants experiencing high HADS depression sub-scale scores after stroke, it may be an effective way to engage with people after stroke following hospital discharge.

All acute ischemic stroke patients presenting between 11/2009 and 2/2011 eligible for tissue plasminogen activator therapy were screened and 56 enrolled. Blood was drawn before (52 patients) and 10 mins after tissue plasminogen activator bolus (30 patients). Demographics, vitals, labs, 24 h National Institutes of Health Stroke Scale, and computed tomography scan results were collected. Patients were compared with normal controls.

Acute ischemic stroke patients had shorter R (4·8 ± 1·5 vs. 6·0 ± 1·7 min, P = 0·0004), greater α Angle (65·0 ± 7·6 vs. 61·5 ± 5·9°, P = 0·01), and shorter K (1·7 ± 0·7 vs. 2·1 ± 0·7 min, P = 0·002) indicating faster clotting. Additionally, a subset formed clots with stronger platelet-fibrin matrices. Treatment with tissue plasminogen activator resulted in reduction in all indices of clot strength (LY30 = 0 (0–0·4) vs. 94·4 (15·2–95·3) P < 0·0001); however, there was considerable variability in response.

Thromboelastography demonstrates that many acute ischemic stroke patients are hypercoaguable. Thromboelastography values reflect variable clot subtype and response to tissue plasminogen activator. Further study based on these data will determine if thromboelastography is useful for measuring the dynamic aspects of clot formation and monitoring lytic therapy.

Endovascularly treated patients with middle cerebral artery occlusion (n = 41) were matched by propensity score with similar patients treated by intravenous thrombolysis and having a considerable post-thrombolysis neurological deficit (n = 82). We compared their three-month outcome (modified Rankin Scale) and frequency of symptomatic intracerebral haemorrhage. For the endovascular group, we report onset-to-puncture time, onset-to-recanalization time, and recanalization rates.

In age, gender, time from onset, admission National Institutes of Health Stroke Scale, systolic and diastolic blood pressure, blood glucose, history of hypertension, diabetes mellitus, hyperlipidaemia, atrial fibrillation, and congestive heart failure, and in aetiology, the groups were similar. Endovascular group patients had a recanalization rate of 90%, and more often reached three-month modified Rankin Scale 0–2 (36·6% vs. 18·3%, P = 0·03). Mortality was equally common (19·5%) in both groups, and frequency of symptomatic intracerebral haemorrhage was 9·8% vs. 14·6% (P = 0·45). The endovascular group's median onset-to-puncture time was four-hours and six-minutes and onset-to-recanalization time was five-hours and 12 min. The latter time was more than one-hour longer in patients treated under general anaesthesia compared with patients treated under conscious sedation (median four-hours 50 min vs. five-hours 58 min; P < 0·01).

Rescue endovascular approach increases likelihood of recanalization and may improve functional outcome in acute ischaemic stroke patients with proximal middle cerebral artery occlusion who did not respond to intravenous thrombolysis.

We evaluated stroke awareness campaigns conducted in England, Australia, and Canada using pre- and post-campaign surveys. We assessed the proportion of people who could name the main signs of stroke, and compared the proportion naming these correctly between locations. We also assessed whether people would call emergency services in the event of a stroke. Proportion responding correctly was compared using chi-square analysis.

The amount spent on the campaigns was different in each country. The post-campaign survey was conducted among 400 people in Australia, 1921 in England, and 2703 in Canada. Sixty-eight per cent of people in Australia and 57% in Canada could name two or more signs of stroke (P < 0·001). After the campaign, knowledge of each of the elements of the campaign (face, arm, speech, time) was significantly greater in England than in Australia (P < 0·001 for each item). A high proportion of participants reported that they would call emergency services in the event of a stroke (97% in England, 90% in Australia, and 67% in Canada).

Knowledge of stroke signs and the action to be taken can be improved with awareness campaigns. The effectiveness of these campaigns may be enhanced by spend on media, media mix, and key messages. It is critical to ensure that campaigns provide the clear and bold message that prompt action is an essential ingredient to reduce death and disability following stroke.

Our purpose was to compare the effect of single and combined treatment with angiotensin type 1 angiotensin receptor blocker, candesartan, and the poly (ADP-ribose) polymerase-1 inhibitor, 1, 5 isoquinolinediol, on brain damage and oxidative stress in transient focal cerebral ischaemia in rats.

Transient focal cerebral ischaemia was induced in Sprague-Dawley rats by an intraluminal technique for two-hours following 48 h of reperfusion. Candesartan (0·05 mg/kg) was administered just after initiation of ischaemia followed by a repeat administration at 24 h while 1, 5 isoquinolinediol (0·1 mg/kg) was given one-hour after of ischaemia. After 24 h of reperfusion, neurological deficit was evaluated in the different treatment groups. After 48 h of reperfusion, the rats were sacrificed and the brain was isolated. Ischaemic brain damage by 2,3,5 triphenyl tetrazolium chloride staining, oxidative stress markers, and levels of reactive oxygen species were determined biochemically.

Single treatment with candesartan and 1, 5 isoquinolinediol significantly reduced neurological deficit, infarct, and oedema volume as compared to ischaemic control and different vehicle groups for each of the drugs. However, treatment with candesartan + 1, 5 isoquinolinediol offered greater reduction in neurological deficit, cerebral infarct volume, and oedema as compared to single-drug treatments. Furthermore, treatment with candesartan + 1, 5 isoquinolinediol significantly decreased oxidative stress as compared to single treatments with each drug.

The study suggests that blockade of either type 1 angiotensin receptor or poly (ADP-ribose) polymerase-1 alone provides neuroprotection, but the better result was achieved when both type 1 angiotensin receptor and poly (ADP-ribose) polymerase-1 were blocked together by the combined use of their pharmacological inhibitor in transient cerebral ischaemia in rat.

The aims of this study were to describe the radiological characteristics of dissection patients ≤55 years and relate these to reported risk factors.

Craniocervical arterial dissection cases ≤55 years, and age- and gender-matched controls were identified from a medical records database between 1998 and 2009. Control cases had stroke from another cause than dissection. Records and radiology were reviewed.

Thirty-six radiologically confirmed dissection cases [20 (56%) vertebral artery, 16 (44%) internal carotid], and 43 controls were identified. Dissections were extracranial with intracranial extension in 10 (28%) cases. Infarction was demonstrated in 22 (61%) dissection cases. The most common wall deficit identified was an intimal flap. Twenty-three (64%) dissection cases had a recent history of neck trauma (P > 0·000) and 13 (36%) had vascular variants (P = 0·013).

Craniocervical arterial dissection cases, particularly vertebral artery, were more likely to have a history of neck trauma. Dissections were most commonly extracranial, in the upper cervical region, with intracranial extension in 28%. Dissection cases with trauma more commonly had a dissection flap and evidence of infarction in the lateral medulla, anterior or posterior inferior cerebellar artery territory. Close inspection of the V3 segment of the vertebral or skull base for internal carotid artery may be warranted with a history of neck trauma.

Databases were searched up to March 2011. A random effects model was used to summarize the pooled estimate. Statistical heterogeneity was assessed using the I² statistic. Forty-four published studies comprising 5760 stroke patients were included. The overall pooled estimate of anxiety disorders assessed by clinical interview was 18% (95%confidence interval 8–29%, I² = 97%) and was 25% (95% confidence interval 21–28%, I² = 90%) for anxiety assessed by rating scale. The Hospital Anxiety and Depression Scale-Anxiety subscale ‘probable’ and ‘possible’ cutoff scores were the most widely used assessment criteria. The combined rate of anxiety by time after stroke was: 20% (95% confidence interval 13–27%, I² = 96%) within one-month of stroke; 23% (95% confidence interval 19–27%, I² = 84%) one to five-months after stroke; and 24% (95% confidence interval 19–29%, I² = 89%) six-months or more after stroke.

Anxiety after stroke occurs frequently although methodological limitations in the primary studies may limit generalizability. Given the association between prevalence rates and the Hospital Anxiety and Depression Scale-Anxiety cutoff used in studies, reported rates could in fact underrepresent the extent of the problem. Additionally, risk factors for anxiety, its impact on patient outcomes, and effects in tangent with depression remain unclear.

The aim of this study is to explore the risk of stroke in patients with ischemic bowel disease during a one-year follow-up period in Taiwan.

Data used in this study were retrieved from the ‘Longitudinal Health Insurance Database 2000. Five hundred sixty-nine patients hospitalized with ischemic bowel disease were included as the study group, and 3414 subjects, matched by age and gender, were randomly extracted as a comparison group. Cox proportional hazards regression analysis was performed to test the relationship of ischemic bowel disease and subsequent stroke during the one-year follow-up period.

The incidence rate of stroke among the sampled subjects during the 30-day, 90-day, and 365-day follow-up period was 1·24, 0·76, and 0·43 per 10 person-years. The adjusted hazard ratio for stroke for those patients with ischemic bowel disease within 30-, 90-, and 365-day follow-up periods was found to be 3·71 (95% confidence interval = 1·89–7·27), 2·11 (95% confidence interval = 1·22–3·66), and 1·70 (95% confidence interval = 1·14–2·52) times that of matched comparisons, respectively. The adjusted hazard ratio of ischemic stroke for patients with ischemic bowel disease was found to be 5·29 during the 30-day follow-up period than comparisons.

We found ischemic bowel disease to be significantly associated with stroke occurrence.

Consecutive young patients (age 15–49) with first-ever ischaemic stroke were included, having their first brain computed tomography/magnetic resonance imaging within seven-days of stroke onset, and second within seven-days from the first imaging. Haemorrhagic transformation in any imaging was classified as haemorrhagic infarct or parenchymal haemorrhage within or remote from the infarct. Symptomatic haemorrhagic transformation was defined according to the European Cooperative Acute Stroke Study II (ECASS II) criteria as any haemorrhage leading to a National Institutes of Health Stroke Scale score increase of ≥4 points or death. Unfavourable three-month outcome was defined as a modified Rankin Scale 2–6.

In 636 eligible patients, any haemorrhagic transformation occurred in 79 patients (12·4%; 10·0–15·2%): 66 (10·4%; 8·24–12·9%) had haemorrhagic infarct, and 13 (2·04%; 1·19–3·46%) had parenchymal haemorrhage. Symptomatic haemorrhagic transformation occurred in 16 patients (2·5%; 4·04–1·55%). In logistic regression analysis, independent factors associated with haemorrhagic transformation were large anterior (18·70; 6·72–52·04), large posterior (9·41; 3·13–28·25), medium-sized (odds ratio 3·30; 95% confidence interval 1·14–9·57) lesions, higher low-density lipoprotein level (1·44 per unit increment; 1·10–1·90), and lower platelet count (1·005 per unit decrement; 1·009–1·001). Haemorrhagic infarct (1·76; 0·76–4·11) or parenchymal haemorrhage (2·39; 0·23–24·76) were not associated with unfavourable functional outcome or death at three-months.

In young adults, haemorrhagic transformation of ischaemic stroke occurred in comparable rates to haemorrhagic transformation in elderly patients. Although haemorrhagic transformation was more common in severe strokes, it was the lesion size and baseline stroke severity that were associated with three-month clinical outcome, not haemorrhagic transformation per se.

The aim of this paper is to present estimates of stroke mortality for Indonesia, Myanmar, Viet Nam, Thailand, and Malaysia, which have been derived using these empirical data.

Age-specific stroke mortality rates were calculated in each of the five countries, and adjusted for data completeness or misclassification where feasible. All data were age-standardized and the resulting rates were compared with World Health Organization estimates, which are largely based on epidemiological models.

Using empirical data, stroke ranked as the leading cause of death in all countries except Malaysia, where it ranked as the second leading cause. Age-standardized rates for males ranged from 94 per 100 000 in Thailand, to over 300 per 100 000 in Indonesia. In all countries, rates were higher for males than for females, and those compiled from empirical data were generally higher than modelled estimates published by World Health Organization.

This study highlights the extent of stroke mortality in selected Asian countries, and provides important baseline information to investigate the aetiology of stroke in Asia and design appropriate public health strategies to address the rapidly growing burden from stroke.

To clarify, the frequency of and factors associated with lesion reduction were investigated.

Patients given intravenous tissue plasminogen activator therapy within three-hours of onset were prospectively enrolled. Magnetic resonance imaging including diffusion-weighted imaging and magnetic resonance angiography was performed four times: on admission, just after intravenous tissue plasminogen activator, 24 h from intravenous tissue plasminogen activator, and seven-days after intravenous tissue plasminogen activator. The diffusion-weighted imaging lesion volume was measured by manual trace using National Institutes of Health imaging software. All patients were divided into three groups according to the early diffusion-weighted imaging lesion volume change from admission to just after intravenous tissue plasminogen activator: the lesion reduction group (>20% decrease); the lesion growth group (>20% increase); and the lesion unchanged group.

In total, 105 patients [56 males, median age 77 (interquartile range 70–83) years, and National Institutes of Health Stroke Scale score 16 (10–22)] were enrolled. Early diffusion-weighted imaging lesion reduction was observed in seven (7%) patients. The decreased lesion increased subsequently. On multivariate analysis, the glucose level on admission (odds ratio 0·95, 95% confidence interval 0·91 to 0·99, P = 0·045) and early recanalization (odds ratio 15·7, 95% confidence interval 1·61 to 153, P = 0·018) were independently related to early lesion reduction.

Early diffusion-weighted imaging lesion reduction was observed in 7% of patients treated with intravenous tissue plasminogen activator. The decreased lesion increased subsequently. Initial glucose level and early recanalization were independently associated with early diffusion-weighted imaging lesion reduction.

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.

NeuroThera^® Efficacy and Safety Trial-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 the 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.

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).

Between 2002 and 2009, we reviewed our computed tomographic angiography database for patients who received full-dose intravenous rtPA and endovascular therapy or endovascular therapy alone for acute ischaemic stroke treatment. Details of demographics, risk factors, endovascular procedure, and symptomatic intracranial haemorrhage were noted. Modified Rankin Scale ≤2 at three-months was used as good outcome. Recanalization was defined as Thrombolysis in Myocardial Ischaemia 2–3 flow on angiography.

Among 157 patients, 104 patients received IV-IA treatment and 53 patients underwent direct IA therapy. There was a higher recanalization rate with IV-IA therapy compared with IA alone (71% vs. 60%, P < 0·21) which was driven by early recanalization after IV rtPA. Mortality and independent outcome were comparable between the two groups. Symptomatic intracranial haemorrhage occurred in 8% of patients (12% in the IA group, 7% in the IV-IA group) but was more frequent as the intensity of intervention increased from device alone to thrombolytic drug alone to device plus thrombolytic drug(s). Recanalization was a strong predictor of reduced mortality risk ratio (RR) 0·48 confidence interval₉₅ 0·27–0·84) and favourable outcome (RR 2·14 confidence interval₉₅ 1·3–3·5).

Combined IV-IA therapy with full-dose intravenous rtPA was safe and results in good recanalization rates without excess symptomatic intracranial haemorrhage. Testing of full-dose IV tPA followed by endovascular treatment in the IMS3 trial is justified.

Men and women aged ≥18 years with acute stroke presenting to four tertiary care hospitals in Karachi, Pakistan were screened using magnetic resonance angiography/transcranial Doppler scans. Trial of ORG 10172 in Acute Stroke Treatment criteria were applied to identify strokes from intracranial atherosclerotic disease.

We studied 245 patients with acute stroke due to intracranial atherosclerotic disease. Two hundred thirty scans were reviewed. Also, 206/230 (89·0%) showed acute ischaemia.

The most frequent presentation was with cortically based strokes in 42·2% (87/206) followed by border-zone infarcts (52/206, 25·2%). Increasing degrees of stenosis correlated with the development of both cortical and border-zone strokes (P = 0·002). Important associated findings were frequent atrophy (166/230, 72·2%), silent brain infarcts (66/230, 28%) and a marked lack of severe leukoaraiosis identified in only 68/230 (29·6%).

A total of 1870 arteries were studied individually. Middle cerebral artery was the symptomatic stroke vessel in half, presenting with complete occlusion in 66%. Evidence of biological disease, symptomatic or asymptomatic was identified in 753 (40·2%) vessels of which 543 (72%) were significantly (>50%) stenosed at presentation.

Intracranial atherosclerotic disease is a diffuse process in Pakistani south Asians, with involvement of multiple vessels in addition to the symptomatic vessel. The middle cerebral artery is the most frequent symptomatic vessel presenting with cortical embolic infarcts. There is a relative lack of leukoaraiosis. Concomitant atrophy, silent brain infarcts and recent ischaemia in the symptomatic territory are all frequently associated findings.

To evaluate the efficacy and safety of intravenous alteplase (0·9 mg/kg) as thrombolytic therapy within three-hours of onset of acute ischaemic stroke in an Asian population.

The 591 patients included were treated at 48 centers in four countries (South Korea, China, India, and Singapore) between 2006 and 2008. Primary outcomes were symptomatic (deterioration in National Institutes of Health Stroke Scale score ≥4 or death within the first 24 h) intracerebral haemorrhage type 2 22–36 h after the thrombolysis and mortality at three-month follow-up. The secondary outcome was functional independence (modified Rankin Scale score 0–2) at three-months. Results were compared with those from Safe Implementation of Thrombolysis in Stroke-Monitoring Study (n = 6483) and pooled results of patients (n = 415) who received intravenous alteplase (0·9 mg/kg) zero- to three-hours from onset of stroke symptoms in four randomized controlled trials (National Institute of Neurological Disorders and Stroke A and B, Altephase Thrombolysis for Acute Noninterventional Therapy in Ischaemic Stroke, and European Cooperative Acute Stroke Study II).

Results are presented as Safe Implementation of Thrombolysis in Stroke-Non-European Union World vs. Safe Implementation of Thrombolysis in Stroke-Monitoring Study vs. pooled randomized controlled trials. Median age was 64 vs. 68 vs. 70 years, National Institutes of Health Stroke Scale score at baseline was 12 vs. 12 vs. 13, time from stroke onset to treatment was 130 vs. 140 vs. 135 mins, and females were 36·4% vs. 39·8% vs. 41·2%. Main outcomes (proportion of patients and 95% confidence intervals) were symptomatic intracerebral haemorrhage: 1·9% (1·1–3·3) vs. 1·7% (1·4–2·0) vs. 3·1% (1·8–5·3); mortality: 10·2% (8·0–12·9) vs. 11·3% (10·5–12·1) vs. 16·4% (13·1–20·3); and functional independence: 62·5% (58·5–66·4) vs. 54·8% (53·5–56·0) vs. 50·1% (45·3–54·9) at three-months. Adjusted odds ratio (95% confidence intervals) between Safe Implementation of Thrombolysis in Stroke-Non-European Union World and Safe Implementation of Thrombolysis in Stroke-Monitoring Study, and between Safe Implementation of Thrombolysis in Stroke-Non-European Union World and the pooled trials were 1·83 (0·89–3·77; P = 0·1156) and 0·63 (0·19–2·07; P = 0·4470) for symptomatic intracerebral haemorrhage, 0·90 (0·64–1·25; P = 0·5092) and 0·93 (0·52–1·64; P = 0·7915) for mortality at three-months, and 1·57 (1·25–1·96; P < 0·0001) and 1·35 (0·91–2·00; P = 0·1325) for functional independence.

These data demonstrate the safety and efficacy of the standard dose of intravenous alteplase (0·9 mg/kg) in an Asian population, as previously observed in the European population studied in Safe Implementation of Thrombolysis in Stroke-Monitoring Study and the populations in pooled randomized controlled trials, when used in routine clinical practice within three-hours of stroke onset. The findings should encourage wider use of thrombolytic therapy in Asian countries for suitable patients treated in stroke centers.

Using the retina as a proxy, we assessed retinal microvascular changes in WML and LI.

We prospectively recruited 1211 acute stroke patients. Four subgroups were identified from neuroimaging: WML alone, LI alone, both WML and LI, neither WML nor LI. Masked retinal photographs identified retinopathy and retinal arteriolar wall signs and measured retinal vascular caliber.

Compared with 448 controls with neither WML nor LI, 384 patients with only WML were more likely to have retinopathy [odds ratio (OR) 1·5, 95% confidence interval (CI) 1·1 to 2·1] and enhanced arteriolar light reflex (OR 1·6, 95% CI 1·1 to 2·3); 200 patients with only LI were more likely to have arteriolar narrowing (OR 1·6, 95% CI 1·1 to 2·3) and enhanced arteriolar light reflex (OR 1·6, 95% CI 1·0 to 2·4); and 179 patients with both WML and LI were more likely to have arteriovenous nicking (OR 1·7, 95% CI 1·1 to 2·6), enhanced arteriolar light reflex (OR 2·0, 95% CI 1·3 to 3·2) and wider venules (OR 2·3, 95% CI 1·4 to 3·6). All analyses were adjusted for age, gender, study site and cardiovascular risk factors.

Both WML and LI were associated with retinal microvascular signs, supporting a microvascular etiology. Differing patterns of association suggest different mechanisms may predominate, e.g. greater endothelial permeability in WML, and ischemia associated with arteriolar wall disease in LI.

The general aim of the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy Trial is to investigate whether multimodal imaging can identify patients who will benefit substantially from mechanical embolectomy for the treatment of acute ischaemic stroke up to eight-hours from symptom onset.

Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy is a randomized, controlled, blinded-outcome clinical trial.

Acute ischaemic stroke patients with large vessel intracranial internal carotid artery or middle cerebral artery M1 or M2 occlusion enrolled within eight-hours of symptom onset are eligible. The study sample size is 120 patients.

Patients are randomized to endovascular embolectomy employing the Merci Retriever (Concentric Medical, Mountain View, CA) or the Penumbra System (Penumbra, Alameda, CA) vs. standard medical care, with randomization stratified by penumbral pattern.

The primary aim of the trial is to test the hypothesis that the presence of substantial ischaemic penumbral tissue visualized on multimodal imaging (magnetic resonance imaging or computed tomography) predicts patients most likely to respond to mechanical embolectomy for treatment of acute ischaemic stroke due to a large vessel, intracranial occlusion up to eight-hours from symptom onset. This hypothesis will be tested by analysing whether pretreatment imaging pattern has a significant interaction with treatment as a determinant of functional outcome based on the distribution of scores on the modified Rankin Scale measure of global disability assessed 90 days post-stroke. Nested hypotheses test for (1) treatment efficacy in patients with a penumbral pattern pretreatment, and (2) absence of treatment benefit (equivalency) in patients without a penumbral pattern pretreatment. An additional aim will only be tested if the primary hypothesis of an interaction is negative: that patients treated with mechanical embolectomy have improved functional outcome vs. standard medical management.

The Outcomes in Patients with TIA and Cerebrovascular disease registry is an international, prospective study. Patients ≥45 years who required secondary prevention of stroke (either following an acute transient ischaemic attack or minor ischaemic strokes (National Institutes of Health Stroke Scale <4) of <24 h duration, or recent (<6 months), stable, first-ever, non-disabling ischaemic stroke) were enrolled in 17 countries in Latin America, the Middle East, and Africa. The main measures of interest were risk factors, comorbidities, and socio-economic variables.

Between January 2007 and December 2008, 3635 patients were enrolled in Latin America (n = 1543), the Middle East (n = 1041), North Africa (n = 834), and South Africa (n = 217). Of these, 63% had a stable, first-ever ischaemic stroke (median delay from symptom onset to inclusion, 25 days interquartile range, 7–77); 37% had an acute transient ischaemic attack or minor ischaemic stroke (median delay, two-days; interquartile range, 0–6). Prevalence of diabetes was 46% in the Middle East, 29% in Latin America, 35% in South Africa, and 38% in North Africa; 72% had abdominal obesity (range, 65–78%; adjusted P < 0·001); prevalence of metabolic syndrome was 78% (range, 72–84%, P < 0·001). Abnormal ankle brachial index (<0·9) was present in 22%, peripheral artery disease in 7·6%, and coronary artery disease in 13%. Overall, 24% of patients had no health insurance and 27% had a low educational level.

In this study, patients in low- and middle-income countries had a high burden of modifiable risk factors. High rates of low educational level and lack of health insurance in certain regions are potential obstacles to risk factor control.

The Outcomes in Patients with TIA and Cerebrovascular disease registry is supported by Sanofi-Aventis, Paris, France.

The aim of the Restore4Stroke Cohort study is to investigate the changes in quality of life of stroke patients and their partners over time, and to determine factors predicting quality of life in several domains, especially personal and environmental factors.

Multicentre prospective longitudinal cohort study. Inclusion and the first assessment take place during hospital stay in the first week post-stroke. Follow-up assessments take place at two months, six months, one year, and two years post-stroke. Recruitment of 500 patients from stroke units in six participation hospitals is foreseen. If the patient has a partner, he or she is also asked to participate in the study.

The main outcome is quality of life, considered from a health-related quality of life and domain-specific quality of life perspective. Factors predicting long-term quality of life will be determined by taking into account the health condition (pre-stroke health condition and stroke-related health condition), personal factors (e.g. coping and illness cognitions), and environmental factors (e.g. caregiver burden and social support).

This study is expected to provide information about the changes in quality of life of stroke patients and their partners over time. Furthermore, the identification of factors predicting quality of life can be used to improve rehabilitation care and develop new interventions for stroke patients and their partners.

Electronic searches of EMBASE, Medline, CINAHL, and PsychInfo were performed. We included peer-reviewed journal articles, in English, between 1 January 1966 and 30 August 2010 reporting stroke survivors' perceived barriers and motivators to physical activity.

Searches identified 73 807 citations of which 57 full articles were retrieved. Six articles were included, providing data on 174 stroke survivors (range 10 to 83 per article). Two reported barriers and motivators, two reported only motivators, and two reported only barriers. Five were qualitative articles and one was quantitative. The most commonly reported barriers were lack of motivation, environmental factors (e.g. transport), health concerns, and stroke impairments. The most commonly reported motivators were social support and the need to be able to perform daily tasks.

This review has furthered our understanding of the perceived barriers and motivators to physical activity after a stroke. This review will enable the development of tailored interventions to target barriers, while building upon perceived motivators to increase and maintain stroke survivors' physical activity.

This study aimed to determine the impact of admission glucose and diabetes on recanalization and outcome after intra-arterial thrombolysis.

We analysed 389 patients (213 men, 176 women) treated with intra-arterial thrombolysis. The association of diabetes and admission glucose value with recanalization, outcome, mortality, and symptomatic intracranial haemorrhage was determined. Recanalization was classified according to thrombolysis in myocardial infarction grades. Outcome was measured using the modified Rankin Scale at three-months and categorized as favourable (modified Rankin Scale 0–2) or poor (modified Rankin Scale 3–6).

The rate of partial or complete recanalization (thrombolysis in myocardial infarction 2–3) did not differ between patients with and without diabetes (67% vs. 66%; P = 1·000). Mean admission glucose values were similar in patients with poor recanalization (thrombolysis in myocardial infarction 0–1) and patients with partial or complete recanalization (thrombolysis in myocardial infarction 2–3; 7·3 vs. 7·3 mmol/l; P = 0·746). Follow-up at three-months was obtained in 388 of 389 patients. Clinical outcome was favourable (modified Rankin Scale 0–2) in 189 patients (49%) and poor (modified Rankin Scale 3–6) in 199 patients (51%). Mortality at three-months was 20%. Diabetics were more likely to have poor outcome (72% vs. 48%; P = 0·001) and to be dead (30% vs. 19%; P = 0·044) at three-months. After multivariable analysis, there remained an independent relationship between diabetes and outcome (P = 0·003; odds ratio 3·033, 95% confidence interval 1·452–6·336), but not with mortality (P = 0·310; odds ratio 1·436; 95% confidence interval 0·714–2·888). Moreover, higher age (P = 0·001; odds ratio 1·039; 95% confidence interval 1·017–1·061), higher baseline National Institutes of Health Stroke Scale score (P < 0·0001; odds ratio 1·130; 95% confidence interval 1·079–1·182), location of vessel occlusion as categorical variable (P < 0·0001), poor collaterals (P = 0·02; odds ratio 1·587; 95% confidence interval 1·076–2·341), poor vessel recanalization (P < 0·0001; odds ratio 4·713; 95% confidence interval 2·627–8·454), and higher leucocyte count (P = 0·032; odds ratio 1·094; 95% confidence interval 1·008–1·188) were independent baseline predictors of poor outcome. Higher admission glucose was associated with poor outcome (P = 0·006) and mortality (P < 0·0001). After multivariate analyses, glucose remained independently associated with poor outcome (P = 0·019; odds ratio 1·150; 95% confidence interval 1·023–1–292) and mortality (P = 0·005; odds ratio 1·183; 95% confidence interval 1052–1·331). The rate of symptomatic intracranial haemorrhage was similar in diabetics and non-diabetics (6·7% vs. 4·6%; P = 0·512). Mean admission glucose was higher in patients with symptomatic intracranial haemorrhage than without (8·58 vs. 7·26 mmol/l; P = 0·010). Multivariable analysis confirmed an independent association between admission glucose and symptomatic intracranial haemorrhage (P = 0·027; odds ratio 1·187; 95% confidence interval 1·020–1·381).

Diabetes and glucose value on admission did not influence recanalization after intra-arterial thrombolysis; nevertheless, they were independent predictors of poor outcome after intra-arterial thrombolysis and a higher admission glucose value was an independent predictor of symptomatic intracranial haemorrhage. This indicates that factors on the capillary, cellular, or metabolic level may account for the worse outcome in patients with elevated glucose value and diabetes.

From the Dutch hospital discharge register, we identified all patients with subarachnoid haemorrhage admission between 1997 and 2008. We determined the accuracy of coding of the diagnosis subarachnoid haemorrhage for patients admitted to our centre. Conditional on survival of three-months after the subarachnoid haemorrhage, we calculated standardized incidence and mortality ratios for fatal or nonfatal vascular diseases, vascular death, and all-cause death. Cumulative risks were estimated with survival analysis.

The diagnosis of nontraumatic subarachnoid haemorrhage was correct in 95·4% of 1472 patients. Of 11 263 admitted subarachnoid haemorrhage patients, 6999 survived more than three-months. During follow-up (mean 5·1 years), 874 (12·5%) died. The risks of death were 3·3% within one-year, 11·3% within five-years, and 21·5% within 10 years. The standardized mortality ratio was 3·4 (95% confidence interval: 3·1 to 3·7) for vascular death and 2·2 (95% confidence interval: 2·1 to 2·3) for all-cause death. The standardized incidence ratio for fatal or nonfatal vascular diseases was 2·7 (95% confidence interval: 2·6 to 2·8).

Dutch hospital discharge and cause of death registries are a valid source of data for subarachnoid haemorrhage, and show that the increased mortality rate in subarachnoid haemorrhage survivors is explained by increased risks for vascular diseases and death.

We aimed to investigate whether statin use is associated with a reduced risk of poststroke pneumonia in acute ischemic stroke patients treated with tissue plasminogen activator within 4·5hours.

Data was extracted from a local register including all consecutive stroke patients who received thrombolysis at our institution. Prior statin use was identified retrospectively from clinical records and had to be continued after hospital admission. Poststroke pneumonia was diagnosed according to standardized criteria of US Centers for Disease Control and Prevention. Mortality and functional outcome at three-months were further assessed.

Overall, 481 ischemic stroke patients were analyzed. Continued statin use was documented in 17% of the patients. Frequency of pneumonia was 11%. Patients with statin use were less likely to develop poststroke pneumonia (5% vs. 13%, P = 0·04). After multivariable adjustment for known risk factors for poststroke pneumonia (age, stroke severity, dysphagia, male sex and diabetes), statin treatment was negatively associated with pneumonia (OR 0·31; 95% CI 0·10–0·94). Occurrence of pneumonia independently predicted three-month mortality and functional outcome.

Use of statins in acute ischemic stroke patients who receive thrombolysis might reduce the risk of poststroke pneumonia. Further studies are warranted to validate this finding.

We compared mortality and inpatient stroke care quality between Veterans Affairs medical centers inside and outside the stroke belt region.

Study patients were veterans hospitalized for ischemic stroke at 129 Veterans Affairs medical centers. Inpatient stroke care quality was assessed by 14 quality indicators. Multivariable logistic regression models were fit to examine differences in quality between facilities inside and outside the stroke belt, adjusting for patient characteristics and Veterans Affairs medical centers clustering effect.

Among the 3909 patients, 28·1% received inpatient ischemic stroke care in 28 stroke belt Veterans Affairs medical centers, and 71·9% obtained care in 101 non-stroke belt Veterans Affairs medical centers. Patients cared for in stroke belt Veterans Affairs medical centers were more likely to be younger, Black, married, have a higher stroke severity, and less likely to be ambulatory pre-stroke. We found no statistically significant differences in short- and long-term post-admission mortality and inpatient care quality indicators between the patients cared for in stroke belt and non-stroke belt Veterans Affairs medical centers after risk adjustment.

These data suggest that a stroke belt does not exist within the Veterans Affairs health care system in terms of either post-admission mortality or inpatient care quality.

We evaluated different methods for estimating the volume of infarcts, hemorrhages, after embolic middle cerebral artery occlusion with or without thrombolysis.

An experimental thromboembolytic rat model was used in this study. The rats underwent surgery and were placed in two groups. Group 1 was treated with saline, and group 2 was treated with 20 mg/kg recombinant tissue plasminogen activator to promote intracerebral hemorrhages. Stereology, semiautomated computer estimation, and manual erythrocyte counting were used to test the precision and efficiency of determining the size of the infarct and intracerebral hemorrhage.

No differences were observed in the infarct volume or amount of bleeding when comparing the three methods of volume estimation. Although semiautomated computer estimation and manual erythrocyte counting provided similar results as the stereological measurements, the stereological method was the most efficient and advantageous.

We found that stereology was the superior method for quantification of hemorrhagic volume, especially for rodent petechial bleeding, which is otherwise difficult to measure. Our results suggest the possibility of measuring both the ischemic and the hemorrhagic components of stroke, two parameters that may be differentially regulated when therapeutic regimens are tested.

We set out to perform external validation of the THRIVE score using data from the largest registry of endovascular stroke treatment performed to date, the Merci Registry.

We compared the performance of the THRIVE score in two different data sets: the development cohort (the MERCI and Multi MERCI trials, n = 305) and a validation cohort (the Merci Registry, a prospective multicenter registry of patients undergoing endovascular stroke treatment, n = 1000). We examined the predictive utility of the THRIVE score across the range of clinical outcomes and used receiver–operator characteristics curve analysis to compare score performance in the two data sets.

The THRIVE score predicted good outcome, death, and the full range of the modified Rankin Scale in a similar fashion between the MERCI trials and the Merci Registry. Receiver–operator characteristics curve comparisons showed no statistically significant difference in the performance of the THRIVE score between the two data sets: for good outcome, the receiver–operator characteristics area under the curve was 0·293 for the MERCI trials and 0·266 for the Merci Registry (P = 0·47) and for death, the receiver–operator characteristics area under the curve was 0·692 for the MERCI trials and 0·717 for the Merci Registry (P = 0·48). The THRIVE score and vessel recanalization were also found to be independent and unrelated predictors of clinical outcome.

The THRIVE score reliably predicts outcomes after endovascular stroke treatment and may be useful as a clinical prognostic tool and to perform severity adjustments in stroke clinical research.

We aim to determine prediction models of different complexity for the combined vascular end-point of stroke, myocardial infarction, and vascular death at three-years after first-ever stroke. An independent external validation of the developed models will be performed.

Prospective observational hospital-based cohort study of patients after first-ever stroke.

The new predictive models will be developed using the following steps: (1) Development of a basic score based on clinical history data (e.g. hypertension, myocardial infarction, and atrial fibrillation); (2) Development of an advanced score including additional factors such as blood-based biomarkers and results of vascular imaging; (3) Comparing the models fit using different methods (discrimination, calibration); (4) Assessment of clinical utility of an advanced score using methods based on reclassification tables (e.g. net reclassification improvement, integrated discrimination improvement, decision curve analysis); and (5) Investigation of external validity.

Primary outcome is a combined vascular end-point composed of stroke, myocardial infarction, and vascular death at three-years after stroke. Furthermore, each component of the composite end-point will be investigated individually and the patterns and time points of risk transitions between vascular end-points and stroke sub-types will be determined.

In families with intracranial aneurysms, we sought to determine whether mortality among subjects with intracranial aneurysm (affected) was higher and related to rupture, compared with unaffected family members.

Subjects enrolled in the Familial Intracranial Aneurysm protocol were contacted yearly and their status was obtained. If reported to be deceased, the cause of death was verified by available records. A Cox proportional hazards model was utilized to compare mortality rates.

Of the 2794 subjects, 1073 were affected and 1721 were unaffected. There were 8525 person-years of follow-up (mean 3·05 ± 1·73 years) and 85 deaths. Age at study entry for the affected (58·4 ± 11·9 years) was significantly older (P < 0·0001) than for the unaffected (52·2 ± 16·1). After adjusting for age, the overall mortality rate for the affected subjects was not significantly different from that for the unaffected (Rate Ratio [RR] 1·26, 95% confidence interval 0·82–1·93, P = 0·292). There was a strong effect modification due to age. The mortality rate ratio of the affected to the unaffected who were ≤60 years of age was RR = 3·48 (95% confidence interval: 1·59–7·63, P = 0·002), the rate for the affected subjects who were ≥60 was less than the rate for the unaffected (RR = 0·69, 95% confidence interval: 0·404–1·19, P = 0·178). The affected who had ruptures had 2·62 times the mortality rate as those without ruptures (95% confidence interval 1·43–4·80, P = 0·002).

The overall mortality was similar for the affected and unaffected subjects in this cohort. Among the affected only, those with ruptured intracranial aneurysm had a higher mortality rate than those without ruptured.

This observational study was based on patients who were discharged alive and registered in the Swedish Stroke Register in 2001 through 2005. Vital status was retrieved by linkage to the Swedish Cause of Death Register. We calculated a propensity score for the likelihood of warfarin prescription at discharge from hospital. The risk of death and 95% confidence intervals were estimated in Cox regression models.

Out of the 20 442 patients with atrial fibrillation and ischaemic stroke (mean age = 79·5 years), 31% (n = 6399) were prescribed warfarin. After adjustment for the propensity score, warfarin was associated with a reduced risk of death (0·67; 95% confidence interval, 0·63–0·71). The crude rate (per 100 person-years) of fatal non-haemorrhagic stroke was lower in patients who received warfarin (1·60; 95% confidence interval, 1·34–1·89) compared to those who received antiplatelet (6·83; 95% confidence interval, 6·42–7·25). The rates (per 100 person-years) of fatal haemorrhagic stroke were 0·21 (95% confidence interval, 0·12–0·32) and 0·43 (95% confidence interval, 0·34–0·55) in patients prescribed warfarin and antiplatelet therapy, respectively.

In addition to its established benefit for stroke prevention, warfarin therapy in patients with atrial fibrillation and ischaemic stroke was associated with a reduced risk of death, without an increased risk of fatal haemorrhagic stroke.

The aim of the present study is to investigate whether procalcitonin ultrasensitive-guided antibiotic treatment improves functional outcome after severe ischaemic stroke by early treatment of pneumonia.

STRAWINSKI is an investigator-initiated, multicentre, randomized, controlled trial with blinded assessment of outcome comparing procalcitonin ultrasensitive-guided antibiotic treatment with standard care.

200 patients with ischaemic stroke in the middle cerebral artery territory and a score >9 on the National Institutes of Health Stroke Scale will be included and randomly assigned to two groups. One group will receive procalcitonin-based antibiotic therapy guidance; the other group will receive standard stroke unit care.

The primary endpoint is functional outcome at day 90 after stroke on the modified Rankin Scale, dichotomized as favourable (0–4) or unfavourable outcome (5–6). Secondary endpoints are time to first event of death, rehospitalization, or recurrent stroke; death rate, infection rate, and days with fever up to day 7; length of hospital stay and hospital discharge disposition; shift analysis of the modified Rankin Scale; Barthel Index and days alive and out of hospital at day 90; use of antibiotics until day 90; and modified Rankin Scale, Barthel Index, and infarct volume at day 180.

We investigated recent trends in the utilization and outcomes of administration of intravenous recombinant tissue plasminogen activator in the United States using the National Inpatient Sample between 2001 and 2008.

We identified patients with a primary diagnosis of acute ischemic stroke who underwent treatment with intravenous recombinant tissue plasminogen activator and studied utilization rates and clinical outcomes: discharge to long-term facility (morbidity), in-hospital death (mortality), and intracranial hemorrhage. Information on demographics, hospital characteristics, and comorbidities was collected. A multivariate logistic regression analysis was performed to determine independent predictors of morbidity, mortality, and intracranial hemorrhage.

Intravenous recombinant tissue plasminogen activator utilization increased from 1·3% in 2001 to 3·5% in 2008. On multivariate analysis, variables associated with increased morbidity after intravenous recombinant tissue plasminogen activator administration included advanced age (P < 0·001), female gender (P < 0·001), and comorbidities of atrial fibrillation (P < 0·001) and hypertension (P < 0·001). Increased mortality was associated with increased age (P < 0·001) and comorbidities of atrial fibrillation, congestive heart failure, coronary artery disease, and diabetes (P < 0·001 for all comorbidities).

Intravenous recombinant tissue plasminogen activator utilization rates increased between 2001 and 2008. Advanced age and atrial fibrillation were significantly associated with increased morbidity and mortality among patients treated with intravenous recombinant tissue plasminogen activator.

The aim of this study was to develop a database to support modeling of patent foramen ovale-attributable recurrence risk by combining extant data sets.

We identified investigators with extant databases including subjects with cryptogenic stroke investigated for patent foramen ovale, determined the availability and characteristics of data in each database, collaboratively specified the variables to be included in the Risk of Paradoxical Embolism database, harmonized the variables across databases, and collected new primary data when necessary and feasible.

The Risk of Paradoxical Embolism database has individual clinical, radiologic, and echocardiographic data from 12 component databases, including subjects with cryptogenic stroke both with (n = 1925) and without (n = 1749) patent foramen ovale. In the patent foramen ovale subjects, a total of 381 outcomes (stroke, transient ischemic attack, death) occurred (median follow-up 2·2 years). While there were substantial variations in data collection between studies, there was sufficient overlap to define a common set of variables suitable for risk modeling.

While individual studies are inadequate for modeling patent foramen ovale-attributable recurrence risk, collaboration between investigators has yielded a database with sufficient power to identify those patients at highest risk for a patent foramen ovale-related stroke recurrence who may have the greatest potential benefit from patent foramen ovale closure.

We carried out a hospital-based prospective observational study at Rajendra Institute of Medical Sciences-Ranchi. Patients of acute stroke, reporting to the medical outpatient department and emergency department from January 1, 2006 to December 31, 2010 were studied. Computed tomography scan was done immediately and again after 24 h to confirm the diagnosis of stroke. To compare the findings between tribal and non-tribal patients, we used chi-square test/Fisher exact test as appropriate.

Of the total 1156 patients included in the study, 536 were tribals, while 620 were non-tribals. Significant differences were found in tribal stroke patients as compared with non-tribals: mean age of tribal subjects was 53·8 years (60·8 years in non-tribals); stroke in young individual was present in 25% of tribal subjects (17% in non-tribals, P = 0·01); primary intracerebral hemorrhage variety was present in 31% of tribals (18% in non-tribals, P-value < 0·001); the 28th day case fatality rate was 43% among tribal subjects (35% among non-tribals, P = 0·02). Hypertension and alcohol abuse was found to be associated with intracerebral hemorrhage in tribal subjects, although no such association was found in non-tribals.

Tribals have early onset, poor outcomes and higher proportion of ICH compared to non-tribals. [Correction added after online publication 7 Aug 2012: The sentence "Tribals have early with non-tribals." in the Conclusion section of the abstract was deleted.]

We investigated the value of cyclosporine A for reducing the infarct size in a model of transient middle cerebral artery occlusion.

Twenty-seven Sprague-Dawley rats sustained a middle cerebral artery occlusion of one-hour. Acute multimodal Magnetic Resonance Imaging (MRI) was used during occlusion to confirm the success of surgery and measure baseline lesion size. Animals were randomly treated by: (i) intracarotid cyclosporine A (10 mg/kg) 20 mins before middle cerebral artery occlusion (pretreatment group); (ii) intracarotid cyclosporine A (10 mg/kg) immediately after reperfusion (post-treatment group); and (iii) intracarotid saline immediately after reperfusion.

Histopathological measurements on day 1 showed a significant reduction of infarct size in the pretreatment group compared to the post-treatment (percentage values of ipsilateral hemispheres: 16 ± 5% vs. 29 ± 11%, P = 0·004) and saline groups (16 ± 5% vs. 42 ± 12%, P = 0·015). No significant difference was observed between the post-treatment and saline groups (P = 0·065). Behavioural examinations on day 1 showed no significant difference between groups. Immunohistochemistry showed a statistically significant reduction of microglial cell count in the pretreatment group compared to either saline or cyclosporine A post-treatment groups.

We conclude that intracarotid cyclosporine A is effective in reducing infarct size when given prior to ischaemia, but not when administered at reperfusion.

The aim of this article is to study whether intravenous thrombolysis with alteplase improves clinical outcome in ischemic stroke patients who do not have arterial occlusion at presentation.

A retrospective medical record-based observational multicenter, multinational study.

Primary outcome measure would be clinical outcome at three-months from stroke onset measured by modified Rankin Scale and National Institute of Health Stroke Scale. Secondary outcome measure will be frequency of intracerebral hemorrhage causing worsening of clinical deficit defined as increase in National Institute of Health Stroke Scale by >4.

We analyzed data on 157 consecutive patients with acute ischemic stroke because of presumed cryptogenic embolism. Agitated saline transcranial Doppler study was conducted in all patients to detect right-to-left shunt. We evaluated the association of the amount (microemboli <20 vs. ≥20) and activity (spontaneous vs. after Valsalva maneuver only) of right-to-left shunt with diffusion-weighted imaging lesion patterns.

Right-to-left shunt was observed in 96 (61·1%) patients. The multiplicity and distribution of diffusion-weighted imaging lesions did not differ depending on the amount and activity of right-to-left shunt. However, the size of diffusion-weighted imaging lesions differed depending on the amount of right-to-left shunt (P = 0·019). Right-to-left shunt was more frequently observed in patients with small (<1 cm) infarcts than in those with a large infarct (66·7% vs. 45·9%), and most patients with a larger amount of right-to-left shunt were found to have small infarcts on diffusion-weighted imaging (80%). The clinical characteristics, including Framingham stroke risk strategy, did not differ between the groups.

Our results indicate that the amount of right-to-left shunt determines the Diffusion-weighted imaging lesion patterns and suggest that mechanisms of stroke other than paradoxical mechanism may play an important role in patients with large cryptogenic embolic stroke.

We included 6268 patients from the Virtual International Stroke Trials Archive: 2734 received intravenous thrombolysis and 3534 were treated conservatively. We compared day 90 outcomes between treated and untreated groups, by modified Rankin Scale (illustrative) and by Cog-4 (primary measure) adjusting for age, baseline National Institutes of Health stroke scale, hemispheric lateralisation as well as baseline Cog-4 and baseline National Institutes of Health Stroke Scale excluding baseline Cog-4 separately. Analysis of Cog-4 was repeated within strata of 90 day modified Rankin Scale. Statistical analyses included proportional odds logistic regression and Cochran–Mantel–Haenszel test.

Modified Rankin Scale showed a difference between treatment groups of expected magnitude (odds ratio 1·56; 95% confidence interval 1·43–1·72; P < 0·001). After adjustment for imbalance in baseline prognostic factors, the distribution of Cog-4 scores at 90 days was better in thrombolysed patients compared with nonthrombolysed patients (odds ratio 1·31; 95% confidence interval 1·18–1·47; P = 0·006). However, Cog-4 analysis stratified by 90-day modified Rankin Scale was neutral between treatment groups (OR 1·01; 95% CI 0·90–1·14), and Cog-4 was not responsive to treatment group even within modified Rankin Scale categories 4 and 5 despite substantial cognitive deficits in these patients.

Although Cog-4 may be responsive to treatment effects, it does not provide additional information beyond modified Rankin Scale assessment.

Ninety-four patients with ischemic stroke (34 patients in acute phase and 60 patients in chronic phase, average six-months after stroke onset) and thirty-seven elderly controls were recruited. Ewing's battery autonomic function tests and power spectral analysis of heart rate variability were performed in all the subjects.

From power spectral analysis of heart rate variability, stroke patients of both acute and chronic phases had significantly lower low frequency power spectral density than controls. From Ewing's battery of autonomic function tests, patients in acute phase showed impairment in two parasympathetic tests (Valsalva ratio: P = 0·002; heart rate response to deep breathing: P < 0·001) and those in chronic phase showed impairment in all parasympathetic tests (all P < 0·05) in comparison with controls.

The comprehensive assessment indicates that autonomic dysfunction occurs in acute phase of ischemic stroke and may persist up to six-months after stroke. Parasympathetic dysfunction rather than sympathetic dysfunction is predominant after ischemic stroke.

Aim of our study was to identify the frequency of poststroke infections in thrombolysed stroke patients and to analyze their effect on the outcome after three-months.

From 1998 to 2011, all patients in our institution undergoing thrombolysis for acute ischemic stroke were included into a prospective database. Baseline variables, clinical, radiographic, and laboratory data were collected prospectively. Outcome measures included symptomatic intracerebral hemorrhage per European-Australasian Acute Stroke Study II criteria, mortality, and modified Rankin Scale at three-months. Logistic regression models were used to identify independent predictors for poor outcome where appropriate.

One thousand sixteen patients were included; of them, 36·3% had an infection during the first week. Pneumonia (9·6%) and urinary tract infections (5·4%) were most frequent. Severity of stroke (P < 0·0001), infarct size (P < 0·0001), atrial fibrillation (P = 0·005), and cardio embolic cause of stroke (P < 0·0001) were associated with infections. Age (odds ratio 1·089, 95% confidence interval 1·064–1·115, P < 0·0001), severity of stroke (odds ratio 1·111, 95% confidence interval 1·073–1·149; P < 0·0001) history of diabetes (odds ratio 0·555. 95% confidence interval 0·357–0·864; P = 0·009), infarct size (odds ratio 4·256 95% confidence interval 2·697–6·745; P < 0·0001), infections (odds ratio 1·548, 95% confidence interval 1·008–2·376; P = 0·046), and symptomatic intracerebral hemorrhage were independent predictors for poor outcome after three-months.

In our cohort of thrombolysed stroke patients, poststroke infections were frequent in patients with severe cardio embolic stroke, a large infarct, and a longer hospital stay; those patients have a higher risk of infection and a poorer functional outcome after three-months. This risk increases after occurrence of symptomatic intracerebral hemorrhage. Prevention of infection with antibiotic therapy or other prophylactic treatment could potentially lead to a better functional outcome and further randomized studies on this aspect are needed.

The main objective of this study is to further characterize the important components of early supported discharge and to confirm superiority of early supported discharge over conventional treatment. The secondary aim will be to compare two different early supported discharge schemes. These early supported discharge schemes are composed of intensive rehabilitation treatment given by a multidisciplinary team in a day unit and, alternatively, the same treatment given in the patients’ homes.

The study is conducted as a randomized controlled trial with three arms: two different forms of early supported discharge and a control arm with conventional treatment. Patients with acute stroke admitted to our hospital's stroke unit and living in the Municipality of Bergen are considered for inclusion. A total of 350 stroke patients are expected.

Primary outcome is modified Rankin Scale six-months after inclusion. Secondary outcomes include Barthel Index and National Institute of Health Stroke Scale at several points in time after inclusion, as well as many other schemes, questionnaires and physical tests. The study is registered in ClinicalTrials.gov registration number NCT00771771.

The purpose of this study was to examine and compare each four distinct acute clinical manifestations and test its perspectives in genetic association studies.

Two hundred forty-five Caucasian patients with sub-arachnoid hemorrhage were evaluated for these four distinct clinical manifestations along with 906 600 single-nucleotide polymorphisms across the human genome.

The four clinical manifestations were significantly associated with each other as P-values ranged from 3·31 × 10⁻⁴ to 8·10 × 10⁻¹⁵. Transcranial Doppler vasospasm showed significant genetic association with single nucleotide polymorphism (SNP) (rs999662, P = 3·39 × 10⁻⁸). Statistical P-value of rs999662 in association with delayed cerebral ischemia, symptomatic ‘vasospasm’, and angiographic vasospasm was 0·0017, 0·0017, and 0·19, respectively.

Despite different criteria for each of the four clinical manifestations, they are significantly associated with each other. Our results suggest transcranial Doppler vasospasm may be an appropriate intermediate but still clinically relevant phenotype for genetic association studies. Association with SNP rs999662 indicates a potential role for the region containing the solute carrier family 12 member 3 (SLC12A3) gene in transcranial Doppler vasospasm following sub-arachnoid hemorrhage.

Using data from a population-based study, we assessed the acute and long-term costs of stroke in atrial fibrillation patients.

Health-care costs one-year before and five-years after stroke were obtained from a large population-based study (Oxford Vascular study). Costs were assessed for the three-months poststroke (acute period) and annually thereafter (postacute period). Annual postacute costs were compared with annual baseline costs. Based on patients' living arrangements, costs of institutionalization after the event were included.

A total of 191 strokes occurred in 153 patients with known prior atrial fibrillation. Mean health-care costs after stroke were £10 413 (standard deviation 15 105) in the acute phase, with annual postacute health-care costs nonsignificantly smaller than those incurred before the event (£2400 vs. £3356, respectively; P = 0·198). However, for the 136 strokes surviving past the 90-day acute period, costs were nonsignificantly higher than those incurred in the year before the event (£3370 vs. £2566, respectively; P = 0·333). After stroke, 25 (13%) patients were newly admitted into long-term warden, nursing, or residential care, resulting in annual costs of £6880 (standard deviation 15 600) averaged across the 136 stroke cases surviving past the acute period.

Although annual post acute phase hospital and primary health-care costs in stroke patients with prior atrial fibrillation were not significantly different to those incurred before the stroke, long-term nursing/residential care costs were substantial.

Our objective was to investigate the association between life events exposure and ischemic stroke onset.

Consecutive patients were interviewed about life events exposure (e.g. bereavement) using the Interview for Recent Life Events. Using a case-crossover approach, life events exposure within one month of stroke onset (hazard period) was compared with exposure during five control periods of one month preceding the hazard period. Similarly, life events exposure within one week of stroke onset was compared with exposure during three control periods of one week. Odds ratios and 95% confidence intervals were calculated using conditional logistic regression.

Two hundred forty-seven patients were interviewed within a median time of five days (interquartile range 3–7). Life events belonging to bereavement, health, and other categories accounted for half of life events. Over the six-month period, 187 patients were exposed to ≥1 life events. Patients were exposed to ≥1 life events more often during the first month preceding stroke onset than during the five control periods (odds ratio = 2·96; 95% confidence interval, 2·19–4·00). Over the four-week period, 97 patients were exposed to ≥1 life events. Patients were exposed to ≥1 life events more often during the first week preceding stroke onset than during the three control periods (odds ratio = 2·10; 1·40–3·17).

Recent life events exposure is associated with an increased risk of ischemic stroke.

In an urban population in Northern Germany (Hannover), a six-month stroke educational campaign was conducted. We expected an increase in stroke knowledge and awareness thereafter.

Computer-assisted telephone interviews were randomly conducted among 1004 representative participants before and 1010 immediately after the educational multimedia campaign. The computer-assisted telephone interviews focused on questions about stroke knowledge and interventions remembered.

Knowledge of stroke risk factors increased during the campaign for overweight, physical inactivity, old age, and stroke in family (P < 0·05). The knowledge of stroke warning signs was low, although it significantly increased during the campaign (P < 0·001) as paresis/weakness (46%) and speech problems (31%) were most frequently named. The majority of respondents indicated that the first action after suffering from stroke should be calling emergency care (74% before vs. 84% after campaign, P < 0·001).

Our data indicate that stroke knowledge and awareness, which could provide earlier presentation to the emergency unit for timely treatment onset, are still low in urban Northern Germany but may decisively be increased by educational campaigns.

Six hundred ninety consecutively recruited patients with first-ever ischemic stroke were classified, using review of clinical data and original imaging, according to the Trial of ORG 10172 in Acute Stroke Treatment and Causative Classification of Stroke system classifications.

There was excellent agreement subtype assigned by between Trial of ORG 10172 in Acute Stroke Treatment and Causative Classification of Stroke system (kappa = 0·85). The agreement was excellent for the major individual subtypes: large artery atherosclerosis kappa = 0·888, small-artery occlusion kappa = 0·869, cardiac embolism kappa = 0·89, and undetermined category kappa = 0·884. There was only moderate agreement (kappa = 0·41) for the subjects with at least two competing underlying mechanism. Thirty-five (5·8%) patients classified as undetermined by Trial of ORG 10172 in Acute Stroke Treatment were assigned to a definite subtype by Causative Classification of Stroke system. Thirty-two subjects assigned to a definite subtype by Trial of ORG 10172 in Acute Stroke Treatment were classified as undetermined by Causative Classification of Stroke system.

There is excellent agreement between classification using Trial of ORG 10172 in Acute Stroke Treatment and Causative Classification of Stroke systems but no evidence that Causative Classification of Stroke system reduced the proportion of patients classified to undetermined subtypes. The excellent inter-rater reproducibility and web-based semiautomated nature make Causative Classification of Stroke system suitable for multicenter studies, but the benefit of reclassifying cases already classified using the Trial of ORG 10172 in Acute Stroke Treatment system on existing databases is likely to be small.

to evaluate the clinical efficacy of enhancing upper and lower limb motor function with FST to explore participants' views (expectations and experiences) of FST, and to determine what cost-effectiveness data to collect in a subsequent Phase III trial.

Randomized, observer-blind trial with embedded qualitative investigation of participants' views of FST (n = 6, purposive sampling).

Participants (n = 58), six months to five years after stroke with difficulty using their paretic upper (UL) and lower limbs (LL) for everyday functional activity. All will be randomized to either FST-UL or FST-LL delivered in their own homes for fours days each week for six weeks. FST involves repetitive progressive resisted exercise during goal directed functional activities. The therapist's main input is to provide verbal prompting and feedback.

Measures will be undertaken before randomization (baseline), after the six-week intervention (outcome) and six weeks thereafter (follow-up). Primary outcomes for clinical efficacy will be the Functional Ambulation Categories (FAC) and the Action Research Arm Test (ARAT). Clinical efficacy analysis will use the proportional odds model for FAC and a Mann-Whitney test for ARAT. Participants' views of FST will be explored at baseline and outcome through audiotaped, semi-structured, narrative approach, interviews. The analytic process for interviews will sort transcribed data thematically and seek categories to inform conceptualization (theory-building). A purpose-designed cost questionnaire will identify what cost resource items are likely to be affected by FST.

The aim of this study was to identify, describe, and analyze printable educational materials on sexual concerns that are available online and easily shared with stroke survivors.

Google search engine was used to locate printable educational materials from the Internet using a search term strategy of 35 phrases that were piloted for accuracy. The content of eligible materials was analyzed using NVivo software to produce both enumerative and thematic data.

Nine educational materials from reputable organizations were included with an average length of seven pages and 1445 words (total 61 pages, 13 000 words). The content of the materials was similar and covered three main content areas:

• problems experienced after stroke: 30% coverage
• suggested solutions: 32% coverage, and
• reassurance: 9% coverage.

Content describing potential problems reflected published research, but solutions and reassurance were general, nonspecific, and often not supported by evidence.

Educational materials on sex after stroke may be helpful for health professionals, stroke survivors, and their partners, yet some messages appear to discourage recovery. Educators, health professionals, and organizations can use this analysis to evaluate their own educational resources and create resources that better address the sexual concerns of stroke survivors and their partners.

One hundred patients with small vessel disease and 55 controls completed the Stroke-Specific Quality of Life scale. The protocol was repeated in 40 patients with the young-onset genetic form of small vessel disease, cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathy, and 35 controls. Disability, activities of daily living, cognition and depression were measured.

Quality of life was significantly lower in small vessel disease versus controls: mean (standard deviation), 196⋅8 (35⋅2) vs. 226⋅8 (15⋅3), P < ⋅0001. Depressive symptoms were the major predictor of quality of life, explaining 52⋅9% of variance. The only other independent predictor was disability, explaining an additional 18⋅4%. A similar pattern was found in the young-onset genetic group, with reduced quality of life 202⋅0 (29⋅7) vs. controls 228⋅6 (13⋅1) P < ⋅0001, and depressive symptoms accounting for 42⋅2% of variance. Disability explained an additional 17⋅6%. Relationships between depression and quality of life, and disability and quality of life were independent of one another.

Depressive symptoms, often unrecognized, are a major determinant of reduced quality of life in small vessel disease. They account for greater reduction than, and are independent of, disability. This relationship may reflect the proposed causal association between white matter disease and depression. Treatment of depressive symptoms might significantly improve quality of life in small vessel disease.

The primary objective is to assess the safety of the peroxisome proliferator-activated receptor gamma agonist, pioglitazone, in increasing doses for three-days followed by a maintenance dose, when administered to patients with spontaneous intracerebral hemorrhage within 24 h of symptom onset compared with standard care. We will determine the maximum tolerated dose of pioglitazone.

This is a prospective, randomized, blinded, placebo-controlled, dose-escalation safety trial in which patients with spontaneous intracerebral hemorrhage are randomly allocated to placebo or treatment. The Continual Reassessment Method for dose finding is used to determine the maximum tolerated dose of pioglitazone. Hematoma and edema resolution is evaluated with serial magnetic resonance imaging (MRI) at specified time points. Functional outcome will be evaluated at three- and six-months.

The primary safety outcome is mortality at discharge. Secondary safety outcomes include mortality at three-months and six-months, symptomatic cerebral edema, clinically significant congestive heart failure, edema, hypoglycemia, anemia, and hepatotoxicity. Radiographic outcomes will explore the time frame for resolution of 25%, 50%, and 75% of the hematoma. Clinical outcomes are measured by the National Institutes of Health Stroke Scale (NIHSS), the Barthel Index, modified Rankin Scale, Stroke Impact Scale-16, and EuroQol at three- and six-months.

To validate the predictive value of established secondary stroke risk scores.

One thousand one hundred sixty-three patients undergoing in-patient rehabilitation following recent ischemic stroke in 15 German neurologic rehabilitation centers were included 0·9 ± 0·5 months after the index event. Outcome information was available for 846 participants (72·7%) after a mean follow-up of 13 ± 2·3 months.

Patients' mean age was 66·3 ± 12·3 years and 42·5% were women. The National Institutes of Health Stroke Scale (mean 4·0 ± 3·9), modified Rankin scale (median 2, range 0–5), and Barthel Index (median 90, range 0–100) indicated good functional status. A recurrent fatal or nonfatal stroke during follow-up occurred in 6·7% and combined vascular events (stroke, myocardial infarction, vascular death) in 10·9%. The predictive accuracy for recurrent stroke was slightly higher on the Essen Stroke Risk Score than on the Stroke Prognostis Instrument II (area under the curve 0·62 vs. 0·56), while both scores had a similar predictive accuracy for combined vascular events.

Risk stratification on the Essen Stroke Risk Score and Stroke Prognostis Instrument II provides a moderate accuracy for the prediction of recurrent stroke and vascular events in patients undergoing neurologic in-patient rehabilitation. Although individual risk prediction may remain imprecise, the use of these scores should be encouraged.

We enrolled 55 acute stroke patients who showed persisting middle cerebral artery occlusion evidenced by transcranial colour-coded duplex ultrasonography in follow-up examination within 48 h postonset of middle cerebral artery stroke syndromes (mean 30·8 ± 5·4 h after admission). Twenty-two of 55 had been treated with tissue plasminogen activator and 33/55 had been treated without tissue plasminogen activator. We compared neurological (National Institutes of Health Stroke Scale) and functional (modified Rankin Scale) scores at baseline, after seven-days, and then after two-months. Risk factors, previous stroke prophylaxis, as well as clinical baseline characteristics were analysed to exclude significant differences between both groups.

Despite later admission to hospital (tissue plasminogen activator patients 1·6 ± 0·66 h vs. non-tissue plasminogen activator patients 7·4 ± 5·84 h; P < 0·001), there was no significant difference between both groups concerning demographic data, severity of symptoms on admission, risk factors, stroke prophylaxis, as well as basic laboratory values (international normalized ratio, leucocyte count, C-reactive protein) blood pressure and body temperature on admission.

Irrespective of Doppler findings demonstrating persistent middle cerebral artery occlusion in all 55 patients, there was a significant neurological and functional improvement in tissue plasminogen activator patients compared to non-tissue plasminogen activator patients. Tissue plasminogen activator patients had a mean improvement on National Institutes of Health Stroke Scale within the first seven-days of 2·8 points, while non-tissue plasminogen activator patients deteriorated by 2·2 points (P < 0·001). Concerning modified Rankin Scale tissue plasminogen activator-treated patients showed a mean improvement within the first seven-days of 0·5 points, while non-tissue plasminogen activator patients deteriorated by 0·3 points (P = 0·019). A favourable overall short-term clinical course (i.e. improvement on National Institutes of Health Stroke Scale >3 points and/or modified Rankin Scale >1 point) was found in 36·4% of tissue plasminogen activator patients and in 6·1% of non-tissue plasminogen activator patients (P = 0·0047). At two-months follow-up, patients still showed a median modified Rankin Scale of 4 points after tissue plasminogen activator treatment and 5 points after non-tissue plasminogen activator treatment (P = 0·023).

Although the prognosis of patients with persisting middle cerebral artery occlusion after tissue plasminogen activator administration is known to be poor, patients do better if treated with tissue plasminogen activator vs. those who could not be treated – mainly for late presentation. This may be due to sufficient small vascular territory recanalization despite persistence of large artery occlusion after tissue plasminogen activator treatment.

To describe reliability of proxy-derived modified Rankin Scale and compare with traditional direct patient interview.

Researchers assessed consenting stroke inpatients and their proxies using a nonstructured modified Rankin Scale approach. Paired interviewers (trained in modified Rankin Scale) performed independent and blinded modified Rankin Scale assessment of patients and appropriate proxies. Interobserver variability and agreement between patient and proxy modified Rankin Scale were described using kappa statistics (k, 95% confidence interval) and percentage agreement.

Ninety-seven stroke survivors were assessed. Proxies were family members (n = 29), nurses (n = 50), or physiotherapists (n = 25). Median modified Rankin Scale from both patient and proxies was 3 [interquartile range (IQR): 2-4]. Reliability for patient modified Rankin Scale interview was weighted kappa = 0·70 (95% confidence interval: 0·30–1·00). Reliability for proxy modified Rankin Scale weighted kappa = 0·62 (95% confidence interval: 0·34–0·90). Subgroup analysis of various proxy information sources were as follows: family weighted kappa = 0·61; nurse weighted kappa = 0·58; therapist weighted kappa = 0·58. There was disagreement between patient-derived modified Rankin Scale and corresponding proxy modified Rankin Scale weighted kappa = 0·64 (95% CI: 0·42–0·86).

There is potential for substantial interobserver variability in proxy modified Rankin Scale and validity of certain proxy assessments is questionable. Direct modified Rankin Scale interview is preferred.

Consecutive acute ischaemic stroke patients who underwent emergent brain computed tomography angiography and bedside power motion transcranial Doppler were studied. Depth ranges for detecting anterior and posterior circulation vessels were derived from power motion transcranial Doppler flow tracks and computed tomography angiography images of the circle of Willis. We calculated percent agreement of power motion transcranial Doppler with computed tomography angiography for the anterior and posterior circulation vessel localization using computed tomography angiography as reference.

Samples were obtained from 34 acute ischaemic stroke patients (mean age 61 ± 16 years, 62% men, median National Institutes of Health Stroke Scale (NIHSS) score 5, interquartile range 2–8). A total of 229 Power motion Doppler computed tomography angiography vessel pairs were analysed. Power motion transcranial Doppler tracks for M1 and proximal M2 middle cerebral artery (MCA) were located at 24–68 mm (M1 MCA: 36–68 mm; M2 MCA: 24–53 mm); anterior cerebral artery (ACA): 50–78 mm; P1 posterior cerebral artery (PCA): 50–74 mm; left vertebral artery: 30–74 mm; right vertebral artery: 30–78 mm; basilar artery: 76–106 mm. The per cent agreement of power motion Doppler-transcranial Doppler for identifying proximal intracranial arteries compared to computed tomography angiography was: M1 and M2 MCA: 100% (95% confidence interval: 96–100%); M1 MCA: 98% (95% confidence interval: 86–100%); M2 MCA: 94% (95% confidence interval: 79–99%); A1 ACA: 82% (95% confidence interval: 68–91%); P1 PCA: 70% (95% confidence interval: 53–83%); left vertebral artery: 96% (95% confidence interval: 80–100%); right vertebral artery: 96% (95% confidence interval: 79–100%); basilar artery: 100% (95% confidence interval: 89–100%).

Power motion transcranial Doppler intercepts proximal vessels with good-to-excellent agreement with computed tomography angiography. Depth ranges (as opposed to average depths) can be used to target intracranial arterial segments for sonothrombolysis.

A comparison of the process indicators associated with these two models of service provision was undertaken within the Ontario healthcare system.

All adults admitted with a diagnosis of stroke for inpatient rehabilitation in Ontario, Canada during the years 2006–2008 were identified from the National Rehabilitation Reporting System database. Each of the admitting institutions was classified as providing rehabilitation services on either a stroke dedicated or nondedicated unit. A dedicated unit was identified by the presence of a collection of geographically distinct, stroke-dedicated beds and dedicated therapists. Selected process indicators from the National Rehabilitation Reporting System database were compared between the two facility types.

Sixty-seven facilities provided stroke rehabilitation services to 6709 adult stroke patients during the years 2006–2008. Of the total number of patients who entered inpatient rehabilitation, 1725 (25·7%) received care in eight facilities that met basic criteria for a dedicated stroke rehabilitation unit. On average, these patients took significantly longer to arrive for inpatient rehabilitation (37·2 ± 155·5 vs. 22·8 ± 95·0 days, P < 0·001), were admitted with higher Functional Independence Measure scores (77·5 ± 22·5 vs. 74·8 ± 24·5, P < 0·001), had significantly longer lengths of stay (42·1 ± 25·9 vs. 35·4 ± 27·2 days, P < 0·001), and demonstrated significantly lower Functional Independence Measure efficiency scores (0·62 ± 0·47 vs. 0·88 ± 1·03, P > 0·001) compared with patients who were admitted to nondedicated units. The proportion of patients admitted to a dedicated unit and subsequently discharged home was similar to that of patients discharged from nondedicated units (70·5% vs. 68·8%, P = 0·206).

In Ontario, patients admitted to dedicated stroke rehabilitation units fared no better on commonly-used process metrics compared with patients admitted to nondedicated rehabilitation units.

To investigate the 90-day risk of ipsilateral ischemic stroke recurrence after amaurosis fugax, retinal artery occlusion, transient ischemic attack, or minor ischemic stroke in patients with 50–99% carotid stenosis before carotid endarterectomy, with emphasis on the first 14 days.

Prospective cohort study. 230 consecutive patients with symptomatic 50–99% carotid stenosis (North American Symptomatic Carotid Endarterectomy Trial grading method) who underwent evaluation before carotid endarterectomy. Of these, 183 underwent carotid endarterectomy; the median delay to carotid endarterectomy was 29 days. Blood pressure lowering medication was used by 93% and lipid-lowering medication by 90%.

The risk of ipsilateral ischemic stroke recurrence before carotid endarterectomy was 5·2% (n = 12) within two-days, 7·9% (n = 18) within seven-days, 11·2% (n = 25) within 14 days, and 18·6% (n = 33) within 90 days of the presenting event. The risk of ipsilateral ischemic stroke recurrence was higher if the presenting event was a stroke (adjusted hazard ratio 12·4, P = 0·015) or transient ischemic attack (adjusted hazard ratio 10·2, P = 0·026) compared with an amaurosis fugax.

The risk of recurrent ipsilateral ischemic stroke was high within the first days of the presenting event. Many recurrences would likely have been avoided if carotid endarterectomy had been performed within the first days of the presenting event.

We assessed consecutive patients presenting within six-hours of ischaemic stroke. Anterior cerebral artery flow diversion, defined as ipsilateral mean velocity of at least 30% greater than the contralateral artery, was used as the Doppler index of leptomeningeal collateralization. Multivariable regression analysis was performed to assess the impact of anterior cerebral artery flow diversion, controlling for other important clinical variables. Leptomeningeal collateralization was also graded on computed tomography angiography. Infarct core and penumbral volumes were defined using computed tomography perfusion thresholds of cerebral blood volume and mean transit time. Infarct volume, reperfusion, and vessel status were measured at 24 h using magnetic resonance techniques.

Fifty-three patients qualified for analysis. Anterior cerebral artery flow diversion was associated with good collateral flow on computed tomography angiography (P < 0·001) and was an independent predictor of admission infarct core volume (P < 0·001), and 24 h infarct volume (P < 0·001). The likelihood of a favourable outcome (modified Rankin Score 0–2) was higher (odds ratio = 27·5, P < 0·001) in those with flow diversion.

Anterior cerebral artery flow diversion indicates effective leptomeningeal collateralization as measured by computed tomography angiography, and independently predicts acute infarct size and 90-day clinical outcome. Flow diversion appears to provide penumbral perfusion, offering some protection against infarct expansion. Acute bedside transcranial Doppler assessment of flow diversion aids prognostication and therapeutic decision making in anterior circulation stroke.

Consecutive patients undergoing transcatheter aortic valve implantation with the self-expandable Medtronic-Corevalve Revalving system were included in a single-centre prospective database. Strokes complicating transcatheter aortic valve implantation in the first five-days following the procedure were documented, and the differences between patients with and without stroke were studied.

Seventy-two patients (32 men, mean age 80·5 ± 6·2) underwent transcatheter aortic valve implantation from September 2008 to April 2011. Of these, eight (11%) had focal neurological deficits in the periprocedural period (three transient ischaemic attacks, five strokes of which three were minor, one moderate, and one major). Patients with stroke/transient ischaemic attacks did not differ from those without cerebral ischaemia in baseline criteria or procedural variables. Six of the events were believed to be embolic resulting from dislodgement of calcific material from the aortic valve, and one transient ischaemic attack was secondary to hypoperfusion during severe bradycardia. One patient with basilar occlusion died, but the remaining six patients survived and all had a modified Rankin score ≤2 at 90 days. None of the patients had a recurrent stroke during follow-up.

Periprocedural cerebral ischaemia following transcatheter aortic valve implantation is not uncommon, but most patients have good outcomes. There was no particular pre-transcatheter aortic valve implantation or procedural risk factor profile that increased the risk for periprocedural stroke. Further studies are warranted to examine whether patients that are at higher risk for developing stroke after transcatheter aortic valve implantation can be identified.

We aimed to study the predictors of poststroke driving or riding and its impact on social life in Indian patients.

This study was done in the stroke and neurology clinics of Christian Medical College, Ludhiana, from May 1, 2008 to May 31, 2010. Patients were recruited if they had completed ≥1-year follow-up. Subjects were interviewed using a structured questionnaire. Stroke outcome was assessed by using the modified Rankin scale. Outcome was classified as good (modified Rankin scale ≤2) and poor (modified Rankin scale >2).

Two hundred and one patients were interviewed. Mean age was 58·0 ± 13·4 years (median 59 years, range 17–85 years), 139 (69·2%) were men. The mean duration of follow-up was 37·4 ± 29·2 months (range 19–210 months). Out of 201 patients, 132 (65·7%) drove or rode before stroke and among them only 54 (40·9%) returned to driving or riding after stroke [men 53 (98·1%)]. Among the 78 who did not return to driving or riding, 51 (65·4%) had an impact on social life. In the multivariate logistic regression analysis, the predictors of inability to drive were lower education (odds ratio 0·32, confidence interval 0·12–0·89, P = 0·03), unemployment (odds ratio 4·59, confidence interval 1·67–12·6, P = 0·003), and poor outcome (odds ratio 3·97, confidence interval 1·06–14·8, P = 0·04).

Only 40·9% of the patients returned to driving or riding. Lower education, unemployment, and poor recovery were the predictors of inability to drive or ride. Inability to drive had a major impact in their social life.

The aim of this study was to elucidate the association between body mass index and stroke in a large Chinese population cohort.

A cohort of 26 607 Chinese people, aged over 35 years, was investigated in 1987. Baseline information of body weight and height was used to calculate BMI (weight in kilograms divided by height in meters squared, kg/m²). Cox proportional hazards model was fitted to estimate hazard ratios of stroke adjusted for age, educational level, smoking and alcohol consumption.

The 11-year follow-up revealed (241 149 person-years) a total of 1108 stroke events (614 ischemic, 451 hemorrhagic, and 44 undefined stroke). Body mass index ≥ 30·0 was an independent risk factor for stroke both in men and women. Compared with normal weight, hazard ratios for total stroke were 0·74 in men underweight (95% confidence interval: 0·53∼1·03), 1·63 overweight (95% confidence interval: 1·35∼1·96), and 2·20 with obesity (95% confidence interval: 1·47∼3·30); and with ischemic stroke, hazard ratios were 0·52 in those underweight (95% confidence interval: 0·30∼0·89), 2·08 overweight (95% confidence interval: 1·65∼2·62), and 3·80 with obesity (95% confidence interval: 2·47∼5·86). In women, the corresponding hazard ratios for total stroke were 0·79 underweight (95% confidence interval: 0·58∼1·07), 1·42 overweight (95% confidence interval: 1·16∼1·73), and 1·57 with obesity (95% confidence interval: 1·06∼2·31); and for those with ischemic stroke, 0·92 underweight (95% confidence interval: 0·59∼1·43), 1·90 overweight (95% confidence interval: 1·44∼2·50), and 2·42 with obesity (95% confidence interval: 1·50∼3·93). There appeared an evident dose-response relationship between body mass index and the risk of developing stroke, which still appeared, however, adjusted low for hypertension, diabetes, and heart disease. Decreased risk for stroke in the leanest group was confined to men only. No association was found between body mass index and hemorrhagic stroke in both genders.

Our data suggest that body mass index was an independent risk factor for total and ischemic stroke but not for hemorrhagic stroke in both genders. Association between body mass index and stroke was extremely mediated by hypertension, diabetes, and heart disease. Decreased risk for the leanest group was confined to men.

The modified Essen stroke risk score was calculated from scores for waist circumference, stroke subtype by etiology, and gender in addition to age, hypertension, diabetes mellitus, previous myocardial infarction, other cardiovascular diseases except myocardial infarction and atrial fibrillation, peripheral artery disease, smoking, and previous stroke or transient ischemic attack. A multiple logistic regression model identified the predictors (each assigned one or two points) and provided c-statistics for the modified Essen stroke risk score. We considered two outcomes, recurrent ischemic stroke and cardiovascular events (defined as the combined outcomes of fatal or nonfatal stroke, myocardial infarction, nonfatal unstable angina, and cardiac death).

Recurrent ischemic stroke occurred in 121 patients (3·7%) and cardiovascular events occurred in 133 (4·0%) within a year. The c-statistic (used for discrimination) was 0·632 for recurrent stroke and 0·640 for cardiovascular events. Patients scoring 6 or greater were classified as high risk, otherwise were classified as low risk. Kaplan–Meier analysis revealed that the modified risk score was more predictive than the Essen stroke risk score in both men and women.

The modified Essen stroke risk score increased the ability of the Essen stroke risk score to predict recurrent cardiovascular events. Patients with a high modified Essen stroke risk score should be candidates for intensified secondary prevention strategies.

To examine different levels of evidence of comprehensive stroke unit compared to other organized inpatient stroke care and share local experience of comprehensive stroke units.

Cochrane Library and Medline (1980 to December 2010) review of English language articles comparing stroke units to alternative forms of stroke care delivery, different types of stroke unit models, and differences in processes of care within different stroke unit models. Different levels of comparative evidence of comprehensive stroke units to other models of stroke units are collected.

There are no randomized controlled trials directly comparing comprehensive stroke units to other stroke unit models (either acute or rehabilitation). Comprehensive stroke units are associated with reduced length of stay and greatest reduction in combined death and dependency in a meta-analysis study when compared to other stroke unit models. Comprehensive stroke units also have better length of stay and functional outcome when compared to acute or rehabilitation stroke unit models in a cross-sectional study, and better length of stay in a ‘before-and-after’ comparative study. Components of stroke unit care that improve outcome are multifactorial and most probably include early mobilization. A comprehensive stroke unit model has been successfully implemented in metropolitan and rural hospital settings.

Comprehensive stroke units are associated with reductions in length of stay and combined death and dependency and improved functional outcomes compared to other stroke unit models. A comprehensive stroke unit model is worth considering as the preferred model of stroke unit care in the planning and delivery of metropolitan and rural stroke services.