Background: Effect of smoking status on the responsiveness of antiplatelet therapy among patients with  minor stroke or transient ischemic stroke (TIA) remained unclear.
Methods: The Platelet Reactivity in Acute Non-disabling Cerebrovascular Events trial randomized acute minor stroke or TIA patients to ticagrelor plus aspirin or clopidogrel plus aspirin. The primary outcome was the proportion of high-on-treatment platelet reactivity (HOPR) to adenosine diphosphate (the P2Y12 reaction unit >208 measured by the VerifyNow P2Y12 assay). 
Results: Among 675 patients enrolled in the study, 370 patients (54.8%) were smokers. Compared with clopidogrel group, the proportion of HOPR in ticagrelor group was significantly lower among smokers and non-smokers (smokers, 5.2% versus 21.8%, p<0.0001; non-smokers, 2.3% versus 34.4%, p<0.0001). There were marginal significant interactions between treatment groups and smoking status on the proportion of HOPR (p =0.056). There were significant interactions between treatment groups and the carrier status of CYP2C19 loss-of-function alleles for the proportion of HOPR among smokers, but no significant interactions were found among non-smokers (smokers, p =0.03; non-smokers, p =0.66). Significant interactions between treatment groups and smoking status for the risk of new stroke were obtained (smokers, 7.0% versus 4.9%, OR, 1.57 [95%CI, 0.65-3.79], p=0.39; non-smokers, 5.3% versus 13.5%, OR, 0.39 [95%CI, 0.17-0.91], p=0.01. p for interaction=0.02). 
Conclusions: Among patients with minor stroke or TIA, ticagrelor might be superior to clopidogrel in inhibiting platelet reactivity and reducing the risk of new stroke, especially among non-smokers. The carrier status of CYP2C19 loss-of-function alleles might play a role in the differential effect among non-smokers and smokers.

Effect of Smoking Status on Platelet Reactivity and Clinical Outcomes of Ticagrelor versus Clopidogrel among Patients with Minor Stroke or Transient Ischemic Attack

Backgrounds - Thrombolytic therapy is the standard treatment for acute ischemic stroke, but there may be disparities across hospitals. 
Methods - This retrospective observational study was performed by analyzing the data of the patients admitted to 258 acute stroke care hospitals covering entire country from the Acute Stroke Quality Assessment Program from 2008 to 2014. Primary outcome was the recanalization therapy rate (RTR) in each hospital. RTR was the proportion of intravenous tPA (IVT) and/or endovascular thrombectomy (EVT) in potentially thrombectomy-eligible population, whose onset-to-arrival time less than 6 hours and initial NIHSS≥4 or GCS≤14. RTR was adjusted with age, sex, onset-to-arrival time and initial stroke severity. Adjusted RTR was compared according to several hospital characteristics.
Results – During the study period, 2,790 potentially thrombectomy-eligible patients were admitted to 174 hospitals in Korea for acute stroke care. Overall RTR was 47.2%, which was composed of IVT alone 39.3%, EVT alone 2.8% and combination 5.2%. Hospital characteristics including number of beds, average stroke admission per month, averaged IVT per month, presence of stroke unit and number of stroke neurologists were significantly associated with increased RTR with dose-responsive manners. Higher number of beds and average stroke admission per month were associated with higher adjusted RTR. (Spearman correlation coefficient = 0.42 and 0.43, p<.0001, separately)
Conclusion – Adequacy of thrombolytic therapy in acute ischemic stroke patients in Korea was associated with hospital characteristics, such as number of beds, average stroke admission per month, averaged IVT per month, presence of stroke unit and number of stroke neurologists.

Disparity across the hospitals in thrombolytic treatment of acute ischemic stroke: Korean Nationwide study

Abstract:
Background: The reduced level of oxidative stress in RVLM decreased blood pressure (BP), emphasized the dominant role of oxidative stress in pathogenesis of hypertension. This effect on the sympathetic regulation was described in this study as to compare BP response to glutamate (Glu) microinjection into RVLM between SHRSP and SHR.

Methods: We measured oxidative stress level in RVLM of SHRSP and SHR. Microinjection  was conducted using Glu, Glu+losartan and Glu+tempol into the RVLM of SHRSP, SHR and  a congenic strain SP.MES (p22phox knock-out in SHRSP). BP was recorded and urinary norepinephrine (u-NE) was quantified under cold stress (4degree celcius).

Results: Oxidative stress level was significantly higher in SHRSP compared to SHR. In response to RVLM microinjection of Glu, BP was increased abruptly in SHRSP compared to SHR; inhibition of this response was also observed (using losartan and tempol) only in SHRSP. Besides, SHRSP showed higher baseline BP and subsequently increased effect under cold stress. SP.MES showed similar effect like SHR.

Conclusion: We observed that BP response to Glu might mostly be influenced by the abnormal activation of NOX in SHRSP. And, if so, SHRSP might depend on this influence for high baseline BP and exaggerated stress response; to activate glutamatergic neurons in RVLM, and AT1R might be involved in this process. The results suggested that the NOX channel in SHR may not as strong as SHRSP to stimulate Glu in RVLM neurons.

BLOOD PRESSURE RESPONSE TO GLUTAMATE MICROINJECTION INTO RVLM WAS GREATER IN SHRSP THAN IN SHR, WHICH MIGHT BE DUE TO THE EXAGGERATED NADPH OXIDASE ACTIVITY

Authors
Moira Teed M.Sc., MSW, RSW, Genevieve Cote MSW, RSW, Beth Donnelly, MHA, Isabelle Martineau, RN, Noha Hamdy, B.Sc.Eng and Frederic Beauchemin, BSc PT, MBA. 

Background
In order to adhere to acute care length of stay (LOS) benchmarks (5 days for ischemic stroke and 7 days for hemorrhagic stroke)1,2, standardization of multidisciplinary practices is essential.  In their efforts to adhere to LOS targets, The Ottawa Hospital Civic Campus Neurology Team created an acute stroke pathway with well-defined protocols for each healthcare discipline, including Social Work.

Methods
In order to assure timely assessments, increased weekend staffing for allied health was implemented and all stroke survivors received automatic allied health referrals.  Prior to the pilot, each discipline outlined the key aspects and sequencing of their stroke care pathways and worked together to ensure alignment. The team continued to meet frequently to address any process issues and daily bullet round meetings aided daily organization. See Figure 1 for the Ischemic Stroke SW Pathway. 
 
Results
Average LOS decreased over the course of the pilot (8.2 days to 6.9 days for all acute stoke cases). In addition, time to rehabilitation referral dramatically shifted toward DAY 3 (shift from 9% to 42% of rehab applications were made on DAY3). The pilot was deemed successful and pilot FTE allocations became base funding.  

Conclusions/Implications
This pilot identified the value of increased allied health FTE and weekend coverage in conjunction with standardized pathways and automatic referrals. These results exhibit the importance of timely access to holistic quality care, especially when looking at the bottom line.

Timely Access Impacts Length of Stay: Acute Stroke Pathway for Social Work

Hyperglycemia has been a point of attention over the past few years with several studies demonstrating the poor effect of elevated blood glucose on intra-cerebral, hemorrhage (ICH) outcome. In this study we tried to identify the impact of stress-induced hyperglycemia (SIH) on the outcome of patients with spontaneous ICH. Among 772 patients who developed acute ICH, only 343 patients have met the inclusion criteria for having spontaneous non-traumatic ICH. SIH was measured using the glycemic gap (GG) which measures the difference between the average pre-admission and on-admission blood glucose levels. The average pre-admission blood glucose was derived from the admission HbA1C according to the equation (28.7*HbA1c + 46.7). ROC analysis was used to determine threshold GG value that differentiate patients in regards of favorable or unfavorable outcomes. Favorable outcome was defined as patients being discharged to either home or rehabilitation facility and unfavorable outcome as being discharged to any other facility (nursing home, LTAC, hospice or patient had expired). We found that, using a cut-off GG of 30mg/dl, the incidence of SIH was 32.7% and the probability of individuals with low GG (< 30) will be discharged home or rehab was 0.79. Also, elevated GG was associated with patients’ mortality. Among patients who died or discharged to hospice the average GG was 44, compared to an average of 9.8 among patients who had survived. This study showed a strong correlation between SIH and poor outcomes among patients with spontaneous ICH as regards patient’s disposition and survival.

IMPACT OF STRESS INDUCED HYPERGLYCEMIA ON SPONTANEOUS NON-TRAUMATIC INTRACEREBRAL HEMORRHAGE OUTCOMES

Objective 
This study investigated the predictors of stroke fatal outcome after a one year follow-up.
Methods
This was a historic cohort of 166 stroke patients from three hospitals in Kinshasa, capital of the Democratic Republic of Congo.  Data were collected from patients as they were admitted. Vital outcome information was collected throughout the follow-up period.
 The Cox proportional hazard modeling was used to measure predictors.
Results 
The patients’ median age was 59 (IQR: 52-68) years. The majority of them were male (65.1%) and known hypertensive (79.5%). At the admission, the median values of glycaemia, Glasgow score, systolic and diastolic blood pressure were 120 (IQR: 91-172) mg/dl, 14 (10-14), 160 (IQR: 130-180) mmHg and 90 (IQR: 80-100) mmHg, respectively. Around 35% patients died within the one year period of follow-up; the median duration between the occurrence of stroke and death was 37 (14-155.5) days. 
An early disorder of consciousness (Glasgow score ˂13) multiplies by 2.5 the risk of death (HR: 2.46, 95% CI [1.3-4.6], p = 0.005) and the glycemia level at day 7 greater than or equal to 180 mg / dl increases the risk of death by 2.4 times (HR: 2.4, 95% CI [1.03 -5.7], p = 0.04).

Conclusion
Hyperglycemia in the acute phase of stroke and early consciousness disorder are predictors of fatal prognosis of stroke, easy to detect in routine clinical practice. They should therefore be used to identify patients with potentially poor prognosis in the short and in the long term for appropriate care.

PREDICTORS OF FATAL OUTCOME AFTER INCIDENT OF STROKE AMONG PATIENTS FROM THREE HOSPITALS IN KINSHASA, DEMOCRATIC REPUBLIC OF THE CONGO

Enhancement of endogenous neurogenesis after ischemic stroke may improve functional recovery. We previously demonstrated that medium B, which is a combination with epidermal growth factor and fibronectin, can promote neural stem/progenitor cell (NSPC) proliferation and migration. Here, we showed that medium B promoted proliferation and migration of cultured NSPCs onto the chitosan scaffold and within the decellularized brain structure. When rat cortical neurons with oxygen glucose deprivation (OGD) were co-cultured with NSPCs, medium B treatment increased neuronal viability and reduced cell apoptosis. In a rat model with transient middle cerebral artery occlusion (MCAO), post-insult intraventricular medium B treatment enhanced proliferation, migration, and neuronal differentiation of NSPCs and diminished cell apoptosis in the infarct brain. In cultured post-OGD neuronal cells and the infarct brain from MCAO rats, medium B treatment increased protein levels of Bcl-xL, Bcl-2, phospho-Akt, phospho-GSK-3β, and β-catenin and decreased the cleaved caspase-3 level, which may be associated with the effects of anti-apoptosis. Notably, intraventricular medium B treatment increased neuronal density, improved motor function and reduced infarct size in MCAO rats. In summary, medium B treatment promotes neurogenesis and reduces apoptosis, leading to less neuronal death and better functional outcome in both cellular and rodent models of ischemic stroke.

COMBINATION TREATMENT WITH EPIDERMAL GROWTH FACTOR AND FIBRONECTIN BENEFITS AN ACUTE ISCHEMIC STROKE MODEL VIA ENHANCEMENT OF NEUROGENESIS

Introduction
The risk for cerebrovascular late effects among childhood cancer survivors is considerable. According to recent studies it is not clear which marker could be reliable for the screening of cerebrovascular diseases among the long-term survivors of childhood cancer. The purpose of this study is to analyse arterial stiffness and intima media thickness as possible early markers of later occurring stroke.
Material and methods 
Twenty-three patients, treated for HD in childhood, were included. They had received radiation therapy to the neck with 20- 65 (med.30) Gy. Twenty-six healthy controls, matched in age, sex, BMI, arterial hypertension, smoking history and total cholesterol levels were compared. High-resolution colour-coded duplex sonography and power Doppler sonography of the carotid arteries were performed and intima –media thickness, number and quality of plaques were measured. Arterial stiffness indices were calculated. 
Results
Plaque deposits and/or arterial wall calcinations were found in 24 out of 43 (55.8 %) vessels in cancer survivors group and 0 out of 52 vessels in the group of healthy controls (p < 0.01). We found significant group differences for all the stiffness parameters we used (P < 0.05), but there was no difference in intima–media thickness between cases and controls (p = 0.92). In a multivariate model, carotid pulse wave velocity was positively associated with smoking.
Conclusion
The arterial stiffness has appeared as a possible surrogate marker for stroke in long-term survivors of childhood cancer. Smoking habit might have an additional negative influence on vascular aging in the group of patients after neck radiotherapy.

Carotid stiffness a possible surrogate for stroke after neck radiotherapy

Purpose:
To introduce a new device class “delivery assist catheter” and report first in vivo experience in acute ischemic stroke treatment.
Methods:
Retrospective data collection and analysis of stroke databases of two comprehensive stroke centers focusing on technical and angiographic parameters – primary endpoint defined as reaching the occlusion with a large-bore reperfusion catheter – from patients receiving endovascular stroke treatment using an AXS Offset™ delivery assist catheter (Stryker, Fremont, CA, USA) between May 2017 and November 2017.
Results:
Using the delivery assist catheter, a 6F catheter could be advanced to an intracranial occlusion for direct aspiration thrombectomy in 30 (88.2%) of a total of 34 patients (male: n=14/34 (41.2%), age in years: mean (SD): 75 (11), median baseline NIHSS: 16 (interquartile range (IQR): 12-21)). In 4/34 (11.7%) cases the occlusion could not be reached with the aspiration catheter because of a preceding non-occlusive arteriosclerotic plaque (n=1, 2.9%) or because of severe elongation and tortuosity of the arterial access route (n=3, 8.8%). After aspiration thrombectomy mTICI 2b-3 was reached in 14/30 (46.7%) patients. In 21/34 (61.8%) patients (additional) stent-retriever-maneuvers (median: 1 (IQR: 0-2) were needed. In 28/34 (82.3%) patients final mTICI 2b-3 could be achieved. 
Conclusion:
Delivery assist catheters to support large-bore reperfusion catheters for thromboaspiration in acute ischemic stroke are effective, in particular in case of vessel tortuosity and anatomic obstacles.

Delivery assist catheters: a new device class and initial experience in mechanical thrombectomy in acute ischemic stroke patients

Background: Duplex sonography is a widely used screening method for carotid artery stenosis. Maximum peak systolic velocity (PSVmax) is the best parameter for grading of stenosis now. The aim of the study was to compare correlations between percentage of internal carotid artery (ICA) stenosis using computed tomography angiography (CTA) and sonographic parameters: PSVmax, PSV ratio [in stenosis(linear probe)/˃3 cm distal to stenosis(transcranial probe)] and lumen reduction in B-Mode.
Methods: Duplex sonography of carotid arteries using linear probe 5–12 MHz and transcranial probe 2–4 MHz were performed in consecutive patients with carotid artery stenosis ˃50% in 2 laboratories. PSVmax, PSV ratio and lumen reduction in B-Mode (NASCET) were evaluated. All patients underwent also CTA within 2 weeks with measurement of stenosis by dedicated software using both diameter (NASCET) and area of lumen reduction. Spearman correlation coefficient was used for evaluation the correlation between sonographic and CTA stenosis grading.
Results: Totally 35 patients (18 males, 17 females, mean age 71.9±8.4 years) were enrolled to the pilot part of the study during 6 months. Higher correlations between stenosis grading using CTA diameter/area reduction were achieved for PSV ratio (r=0.65/r=0.65, p˂0.05) than for PSVmax (r=0.53/r=0.55, p˂0.05) or lumen reduction in B-Mode (r=0.56/r=0.56, p˂0.05), resp. PSV ratio cut-off of 4.5 had 69% sensitivity, 84% specificity, 79% positive and 76% negative predictive value for detection of 70% stenosis.
Conclusion: PSV ratio seems to be better parameter for ICA stenosis grading than maximum PSV or lumen reduction in B-Mode.
Supported by grants MHCR 17-31016A, 16-30965A.

Peak systolic velocity ratio as a new parameter for carotid artery stenosis grading

Endovascular thrombectomy(EVT) is the mainstay of treatment of acute ischemic stroke(AIS) with large artery occlusion(LAO). Although recanalization of LAO is the strong predictor of good clinical outcome, it is not well known how many attempts for recanalization it would be advisable. We evaluated the relationship of the number of EVT attempt and clinical outcome.

Methods: Patients who treated with EVT for LAO in anterior circulation and within 24 hours from last seen normal time were included. Patients who needed to the carotid artery stenting during EVT were excluded. The number of EVT attempt counted 1 to 5 or more. Used EVT methods were suction thrombectomy, stent thrombectomy, angioplasty, and chemical thrombolysis.

Results: 207 patients were included. Successful recanalization(mTICI 2b-3) was achieved in 156(75.3%). 78.7% of patients had stent thrombectomy, 31.4% had suction thrombectomy, 21.5% had intracranial angioplasty, and 6.2% had chemical thrombolysis. As the number of EVT attempt increased, the rate of favorable outcome(mRS 0-2) was significantly lowered. Even in case of successful recanalization, the rate of favorable outcome was decreased according to the increase in the number of EVT attempt. Whereas the clinical outcome of patients with 1 to 3 EVT attempt was more favorable than patients without successful recanalization, the clinical outcome of patients with more than 4 EVT attempt was not better. 

Conclusions: An increase of number of EVT attempt to achieve successful recanalization is not related to better outcomes. Even if successful recanalization of the LAO in AIS is essential, more than 4 EVT attempt could be futile.

The number of thrombectomy attempt is associated with the clinical results in patients with the acute ischemic stroke caused by large artery occlusion

Background: Covert strokes (CS, previously ‘silent’ strokes) are parenchymal lesions which are present on neuroimaging but not associated with acute symptoms. These lesions have been associated with cognitive dysfunction, memory impairment/dementia, depression, gait disturbances, subsequent symptomatic stroke and early mortality. Current stroke guidelines recommend primary prevention interventions for CS. A systematic review of the evidence would assist clinicians and guideline developers.

Methods: We searched Pubmed and Cochrane Review Libraries (April, 1970 to March, 2018) for randomized/non-randomized controlled studies or observational studies which assessed medical interventions for the prevention of CS, as detected by MRI or CT.   The Jadad score was calculated where appropriate.

Results: Twenty-one studies were found of which 14 were randomized controlled trials, 2 were non-randomized controlled trials and 8 were observational cohort studies. Inconsistent definitions of the endpoint were used and study quality was variable (Jadad scores: mean 3.7, IQR = 1).  The most common intervention tested was an antithrombotic for prior overt stroke/atrial fibrillation or blood transfusion/hydroxyurea for sickle cell. Most trials were small, targeted specific populations, and suffered from short follow-up periods and loss to follow up.

Conclusions: Limited evidence exists to guide clinicians seeking to prevent covert vascular disease of the brain. Future trials should use consistent and well-defined criteria for CS, be properly powered and randomized, and involve broader populations.

Interventions for the Prevention of Covert Stroke: A Systematic Review

EVALUATION OF THE INFORMAL CAREGIVER BURDEN IN THE CARE OF STROKE PATIENTS AT KENYATTA NATIONAL HOSPITAL
L. Mahinda, **E. Amayo, J. Kwasa University of Nairobi, College of Health Sciences Kenyatta National hospital Nairobi
Background
Most stroke survivors return home after discharge and the burden of caring for them falls on their families. These informal caregivers have higher risks of mental and physical illnesses. 
Objective: To determine the level of informal caregiver burden of stroke patients at Kenyatta National Hospital(KNH).
Material and methods
This was a cross sectional study at the KNH Neurology clinic physiotherapy unit and medical wards. 135 Informal Care givers identified in the clinic and the wards were interviewed with pretested questionnaire. Informal caregiver burden was evaluated using ZBI questionnaire and depression using PHQ9 Test Questionnaire, 
Results: Their mean age was 36.2 years with 54.5% females. The stroke caregivers were: adult offspring 50.7%, spouses 24.1% and siblings 13.8%. 47.6% of the care givers had moderate to severe depression. The level of informal caregiver burden was found to be moderate in 58.6% (CI 50.3%-66%). The major factors that contributed to burden were financial, social and psychological. The caregiver factors were daughters, being employed, shorter duration of care giving and depression. The patient factors were higher levels of disability, shorter duration of stroke, lack of health insurance and  single. There was little preparation of caregivers prior to discharge 
Conclusion:. There is need to institute measures for preparation and support of caregivers .

INFORMAL CAREGIVER BURDEN IN THE CARE OF STROKE PATIENTS AT KENYATTA NATIONAL HOSPITAL

We have introduced a so-called “Neurosurgery Hotline” to detect stroke, severe head injuries and seizures without burdening duty doctors. All 556 registered cased during the last 3 years (January 2014 to December 2016) were compared to the registered 546 patients’ data between 2009 and 2012. The number of patients (557 vs. 546) and male/female ration was almost the same as the former data(289/261 vs. 285/261) but the mean age increased with statistical significance (69.0 years old vs. 65.0). 
The concordance rate of initial symptom with an exact stroke improved from 49.9% to 57.2% and number of properly referred patients also improved from 372 (68%) to 415 (74.6%). Speech disturbance (79.7%), paralysis (92.5%) and coma (93.3%) still showed high concordance rates.
On the contrary, representative stroke mimics such as, benign paroxysmal positional vertigo (26 to 15), hypertension (22 to 11), inflammatory diseases (22 to 15) and hypoglycemia (10 to 1) significantly decreased. 
Our hotline system has improved and still works well as a method for broad stroke triage. Finally, further work to eliminate and decrease stroke mimics is the key to improving this system.

Implementing a neurosurgery hotline system; a comparison of the last three years to the initially reported study

Sixty-five-year-old man who developed pulmonary tuberculosis 3 months prior was treated at another hospital before transferring to our institution. On admission, he had disturbance of consciousness. The eyes were found to be in the mid-position and fixed. He had no obvious limb paresis and sensory deficits. On day 5, Candida albicans was detected from blood culture, and vegetation was detected on the mitral valve using transesophageal echocardiogram. The patient was started on an antifungal agent for Candida albicans. On day 6, we obtained brain computed tomography (CT) scans and detected subcortical hemorrhage in the right frontal lobe. No intracranial aneurysm was found in CT angiography. On day 8, surgical removal of the hematoma was performed. On day 16, he suddenly suffered a cardiopulmonary arrest, and cardiopulmonary resuscitation was performed. Brain CT scan showed recurrent subcortical hemorrhage in the left frontal lobe. CT angiography showed a mycotic aneurysm at a branch of the left middle cerebral artery. Although we continued medical treatment, he died on day 79 after admission. In this case, a unique balloon-like aneurysm was formed, and it progressed rapidly for only 10 days. Time course of progression of candidial mycotic aneurysms is unknown. Zimmerman et al. reported a more rapid progression of candida infective endocarditis. Therefore, close observation and immediate management are needed for improving the prognosis for candida mycotic aneurysm. In addition, volume rendering images clearly revealed mycotic aneurysm. We suggest that constructing volume rendering images is suitable for detecting the formation of mycotic aneurysm.

Rapid progressive intracranial aneurysm resulting from candida infective endocarditis

Background: An ambulance equipped with a multimodal CT scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit, MSU) may facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology.

Methods: We report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment.

Results: Prehospital CTA by use of a MSU allowed to detect large-vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment (Fig.1 a-d). 
	In complementary cases, prehospital imaging not only allowed diagnosis of hemorrhage in one patient and of subarachnoid hemorrhage in another, but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions (Fig.1 e-h). Stroke management metrics are shown in Table 1. 

Conclusion: Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the appropriate target hospital and specialized treatment.

Prehospital CT Angiography in Acute Stroke Management

BENEFIT OF A COMMUNICATION DISORDERS ASSISTANT ON AN ACUTE STROKE UNIT… 2 YEARS LATER
Communication Disorders Assistants (CDA) are becoming more widely used within healthcare organizations1. CDAs offer an array of supportive roles to Speech-Language Pathologists and Audiologists.  In 2015, the SLPs working within the Integrated Stroke Program in Hamilton proposed to their management team consideration to hire a CDA for the acute care stroke program. Anticipated benefits included:
•	Improve ability to meet Stroke Best Practice Guidelines for communication and dysphagia
•	Commence therapy for those patients awaiting a bed in rehab
•	Increase education to patients and families
Success! 2 years later, the benefit of the role has been many!  Stroke patients have their communication abilities screened in a timely manner, education for patients and families, therapy at the bedside in acute care can occur and so on and so forth.

BENEFIT OF A COMMUNICATION DISORDERS ASSISTANT ON AN ACUTE STROKE UNIT… 2 YEARS LATER

【Background and Aims】We aimed to examine patients with cervicocephalic arterial dissection (CAD) and to investigate the clinical characteristics of CAD in Japan.【Method】We examined 68 patients with CAD who were admitted to our stroke center from January 2006 to November 2017.【Results】There were 47 patients with vertebral artery (VA) dissection (36 men and 11 women; mean age, 46.9 years); of these, 46 had intracranial VA dissection. Twenty-two patients had cerebral infarctions (CIs) and 14 had subarachnoid hemorrhages (SAHs). One patient exhibited SAH accompanied by CI. Among the 22 patients who developed only CI, antithrombotic agents were not administered to 14, whereas edaravone was administered to eight patients. Activities of daily living (ADL) at discharge were recorded as modified Rankin Scale (mRS) score of 0–2 in 19 patients and 3–6 in three patients. Among the 15 patients who developed SAH, the mRS score was 0–2 in eight and 3–6 in seven. There were nine patients with internal carotid artery (ICA) dissection (seven men and two women; mean age, 43.4 years); of these, seven had extracranial ICA dissection. Eight patients presented with CIs; one patient had SAH accompanied by CI. Antithrombotic agents were administered to all eight patients who developed only CI. mRS score at discharge was 0–2 in six patients and 3–6 in three patients.【Conclusion】CAD was commonly observed in men and juvenile. The intracranial VA was the most common dissection site. Patients with CI demonstrated better recovery than those with SAH. Edaravone was commonly administered in patients with CI.

CURRENT STATUS OF PATIENTS WITH CERVICOCEPHALIC ARTERIAL DISSECTION

Introduction:The interplay between stroke and cancer seems to be complex. Cancer and stroke may occur independently  or cancer may directly or indirectly might be related to stroke.
Aim: In  this study, we aimed to look for a relation between cancer and stroke in patients who were referred to our Neurology Clinics with an acute onset stroke. 
Methods: Patients who were assessed in Neurology inpatient clinics with acute onset stroke between 0/2016-09/2017 were retrospectively evaluated. 
Results: 500 patients with acute stroke were retrospectively evaluated.  All differential diagnosis including cardiac, vascular assessments were normal. Patients were also tested for coagulability and were normal.
Discussion: Stroke and cancer may be intertwined because of their relatively common occurrence within the general population. It should however be noted that cancer is not the most common etiology of stroke, and that even in patients with cancer; the traditional risk factors are most commonly the underlying cause.

Is there a relationship between stroke and cancer or is it just a coincidence?

Objective: To assess comprehensive clinical rehabilitation treatment outcomes. 
Materials and Methods: 59 patients were analyzed with the effects of stroke who underwent comprehensive rehabilitation treatment in neurorehabilitation department of the National Neurosurgery Center from January 2016 to February 2018.   
The comprehensive rehabilitation treatment included pharmacological therapy, physical therapy exercises using various methods, acupuncture, sessions with a psychologist, speech therapist and hyperbaric oxygenation. 
The assessment of the daily living activities level at admission and at discharge of the patients were determined by Barthel scale.
Results: 36 patients were (61%) of an employment age, <60 years old. Motor dysfunction were in 53 cases (89.8%): right hemiparesis – 26, left hemiparesis – 25, quadriparesis – 2.  
Physiotherapeutic procedures were performed in 91.5% cases (54 patients). Hyperbaric oxygenation series performed in 59.3% cases (35 patients). Physical therapy exercises carried in all patients (100%). Acupuncture was performed 57.6% cases (34 patients).
Assessment of daily living activities level was carried out by Barthel scale upon admission (the average score was 45±5), and at discharge (the average score was 70±5).

COMPARATIVE OUTCOMES ASSESSMENT OF CLINICAL REHABILITATION OF PATIENTS WITH THE EFFECTS OF STROKE

Large-artery atherosclerosis (AT), cardioembolism (CE), and small-vessel disease constitute the most common causes of ischemic stroke. However, standardized evaluation fails to detect an underlying cause in one third of ischemic strokes. Cryptogenic strokes (CS) still await to be better delineated. Here we tried to identify the similarities and differences in risk factors among patients with cryptogenic stroke, and stroke due to AT or CE.
Out of 2223 patients with ischemic stroke being followed-up in our Stroke Outpatient Clinic, 19.9% were classified as AT, 25.3% as CE, and 22.9% were due to small vessel disease. CS were diagnosed in 31.9% of patients (n=710). Patients with CS were younger than patients with AT or CE (p<0.001). Male ratio was 71.3% in patients with AT and 49.1% in patients with CE. In patients with CS, on the other hand, male ratio was 49.9%, which is similar to CE (p=0.791) but significantly different from AT (p<0.001). Hypertension was significantly lower (p<0.001) in CS (57.7%) then both AT (76.5%) and CE (71.2%). Other risk factors including diabetes mellitus, hyperlipidemia, smoking and alcohol consumption were all similar in patients with CS and CE, but significantly different from AT (p<0.001). 
The comparison of risk factors shows us there are many similarities between cryptogenic stroke and cardioembolism, while there are differences between cryptogenic stroke and atherothrombosis. On the basis of these findings, the potential mechanisms in cryptogenic stroke may be related to cardiac system, and patients with cryptogenic stroke deserve more sophisticated cardiac evaluation and prevention strategies.

RISK FACTORS IN CRYPTOGENIC STROKE

Limb-shaking transient ischemic attacks (LSTIAs) are  rare manifestations of carotid (ICA) occlusive disease.The absence of acute ischemic lesions in TIA patients makes it difficult to differentiate the vascular etiology. We are reporting a patient with LSTIAs confusing with seizures before dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) depicted.

A 65-year-old male was referred to our department complaining of transient episodes of his right hand shaking. These episodes would last less than 5 minutes, more than once a day and the patient was responsive with no alterations in his reactions. His medical history was notable for coronary disease, by-pass surgery 8 years ago, hypertension and smoking. In addition to vascular diseases, the patient had two tonic-clonic seizures in the last 8 months, was given an antiepileptic drug (levetiracetam 500mg/day). After hand shaking attacks began, he received high dose drug (1000 mg/day) without any reduction in the frequency of the attacks. The patient proceeded with an MRI, which showed no evidence of acute stroke but old infactions in the left frontal lobe and centrum semiovale. A pre-occlusive stenosis of left ICA was noted on cerebral angiography, but left middle cerebral artery was filled with collaterals from the circle of Willis and leptomeningeal vessels. DSC-MRI showed left territorial perfusion abnormality, which helps explain hemodynamic mechanism responsible for LSTIAs and also decide on an endovascular treatment.

DSC-MRI is useful in distinguishing whether the transient neurological symptoms in radiologically inexplicit patients are real vascular events, and will help understand the mechanism of TIA.

LIMB-SHAKING TIA and DYNAMIC SUSCEPTIBILITY CONTRAST MRI

Introduction: Papillary fibroelastomas are rare and benign cardiac tumors in young patient. The most common clinical presentation is completed stroke or transient ischemic attack caused by emboli.

Observation: A 36-year-old man who presented to the neurology department at Fann teaching hospital(Senegal), reported a fall and transient loss of consciousness. The physical examination revealed weakness of the left arm and leg. On admission, physical examination showed that he was in sinus rhythm, had a pulse rate of 80 bpm, and a blood pressure of 108/69 mm Hg. On auscultation, he had murmur of 4/6th breath. 

Cerebral CT-scan revealed a hypodensity in the territory of the right middle cerebral artery. Laboratory tests were normal. He had a normal chest X-ray. The electrocardiography showed: a ventricular extrasystole sinus rhythm, left ventricular hypertrophy. Transthoracic echocardiography showed: moderate dilatation of the Lateral Ventricle, calcified thickened aortic sigmoid with restriction of the left anterior sigmoid leading to a central coaptation defect responsible for a major leak. Presence of highly mobile hyperhecogenous mass appended to the anterior surface of the left ventricular flushing chamber. Trans-esophageal echocardiography: severe rheumatic aortic insufficiency with presence of evoking aortic papillary fibroelastoma on the left anterior sigmoid. The patient has been on anticoagulant and is waiting for surgery.

Comment and conclusion: Cardiac papillary fibroelastoma is a rare cause of ischemic stroke. Transoesophageal echocardiography may be essential for easy diagnosis, and should be performed to make the appropriate diagnosis. Careful attention should be paid in order to find these masses in echocardiography.

Aortic fibroelastoma, rare cause of ischemic stroke in a young man: a case report

Background: Fever in acute stroke occurs in up to 61% of patients, increases with the severity of stroke, and is a strong predictor of an unfavourable outcome. 
Objective: To determine the occurrence of fever in patients with acute stroke, the practice of antibiotic administration and its association with in-hospital mortality.
Methods: All patients with acute stroke (both ischemic and haemorrhagic) admitted to Neurology services were recruited in the study. The period of study was January 2017 and December 2017. The occurrence of fever, antibiotics (number, type and duration) and in-hospital mortality were recorded. 
Results: There were 177 patients (128 (72.3%) ischemic) in the study period. The mean age was 53.9 (SD: 14.0) years. 123 (69.5%) of the patients were males. Fever was present in 113/174 (64.9%). Fever maximally occurred on second day of ictus. Antibiotics were administered in 104/124(83.9%) of all patients. The median duration of antibiotics given were 9 days (IQR: 5.6; 17.3). The median number of antibiotics administered was 3 (IQR: 2; 5). The median duration of hospital stay was 11 (IQR: 7.0; 25.3) days. The in-hospital mortality was 29/155 (18.7%). There was no association of fever and antibiotic administration with in-hospital mortality (p value=0.413, OR 1.45 (0.59; 3.56))
Conclusion: The study depicts the frequent use of antibiotics in stroke patients with fever. There was however, no association with of fever and antibiotic administration with in-hospital mortality. This challenges the use of antibiotics in febrile stroke patients, as the outcome may be primarily determined by stroke severity.