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      Frequency of Hemorrhage on Follow Up Imaging in Stroke Patients Treated With rt-PA Depending on Clinical Course

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          Abstract

          Background: According to current guidelines, stroke patients treated with rt-PA should undergo brain imaging to exclude intracerebral bleeding 24 h after thrombolysis, before the start of medical secondary prevention. However, the usefulness of routine follow-up imaging with regard to changes in therapeutic management in patients without neurological deterioration is unclear. We hypothesized that follow up brain imaging solely to exclude bleeding in patients who clinically improved after rt-PA application may not be necessary.

          Methods: Retrospective single-center analysis including stroke patients treated with rt-PA. Records were reviewed for hemorrhagic transformation one day after systemic thrombolysis and brain imaging-based changes in therapeutic management. Twenty-four hour after thrombolysis patients were divided into four groups: (1) increased NIHSS score; (2) unchanged NIHSS score; (3) improved NIHSS score and; (4) NIHSS score = 0.

          Results: Out of 188 patients (mean age 73 years, 100 female) receiving rt-PA, 32 (17%) had imaging-proven hemorrhagic transformation including 11 (6%) patients with parenchymal hemorrhage. Patients in group (1, 2) more often had hypertension ( p = 0.015) and more often had parenchymal hemorrhage (9 vs. 4%; p < 0.206) compared to group (3, 4) and imaging-based changes in therapeutic management were more frequent (19% vs. 6%; p = 0.007). Patients of group (3, 4) had no changes in therapeutic management in 94% of the cases. Patients in group (4) had no hemorrhagic transformation in routine follow-up brain imaging.

          Conclusions: Frequency of hemorrhagic transformation in Routine follow-up brain imaging and consecutive changes in therapeutic management were different depending on clinical course measured by NHISS score.

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          Most cited references10

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          Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008

          This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.
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            The ABCs of measuring intracerebral hemorrhage volumes.

            Hemorrhage volume is a powerful predictor of 30-day mortality after spontaneous intracerebral hemorrhage (ICH). We compared a bedside method of measuring CT ICH volume with measurements made by computer-assisted planimetric image analysis. The formula ABC/2 was used, where A is the greatest hemorrhage diameter by CT, B is the diameter 90 degrees to A, and C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness. The ICH volumes for 118 patients were evaluated in a mean of 38 seconds and correlated with planimetric measurements (R2 = 9.6). Interrater and intrarater reliability were excellent, with an intraclass correlation of .99 for both. We conclude that ICH volume can be accurately estimated in less than 1 minute with the simple formula ABC/2.
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              The modified National Institutes of Health Stroke Scale: its time has come.

              The National Institutes of Health Stroke Scale (NIHSS) is a well known, reliable and valid stroke deficit scale. The NIHSS is simple, quick, and has shown significant reliability in diverse groups, settings, and languages. The NIHSS also contains items with poor reliability and redundancy. Recent investigations (include assessing a new training DVD, analyzing webbased or videotape certifications, and testing foreign language versions) have further detailed reliability issues. Items recurrently shown to have poor reliability include Level of Consciousness, Facial Palsy, Limb Ataxia, and Dysarthria. The modified NIHSS (mNIHSS) minimizes redundancy and eliminates poorly reliable items. The mNIHSS shows greater reliability in multiple settings and cohorts, including scores abstracted from records, when used via telemedicine, and when used in clinical trials. In a validation of the mNIHSS against the NIHSS, the number of elements with excellent agreement increased from 54% to 71%, while poor agreement decreased from 12% to 5%. Overall, 45% of NIHSS items had less than excellent reliability vs. only 29% for the mNIHSS. The mNIHSS is not the ideal stroke scale, but it is a significant improvement over the NIHSS. The mNIHSS has shown reliability at bedside, with record abstraction, with telemedicine, and in clinical trials. Since the mNIHSS is more reliable, it may allow for improved practitioner communication, improved medical care, and refinement of trial enrollments. The mNIHSS should now serve as the primary stroke clinical deficit scale for clinical and research aims. When it comes to the mNIHSS, its time has come!
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                Author and article information

                Contributors
                Journal
                Front Neurol
                Front Neurol
                Front. Neurol.
                Frontiers in Neurology
                Frontiers Media S.A.
                1664-2295
                16 April 2019
                2019
                : 10
                : 368
                Affiliations
                [1] 1Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin , Berlin, Germany
                [2] 2Department of Neurology, Charité–Universitätsmedizin Berlin , Berlin, Germany
                [3] 3Department of Neurology, Universitätsklinikum Würzburg , Würzburg, Germany
                [4] 4Insitute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin , Berlin, Germany
                [5] 5Berlin Institute of Health (BIH) , Berlin, Germany
                [6] 6German Center for Neurodegenerative Diseases , Bonn, Germany
                Author notes

                Edited by: Jean-Marc Olivot, Centre Hospitalier Universitaire de Toulouse, France

                Reviewed by: Laurent Derex, Université de Lyon, France; Carlos Garcia-Esperon, Hunter New England Health, Australia

                *Correspondence: Johannes Schurig johannes.schurig@ 123456charite.de

                This article was submitted to Stroke, a section of the journal Frontiers in Neurology

                Article
                10.3389/fneur.2019.00368
                6476977
                62adff48-be8b-4bda-a10a-045c72964c27
                Copyright © 2019 Schurig, Haeusler, Grittner, Nolte, Fiebach, Audebert, Endres and Rocco.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 21 December 2018
                : 25 March 2019
                Page count
                Figures: 0, Tables: 4, Equations: 0, References: 15, Pages: 7, Words: 5049
                Categories
                Neurology
                Original Research

                Neurology
                thrombolysis,stroke,stroke management,magnetic resonance imaging,computerized tomography,intracerebral hemorrhage

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