Abstract Background/Objective: There is controversy regarding the need to use advanced imaging to select candidates for thrombectomy in late window acute ischemic stroke (AIS). Hypoattenuation on CT angiography source images (CTA-SI) in arterial phase has been shown to be more sensitive than Alberta Stroke Program Early CT Score (ASPECTS) of brain parenchyma to determine tissue at risk of ischemia. Our hypothesis is that the addition of a second acquisition at 35-50 seconds could complement the assessment of hypoperfused tissue that fails to receive flow through pial vessels. Methods: Patients with large vessel occlusion and 6-24 hours from symptom onset, admitted between August 2019 and July 2023, were evaluated with dual-phase CT angiography (CTA) and CT-Perfusion. A vascular neurologist estimated CTA-SI ASPECTS in both phases at the time of data entry into the RECCA registry. In contrast, the post-processing of CT-Perfusion images was performed in an automated way through RAPID© software. The association between automated CT-perfusion values and dual-phase CTA-SI ASPECTS was assessed through a correlation coefficient. Results: Pearson’s coefficient demonstrated a high correlation between ischemic core volume and delayed phase CTA (CTA-DP) ASPECTS with an inverse association of −0.93 and between Tmax ≥ 6 sec volume and arterial phase CTA (CTA-AP) ASPECTS with a value of −0.88. Conclusions: CTA-derived source images (CTA-SI) in two phases may be useful in the selection of patients with AIS presenting beyond the 6-hour window.

Resumen Introducción/Objetivo: La recomendación actual es realizar el tamizaje de pacientes con ataque cerebrovascular ACV y oclusión de grades vasos LVO (por sus siglas en ingles) potencialmente candidatos a trombectomía mecánica en ventana extendida a través de un estudio de TC perfusión con post procesamiento automatizado. El acceso a TC perfusión no está ampliamente disponible en el mundo, por lo que existe controversia en relación a que sea una herramienta imprescindible. Métodos: Este es un estudio prospectivo de un registro retrospectivo unicéntrico con pacientes con ACV de circulación anterior, LVO y un tiempo entre 6-24 horas desde el inicio de los síntomas hasta la realización del estudio imagenológico. A todos los pacientes se les realizó un AngioTC en 2 fases, con evaluación de sus imágenes fuentes CTA-SI (por sus siglas en ingles) y un estudio de perfusión con post procesamiento por software RAPID. Resultados: El coeficiente de Pearson’s mostró una alta correlación entre el volumen de núcleo isquémico medido por FSC < 30% y el valor CTA-SI ASPECTS en fase tardía, con una asociación inversa de −0.93. Conclusión: La interpretación de CTA-SI ASPECTS en 2 fases entrega información congruentes con los resultados automatizados de los mapas de TC perfusión.

Abstract Background The efficacy of intravenous thrombolysis (IVT) is time-dependent. Objective To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. Methods Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. Results A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66–11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44–10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02–1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96–0.99; p < 0.003) remained significant. Conclusions Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.

Resumen Antecedentes La respuesta a la trombólisis intravenosa (TIV) es dependiente del tiempo. Objetivo Comparar los tiempo puerta-aguja (TPAs) de neurólogos vasculares (NVs) contra los de neurólogos no vasculares (NNVs) y médicos emergencistas (MEs), y determinar los elementos asociados a un PTA ≤ 20 minutos. Métodos Análisis observacional prospectivo de pacientes con TIV tratados en Clínica Alemana entre junio de 2016 y septiembre de 2021. Resultados En total, 301 pacientes con TIV fueron tratados. El TPA promedio fue de 43,3 ± 23,6 minutos. Un total de 173 (57,4%) pacientes fueron evaluados por NVs, 122 (40,5%), por NNVs, y 6 (2,1%), por MEs; los TPAs promedios fueron de 40,8 ± 23; 46 ± 24,7 y 58 ± 22,5 minutos, respectivamente. Los TPAs ≤ 20 minutos fueron más frecuentes en pacientes tratados por NVs versus NNVs y MEs: 15%, 4% y 0%, respectivamente (odds ratio [OR]: 4,3; intervalo de confianza del 95% [IC95%]: 1,66–11,5; p = 0,004). El análisis univariado demostró que TPA ≤ 20 minutos se asoció con: tratamiento por NVs (p = 0,002), periodo de la pandemia de enfermedad por coronavirus 2019 (COVID-19; p = 0,21), tiempo a urgencia (p = 0,21), diabetes (p = 0,142), hipercolesterolemia (p = 0,007), fibrilación auricular (p < 0,09), puntaje en la National Institutes of Health Stroke Scale [NIHSS] (p = 0,001), presión arterial sistólica (p = 0,143) y diastólica menores (p = 0,21), Alberta Stroke Program Early CT Score (ASPECTS ; p = 0,09), oclusión de vasos cerebrales (p =0,05), uso de tecneteplase (p = 0,18), trombectomía (p = 0,13) y años de experiencia del médico (p < 0,001). El análisis multivariado demostró que ser tratado por NVs (OR: 3,95; IC95%: 1,44–10,8; p = 0,007), el puntaje en la NIHSS (OR: 1,07; IC95%: 1,02–1,12; p < 0,002) y la presión arterial sistólica (OR: 0,98; IC95%: 0,96–0,99; p < 0,003) se asociaron a TPA ≤ 20 minutos. Conclusões El tratamiento por NVs resultó en un TPA menor y en una mayor probabilidad de tratamiento ≤ 20 minutos.

Background: Intravenous thrombolysis (IT) in acute ischemic stroke (AIS) is time dependent. The time elapsed from hospital admission to the thrombolytic bolus is named door to needle time (DNT) and is recommend to be of less than 60 min. Aim: To describe the DNT in our center and determine those factors associated with a DNT longer than 60 min. Material and Methods: Prospective analysis of patients treated with IT at a private hospital between June 2016 and June 2019. The percentage of patients with DNT exceeding 60 min, and the causes for this delay were evaluated. Results: IT was used in 205 patients. DNT was 43.6 ± 23.8 min. Forty patients (19.5% (95% CI, 14.4-25.7), had a DNT longer than 60 min. Uni-varied analysis demonstrated that AIS with infratentorial symptomatology (ITS), was significantly associated with DNTs exceeding 60 min. A history of hypertension, a higher NIH Stroke Scale score, the presence of an hyperdense sign in brain tomography (p = 0.001) and the need for endovascular therapy (p = 0.019), were associated with DNT shorter than 60 min. Multivariate analysis ratified the relationship between ITS and DNT longer than 60 min (Odds ratio: 3.19, 95% confidence intervals 1.26-8). Conclusions: The individual elements that correlated with a DNT longer than 60 min were the failure to detect the AIS during triage and doubts about its diagnosis.

Background: The effectiveness of intravenous thrombolysis (IVT) in cerebral ischemia is time dependent. Stroke mimics (SM) are frequent in emergency rooms. The effort to reduce door to needle time, can lead to administer thrombolytics to SM. Aim: To describe the frequency and prognosis of SM treated with IVT. Material and Methods: Prospective analysis of all patients evaluated in a Chilean private clinic between December 2004 and July 2015 with a suspected acute ischemic stroke (AIS). We calculated the number of SM that were treated with IVT. In these patients, we analyzed the presence of symptomatic cerebral hemorrhage defined as the presence of a neurological deterioration of four points or more on the National Institute of Health Stroke Scale, the presence of extracranial bleeding according to Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries criteria and the patient’s functional status at three months by modified Rankin scale (MRS). Results: We evaluated 1,417 patients with suspected AIS, of which 240 (16.9%) were finally diagnosed as SM. A total of 197 patients were treated with IVT, of these 10 (5%) corresponded to SM. All SM patients treated with thrombolytic drugs were functionally independent at 3 months and showed no bleeding complications. Conclusions: Occasionally SM patients were treated with IVT. This treatment was not associated with bleeding complications and the prognosis of these patients at three months was favorable.

Background: Sonothrombolysis (ST) is an emerging modality for the treatment of stroke. Aim: To assess the feasibility to perform ST in a Chilean hospital. Material and Methods: Patients attended at a private clinic with an acute ischemic stroke, between September 2002 and May 2013 and eligible for endovenous thrombolysis, were studied with a transcranial Doppler (Spencer PMD 100 or 150®). Those with an adequate sonographic window and a demonstrated arterial occlusion were monitored continuously with transcranial Doppler at the site of worst residual flow following the CLOTBUST study protocol. Results: One thousand twenty six patients were studied, of whom 136 received intravenous thrombolysis (rt-PA) and 61, aged 66 ± 18 years (59% males), were subjected to ST (7% of total). Their median National Institutes of Health Stroke Scale score was 14, the lapse from symptom onset to rt-PA was 127 minutes (43-223). Middle cerebral artery (MCA) occlusion was found in 88.5% of patients. Complete recanalization was achieved in 44.3% of patients. Sixty percent had Modified Rankin Scale of 0 to 2 at 3 months (95% confidence intervals (CI) 48.1 to 72). Case fatality was 9.8% and asymptomatic intracranial hemorrhage occurred in 9.8% (95% CI: 4.3 to 20.2). Conclusions: ST can be carried out in a complex medical center and is safe.

Background: The clinical diagnosis of brain death is complex. Aim: To evaluate the diagnostic accuracy of transcranial Doppler (TCD) for brain death. Patients and Methods: Patients seen on the intensive care unit of a private hospital between January 2004 to December 2008, were included if they were in structural coma, had no craniectomy and had a blind evaluation by a neurologist and TCD done in less than three hours. The diagnosis of brain death was based on a clinical evaluation that considered the absence of sedative drugs, median blood pressure >60 mmHg, body temperature over 35º Celsius and complete absence of brainstem refexes. An expert neurosonologist, with a TCD-PMD-100, 2 Mhz transducer, used an institutional protocol that considers the examination as positive for brain circulatory arrest when there is presence of reverberating, small systolic peaks or the disappearance of a previous signal present on both middle cerebral arteries and intracranial vertebral arteries. Results: Fifty three patients were evaluated, 25 with clinical brain death. On 45 cases (84.9%), the interval between both evaluations was less than one hour. The sensitivity, specifcity, positive and negative predictive values for the diagnosis of brain death with TCD were 100, 96, 96.1 and 100% respectively. Positive and negative likelihood ratios for brain death were 28 and 0, respectively. Conclusions: TCD is a valid and useful technique for the diagnosis of brain death and can be used on complicated cases.