Wednesday, April 16, 2014

Hemicraniectomy for malignant middle cerebral artery infarction: Current status and future directions

Hemicraniectomy for malignant middle cerebral artery infarction: Current status and future directions


  • decompressive surgery;
  • hemicraniectomy;
  • malignant;
  • middle cerebral artery infarction;
  • space-occupying
Malignant middle cerebral artery infarction is a life-threatening sub-type of ischemic stroke that may only be survived at the expense of permanent disability. Decompressive hemicraniectomy is an effective surgical therapy to reduce mortality and improve functional outcome without promoting most severe disability. Evidence derives from three European randomized controlled trials in patients up to 60 years. The recently finished DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY – II trial gives now high-level evidence for the effectiveness of decompressive hemicraniectomy in patients older than 60 years. Nevertheless, pressing issues persist that need to be answered in future clinical trials, e.g. the acceptable degree of disability in survivors of malignant middle cerebral artery infarction, the importance of aphasia, and the best timing for decompressive hemicraniectomy. This review provides an overview of the current diagnosis and treatment of malignant middle cerebral artery infarction with a focus on decompressive hemicraniectomy and outlines future perspectives.

Prevalence of stroke and coexistent conditions: disparities between indigenous and nonindigenous Western Australians


  • Australia;
  • comorbidity;
  • epidemiology;
  • indigenous;
  • linked data;
  • prevalence;
  • stroke


Worldwide, the prevalence of stroke is poorly described in indigenous populations, despite high stroke burden. This paper reports the average point prevalence of hospitalized stroke and coexistent conditions (2007–2011) in indigenous and nonindigenous people in Western Australia, the largest and most sparsely populated Australian jurisdiction.


Using state-wide linked hospital and mortality data, indigenous and nonindigenous prevalent stroke cases (aged 25–84 years) were identified after reviewing stroke admissions over a fixed 20-year look-back period. Prevalent cases were those alive at midyear of each study year. The 2007–2011 period prevalence was a weighted average of annual prevalence. Histories of 11 comorbidities were identified using the 20-year look-back period.


Indigenous cases comprised 5% of the average 13 591 annual prevalent cases. Indigenous patients were more likely to be younger, female, and have unknown stroke type. Indigenous prevalence was higher at every age. The age-standardized prevalence in indigenous men (33·7 per 1000; 95% confidence interval 31·9–35·4) was 3.7 times greater than in nonindigenous men (9·1 per 1000; 95% confidence interval 9·0–9·2). The corresponding estimates for women were 27·1 per 1000 (25·7–28·4) and 6·1 per 1000 (6·0–6·2) (ratio = 4·4). The percentage with selected comorbid conditions was substantially higher for indigenous patients.


The high stroke prevalence in indigenous Western Australians, coupled with clinical complexity from comorbid conditions, requires access to culturally appropriate medical, rehabilitation, and logistical support. Intensified primary and secondary prevention is needed to reduce the impact of stroke on indigenous people.

Tuesday, April 1, 2014

Uploading slides from IJS for your own talks!

Did you know that you can upload slides to use in the enhanced html section of the Wiley online library?
Here's a screen shot to show you how easy it is!

Statistical analysis plan for the ‘Efficacy of Nitric Oxide in Stroke’ (ENOS) trial

Statistical analysis plan for the ‘Efficacy of Nitric Oxide in Stroke’ (ENOS) trial

High blood pressure is common during the acute phase of stroke and is associated with a poor outcome. However, the management of high blood pressure remains unclear. The ‘Efficacy of Nitric Oxide in Stroke’ trial tested whether transdermal glyceryl trinitrate, a nitric oxide donor that lowers blood pressure, is safe and effective in improving outcome after acute stroke. Efficacy of Nitric Oxide in Stroke is an international multicenter, prospective, randomized, single-blind, blinded endpoint trial, with funding from the UK Medical Research Council. Patients with acute ischemic stroke or intracerebral hemorrhage and systolic blood pressure 140–220 mmHg were randomized to glyceryl trinitrate or no glyceryl trinitrate and, where relevant, to continue or stop prestroke antihypertensive therapy. The primary outcome is shift in modified Rankin Scale at three-months. Patients or relatives gave written informed (proxy) consent, and all sites had research ethics approval. Analyses will be done by intention to treat. This paper and attachment describe the trial's statistical analysis plan, developed prior to unblinding of date. The statistical analysis plan contains design and methods for analyses, and unpopulated tables and figures for the two primary publications and some secondary publications. The database will be locked in late February 2014 in preparation for presentation of the results in May 2014. The data from the trial will improve the precision of the estimates of the overall treatment effects (efficacy and safety) of results from completed trials of blood pressure management in acute stroke, and provide the first large-scale randomized evidence on transdermal glyceryl trinitrate, and of continuing (vs. stopping) prestroke antihypertensive medications, in acute stroke.

  • Keywords: acute stroke trial;
  • blood pressure;
  • glyceryl trinitrate;
  • intracerebral hemorrhage;
  • ischemic stroke;
  • statistical analysis plan

  • ENOS

    1. Philip M. W. Bath, 
    2. Aimee Houlton, 
    3. Lisa Woodhouse, 
    4. Nikola Sprigg, 
    5. Joanna Wardlaw,
    6. Stuart Pocock and
    7. on behalf of the ENOS Trialists

    Thursday, March 13, 2014

    Submission to: The Canadian Journal of Neuroscience Nurses Guest Editorial by Patrice Lindsay RN, PhD and Theresa Green RN, PhD March 4th, 2014

    Submission to:  The Canadian Journal of Neuroscience Nurses
    Guest Editorial by Patrice Lindsay RN, PhD and Theresa Green RN, PhD
    March 4th, 2014
    The field of neuroscience nursing, and in particular nursing people with stroke, has evolved significantly over the past two decades.  Nurses working with people who have had a stroke and their families are called upon to use advanced assessment skills, apply nursing diagnoses across the whole continuum of care, and identify and implement a wide range of interventions. As the volume of research evidence across disciplines mounts, nurses are challenged to ‘keep up on the latest’.
    The World Stroke Organization (WSO) plays an important role in bringing stroke to the forefront of the international agenda.  To increase our impact in the field of stroke and hence reduce the global burden of stroke, we need support from as many Professionals as possible involved in stroke care.   Within this mission, the WSO has recognized the important role nurses play in the care and recovery of people with stroke across all phases of care and settings and from acute hospital care to inpatient rehabilitation, community care, and long term care.  The WSO has committed to the development of an international community of stroke nurses.  This community will provide forums for sharing ideas, knowledge, resources, tools, practical tips and other aspects of nursing science across the globe.  It is an opportunity for nurses in more developed countries to mentor nurses working within stroke in lower and middle income countries, and provide education and leadership.  
    The WSO is calling on nurses from around the globe working in stroke to join together to improve the lives of stroke patients and families regardless of where they live.  To accomplish these commitments and enrich the international community of stroke nurses, the WSO has taken many actions to enhance membership opportunities and benefits for nurses, and they have also created a special low-cost membership fee of $25 (USD) for nurses and allied health professionals.  In addition to being a part of a global network of leading stroke and neurology experts, other membership benefits include: online access to the International Journal of Stroke (IJS); discount on the registration fee for future World Stroke Congresses as well as dedicated sessions for nurses and allied health professionals which address emerging topics in stroke patient care and recovery; eligibility to apply for WSO travel fellowships and awards;  access to Webcasts/podcasts of WSO congress sessions;  to premium content of the revamped World Stroke Academy – a series of online educational sessions on many stroke topics, with a new module under development for nurses;  access to the WSO  app with access to IJS and WSA;  listing in and access to the WSO Membership Directory;  ability to vote for, be nominated or elected to the Board of Directors and receipt of regular WSO newsletter.  There are also opportunities to connect and network with stroke nurses around the world using social media tools within the WSO community.
    In a recent Canadian study on the implementation of stroke best practices, nurses were identified  as playing  a leading role in many aspects of stroke care and recovery.  The WSO is providing an opportunity to connect, share with, and learn from dedicated and committed stroke nurses internationally.  All nurses, from the smallest villages to the largest cities are called upon to join together through the WSO to improve the lives of stroke patients and their families.

    For WSO membership information, please go to:

    Thursday, January 23, 2014

    Global Stroke Statistics IJS

    Readily accessible comparative data will help to shift the priority of stroke globally –
    Global Stroke Statistics in the International Journal of Stroke
    The inaugural annual review of country-specific stroke epidemiology in the International Journal of Stroke article ‘Global Stroke Statistics’ uses an extensive literature review with a major focus on published systematic reviews on stroke incidence, and direct acquisition and collation of data from the World Health Organization (WHO) to present the most current estimates of stroke mortality for each country recognized by the WHO.
    The paper, authored by some of the world’s most eminent stroke researchers, includes stroke epidemiologist Amanda Thrift, Peter Rothwell, Geoffrey Donnan, Virginia Howard, Dominique Cadilhac and George Howard. 
    In many countries, stroke is a lower priority than other diseases despite its public health impact, partly due to a lack of readily accessible comparative data to help make the case for the development of national stroke strategies. To assist in this process we need a common repository of the latest published information on the burden of stroke worldwide.

    When adjusted to the WHO World standard population, incidence rates for stroke ranged from 41 per 100,000 people per year in Nigeria (1971-74) to 316 per 100,000 people per year in urban Dar-es-Salaam (Tanzania). Of the 123 countries reporting mortality data to the WHO, crude mortality was greater in Kazhakstan (in 2003) than any of the other countries reporting mortality data to the WHO. Some countries like Montserrat, Kazhakstan and Albania had very high mortality despite the presence of a relatively young population. Conversely, others, most notably Japan, had a lower crude mortality than expected despite having a relatively older population (approximately 23% were aged ≥65 years). This country-level data is essential for citizens, clinicians and policy makers, so that action can be taken at a local and global level to reduce the overall burden of stroke.

    Monday, December 2, 2013

    How important are keywords for your article?

    Very important.  Check out this Keywords advisor PDF, which is an incredibly supportive document to  utilise when putting an article together for a journal.

    Tuesday, October 15, 2013

    2014 will bring surprises and improvements ...

    2014 will bring surprises and improvements
    December 2014 Editorial

    Once again we have reached the end of a very successful year in the history of the International Journal of Stroke. Now at the end of our eighth year, we are in the fortunate position of having an impact factor on the rise, attributed to the quality of manuscripts, which you are submitting, and the readability of the journal. In this vein the structure continues to evolve.

    Many of you will recall that we launched the journal with a content focused solely on review, but have gradually evolved the format to include a modest number of high quality research articles, and an annual bumper research edition. 

    This change in structure has also been in response to the extraordinary number of submissions that you have made, emphasizing the appetite and need for more top quality science to be published, and new vehicles for publication. The whole publishing industry is undergoing the most rapid change, perhaps since the invention of the printing press. What the journal landscape will look like even within five years is hard to predict, what we do know is that we must evolve rapidly!

    The second structural alteration has been to expand our Editorial Board roles. We have introduced new section editors, who are leaders in their field, I warmly welcome:  Genetics: Martin Dichgans - Germany, Hugh Markus - UK; Basic Science: Malcolm McLeod – UK, David Howells - Australia; Imaging: Mark Parsons – Australia; Acute therapy: Andrew Demchuk – Canada, Peter Sandercock – UK; Rehabilitation:
    Marion Walker – UK, Julie Bernhardt – Australia; Cognition disorder: Amy Brodtmann – Australia, and Sarah Pendlebury – UK.
    I am certain they will all make a wonderful contribution to the matrix of the journal.

    As well as working to engage science leaders in their field, we are also building on the wealth of experience in the field of stroke from our senior colleagues who will contribute as consulting editors; it is a pleasure to welcome: Stephen Davis – Australia; Veronika Skvortsova – Russia; Bo Norrving – Sweden; Ulrich Dirnagl –Germany; Graeme Hankey – Australia; Conrado Estol – Argentina.

    We would like to thank Michael Hennerici for agreeing to continue to support us in this role after assisting us to pioneer the journal.

    You’ll be pleased to know that the evolutionary process continues, and in 2014 there will be a number of surprises and improvements for our expanding and dedicated readership. See you next year!

    Geoffrey A. Donnan

    Thursday, August 15, 2013

    Canadian Best Practice Recommendations for Stroke Care : Stroke Rehabilitation update

    New recommendations released by the Heart and Stroke Foundation of Canada stroke guidelines team for physicians, nurses and allied health professionals, reinforce that stroke rehabilitation is not limited to a single location, but is an ongoing process that includes a range of activities in many settings taking place over months or years. This updated set of recommendations emphasizes all components of dedicated stroke rehabilitation services, from rehabilitation units, to outpatient clinics and programs in the community; taking a more holistic approach to stroke rehabilitation as being available ‘anywhere, anytime'.

    "Stroke rehabilitation is a progressive, dynamic, goal-oriented process that works to restore neurological deficits occurring as a consequence of a stroke. Rehabilitation should begin immediately after a stroke and involves interdisciplinary teams working together to maximize the individual's recovery. Rehabilitation continues after the patient leaves hospital to ensure the patient achieves maximal recovery and is successfully reintegrated back into the community."
    says Dr. Robert Teasell, Professor of Physical Medicine and Rehabilitation, Schulich School of Medicine, Western University in London, and senior writer, Stroke Rehabilitation Writing Group.

    The recommendations also highlight the need for an increase in early-supported discharge, which allows patients to return to their previous living setting as early as possible, where appropriate. The significant benefits to this approach include better quality of life for the patient and decreased burden on the health care system. In order for early supported discharge to be successful, it needs to be delivered within an organized system of stroke care to provide the best outcomes for patients.

    Recent reports on the quality of stroke rehabilitation and recovery services reveal considerable variation in availability and access within Canada and across many developed countries.  Access is considerably more variable and less available in developing countries that lack the expertise and resources for long-term rehabilitation.  New strategies and the use of technology, such as telestroke, should be considered to bridge this gap.
    “The evidence supporting the positive impact that rehabilitation plays in stroke recovery is both strong and growing. However, the key is the availability and accessibility to critical rehabilitation programs and services. On a system level there continues to be many gaps in terms of people being able to access timely and intensive rehabilitation in both inpatient and outpatient settings. Rehabilitation should clearly be an area of focused uptake for stroke care best practices as it will result in significant gains for both patients and the health system”
     says Mark Collison, Director, Advocacy & Stakeholder Relations, Heart and Stroke Foundation, British Columbia and Yukon.

    Rehabilitation crosses all settings of care, and a broad range of providers and caregivers, and families and other informal caregivers play a critical role.  The patient, their family and caregivers must be included in goal setting, planning for the types of rehabilitation required and selecting the most appropriate setting to receive the needed rehabilitation.

    The Canadian Best Practice Recommendations for Stroke Care is a joint initiative of the Heart and Stroke Foundation and the Canadian Stroke Network.

    Patty Lindsay

    Director Best Practices and Performance, Stroke
    Heart and Stroke Foundation | Fondation des maladies du cœur et de l'AVC