Among patients with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with the standard practice of short-duration ECG monitoring. (Funded by the Canadian Stroke Network and others; EMBRACE ClinicalTrials.gov number, NCT00846924.).

Background and Purpose— Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. Methods— We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. Results— Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142–1973) among those who subsequently had AF detected versus 45 (interquartile range, 14–250) in those without AF ( P <0.001). APB count was the only significant predictor of AF detection by 30-day ECG ( P <0.0001), and at 90 days ( P =0.0017) and 2 years ( P =0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from <9% among patients with <100 APBs/24 h to 9% to 24% in those with 100 to 499 APBs/24 h, 25% to 37% with 500 to 999 APBs/24 h, 37% to 40% with 1000 to 1499 APBs/24 h, and 40% beyond 1500 APBs/24 h. Conclusions— Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00846924.

Background: Longitudinal, patient-level data on resource use and costs after an ischemic stroke are lacking in Canada. The objectives of this analysis were to calculate costs for the first year post-stroke and determine the impact of disability on costs. Methodology: The Economic Burden of Ischemic Stroke (BURST) Study was a one-year prospective study with a cohort of ischemic stroke patients recruited at 12 Canadian stroke centres. Clinical history, disability, health preference and resource utilization information was collected at discharge, three months, six months and one year. Resources included direct medical costs (2009 CAN$) such as emergency services, hospitalizations, rehabilitation, physician services, diagnostics, medications, allied health professional services, homecare, medical/assistive devices, changes to residence and paid caregivers, as well as indirect costs. Results were stratified by disability measured at discharge using the modified Rankin Score (mRS): nondisabling stroke (mRS 0-2) and disabling stroke (mRS 3-5). Results: We enrolled 232 ischemic stroke patients (age 69.4 ± 15.4 years; 51.3% male) and 113 (48.7%) were disabled at hospital discharge. The average annual cost was $74,353; $107,883 for disabling strokes and $48,339 for non-disabling strokes. Conclusions: An average annual cost for ischemic stroke was calculated in which a disabling stroke was associated with a two-fold increase in costs compared to NDS. Costs during the hospitalization to three months phase were the highest contributor to the annual cost. A "back of the envelope" calculation using 38,000 stroke admissions and the average annual cost yields $2.8 billion as the burden of ischemic stroke.RÉSUMÉ: Impact du degré d'invalidité sur les coûts reliés à l'accident vasculaire cérébral ischémique au cours de la première année au Canada. Contexte : Nous n'avons pas de données longitudinales sur l'utilisation des ressources par les patients et les coûts ainsi engendrés suite à un accident vasculaire cérébral (AVC) ischémique au Canada. Les buts de cette analyse étaient de calculer les coûts engendrés au cours de la première année après un AVC et de déterminer l'impact de l'invalidité sur ces coûts. Méthode : Le Economic Burden of Ischemic Stroke (BURST) Study est une étude prospective d'une durée de un an chez une cohorte de patients ayant subi un AVC ischémique qui ont été recrutés dans 12 centres canadiens de traitement de l'AVC. Des informations ont été recueillies sur l'histoire clinique, l'invalidité, les choix de santé et l'utilisation des ressources au moment du congé hospitalier, trois mois, six mois et un an plus tard. Les ressources incluaient les coûts médicaux directs (en $ canadiens 2009) comme les services d'urgence, les hospitalisations, la réadaptation, les frais médicaux, diagnostiques et thérapeutiques, les autres services professionnels, les soins à domicile, les équipements médicaux/accessoires fonctionnels, les changements effectués au lieu de résidence et les aidants rémunérés ainsi que les ...

Background and Purpose-Benefit-risk ratios from recombinant tissue plasminogen activator (rtPA) therapy for acute ischemic stroke demonstrate lack of efficacy if intravenous administration is commenced beyond 3 hours of symptom onset. We undertook to enhance therapeutic effectiveness by ensuring equitable access to rtPA for patients affected by acute ischemic stroke within a 20 000 km 2 population referral base served by a tertiary facility. Methods-Representatives of all provider groups involved in emergency medical services developed a Regional Acute Stroke Protocol (RASP), a coordinated regional system response by dispatch personnel, paramedics, physicians, community service providers, emergency and inpatient staff in community hospitals, and the tertiary facility acute stroke team. Results-As of July 26, 1999, all ambulance services in Southeastern Ontario began bypassing the closest hospital to deliver patients meeting the criteria for the RASP to the Kingston General Hospital. At 12 months, approximately 403 ischemic strokes have occurred in the region, the RASP has been activated 191 times, and 42 patients have received rtPA. Conclusions-We conclude that (1) acute stroke patients in Southeastern Ontario have improved access to interventions for stroke care; (2) geography of the region is not a barrier to access to interventions for patients with acute stroke; and (3) acute ischemic stroke patients treated with rtPA account for 5% of all acute strokes and 10% of all ischemic strokes in this region. (Stroke. 2001;32:652-655.)

Background: The treatment of chronic daily headache (CDH) due to medication overuse remains a common and difficult problem. For selected patients refractory to outpatient management we have used a treatment protocol using dihydroergotamine (DHE) as introduced by Raskin, during a brief (typically 48 hours) in-patient stay. While many studies have documented the short-term efficacy of the DHE protocol, there are limited data on its long-term effects. The purpose of this study was to evaluate the efficacy of the protocol on headache frequency and severity, analgesic use, absences from work, and quality of life, at three months post treatment and the present time. Methods: A retrospective chart review of all patients admitted for the DHE protocol from 1991 to 1996 revealed 174 cases. Of these, 132 patients were interviewed by phone. Results: The DHE protocol was shown to decrease headache frequency, severity, headache medication use, and absences from work both at three months and the time of interview. Conclusion: This study has the largest patient base and the longest follow-up period for the use of DHE for CDH. The results confirm that the DHE protocol is helpful in breaking the cycle of CDH, although the long-term outcomes of this study are more conservative than other studies have reported. RESUME: Traitement hospitalier de la cephalee quotidienne chronique au moyen de la dihydroergotamine: une etude a long terme. Introduction: Le traitement de la cephalee quotidienne chronique (CQC) due a la surutilisation mSdicamenteuse demeure un probleme frequent et difficile. Pour des patients externes bien choisis, reTractaires au traitement en externe, nous avons utilise le protocole de Raskin utilisant la dihydroergotamine (DHE) au cours d'un court sejour hospitalier (habituellement de 48 heures). Bien que plusieurs etudes ont montr6 l'efficacite a court terme du protocole DHE, il existe peu de donnees sur les r&ultats a long terme. Le but de cette 6tude etait d'dvaluer l'efficacite du protocole quant a la frequence et la severite des c6phalees, l'utilisation d'analgesiques, l'absentSisme au travail et la quality de vie trois mois apres le traitement et jusqu'au moment de l'etude. Methodes: Une revue retrospective des dossiers de tous les patients admis pour traitement au moyen du protocole DHE de 1991 a 96 a indique' qu'il y avait eu 174 cas ainsi traites. Parmi ceux-ci, 132 patients ont eu une entrevue t£16phonique. Resultats: Le protocole DHE a diminud la frequence des c6phalees, leur severity, la prise de medicaments et l'absenteisme au travail a 3 mois et au moment de I'entrevue. Conclusion: Cette etude inclus le plus grand nombre de patients et le suivi le plus long apres l'utilisation de la DHE dans les cas de CQC. Ces resultats confirment que le protocole DHE aide a briser le cycle de la CQC, meme si les resultats a long terme rapportes dans cette 6tude sont plus conservateurs que ceux rapport6s dans d'autres etudes.Can. J. Neurol. Sci. 1998; 25: 146-150 Chronic daily headache (CDH) is a difficult c...