M ultiple trials have shown the benefit of endovascular recanalization therapy in selected stroke patients. [1][2][3] Earlier treatment is associated with better functional outcome. 4 The time from symptom onset to treatment is influenced by prehospital and in-hospital processes. Healthcare systems are being reorganized to offer stroke patients rapid and effective medical care. Stroke services had already changed their workflow since intravenous tPA (tissue-type plasminogen activator) for selected stroke patients was proven effective. 5 Implementation of new strategies to improve the workflow process for treatment with intravenous tPA has led to a significant reduction of in-hospital delay. 6 Providing an optimal diagnostic process and rapid endovascular stroke treatment requires close collaboration of the emergency medical service, emergency department team, stroke team, neurointerventional team, and anesthesia team. Diagnostic imaging and endovascular treatment facilities should be available in little time. Several strategies to reduce the time to endovascular stroke treatment have been proposed. [7][8][9] However, the effect of individual and combined strategies on reducing time to treatment is unclear. We performed a systematic review and meta-analysis on the effectiveness of specific workflow improvement interventions for rapid delivery of endovascular stroke treatment.

Health-care professionals and researchers have a legal and ethical responsibility to inform patients before carrying out diagnostic tests or treatment interventions as part of a clinical study. Interventional research in emergency situations can involve patients with some degree of acute cognitive impairment, as is regularly the case in traumatic brain injury and ischaemic stroke. These patients or their proxies are often unable to provide informed consent within narrow therapeutic time windows. International regulations and national laws are criticised for being inconclusive or restrictive in providing solutions. Currently accepted consent alternatives are deferred consent, exception from consent, or waiver of consent. However, these alternatives appear under-utilised despite being ethically permissible, socially acceptable, and regulatorily compliant. We anticipate that, when the requirements for medical urgency are properly balanced with legal and ethical conduct, the increased use of these alternatives has the potential to improve the efficiency and quality of future emergency interventional studies in patients with an inability to provide informed consent.

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A 73-year-old man was referred to the outpatient clinic with a 2-week history of headache and apathy. Neurologic examination revealed mild left-sided facial, arm, and leg paresis. Head CT appeared to show a right frontal lobe tumor with finger-like vasogenic edema. Instead, MRI revealed a subacute lobar hemorrhage with perihematomal edema (figure). On follow-up imaging, no underlying cause was found.The temporal changes in density on CT can make a hemorrhage difficult to recognize, particularly in the late subacute phase. 1,2 MRI is able to detect several phases of hematoma evolution and shows better discrimination of the lesion from surrounding edema. Head CT (A) shows an irregular area of low density in the right frontal lobe. On T2-weighted fluid-attenuated inversion recovery MRI (B), this irregular area consists of a hyperintense central lesion (subacute hematoma) lined by a hypointense rim (hemosiderin) surrounded by a hyperintense finger-like zone (vasogenic edema). AUTHOR CONTRIBUTIONS

Background Although the provision of performance feedback to healthcare professionals based on data from quality registries is common practice in many fields of medicine, observational studies of its effect on the quality of care have shown mixed results. The objective of this study is to evaluate the effect of performance feedback on the quality of care for acute ischemic stroke. Methods PERFEQTOS is a stepped wedge cluster randomized trial in 13 hospitals in the Netherlands providing endovascular thrombectomy for ischemic stroke. The primary outcome is the hospital’s door-to-groin time. The study starts with a 6-month period in which none of the hospitals receives the performance feedback intervention. Subsequently, every 6 months, three or four hospitals are randomized to cross over from the control to the intervention conditions, until all hospitals receive the feedback intervention. The feedback intervention consists of a dashboard with quarterly reports on patient characteristics, structure, process, and outcome indicators related to patients with ischemic stroke treated with endovascular thrombectomy. Hospitals can compare their present performance with their own performance in the past and with other hospitals. The performance feedback is provided to local quality improvement teams in each hospital, who define their own targets on specific indicators and develop performance improvement plans. The impact of the performance feedback and improvement plans will be evaluated by comparing the primary outcome before and after the intervention. Discussion This study will provide evidence on the effectiveness of performance feedback to healthcare providers. The results will be actively disseminated through peer-reviewed journals, conference presentations, and various stakeholder engagement activities. Trial registration Netherlands Trial Register NL9090. Registered on December 3, 2020

Introduction: In the Netherlands, acute endovascular treatment (EVT) for ischemic stroke was not reimbursed andonly allowed as rescue treatment according to national guidelines until 2016. We describe the trend in use of EVT before, during and after the pivotal thrombectomy trials. Methods: Our study used data from all patients who were treated with EVT in the Netherlands from Jan 2002 until Jun 2016 in the Pretrial Registry, MR CLEAN trial and the ongoing MR CLEAN registry. We undertook a time-series analysis to examine trends in the use of EVT using a mixed-effects Poisson regression analysis and several observation plots. Rate ratios (RR) per quarter and 95% confidence intervals (95% CI) were obtained to demonstrate the impact and implementation after the publication of the trial. Regional plots were adjusted for exposure time and population density. Results: Between 2004 and 2010, 491 patients were treated with EVT in the Netherlands. In 2010, the MR CLEAN trial started. All hospitals providing EVT in the Netherlands included patients and reimbursement was conditional on participation in MR CLEAN. At first, a non-significant increase in EVT-treated patients was observed (RR: 4.6 [95%CI 0.1-9.1]). In 2015, an immediate steep increase in EVT-treated patients (RR: 20.9 [95%CI 5.5-30.1]) (Fig. 1) and a more even spread over the country was observed (Fig. 2). In the first years after the trial, 33% of the patients who were considered to be eligible for EVT were treated with EVT. Conclusion: A strict national policy regarding evidence based treatments can be successful. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT.

The phenotype of C9ORF72 repeat expansions is rapidly expanding. Originally found to be the major genetic cause of familial frontotemporal dementia with amyotrophic lateral sclerosis, several other clinical characteristics have been described more recently. Here, we report on a family diagnosed with 'degenerative schizophrenia' and harbouring a C9ORF72 repeat expansion, in which at least the index patient and an uncle showed a photoparoxysmal response during electroencephalography. Whereas epilepsy has been described in several repeat expansion disorders, photosensitivity has thus far only been reported in dentatorubral-pallidoluysian atrophy. The photoparoxysmal response may therefore be a new clinical feature of C9ORF72 repeat expansion related disease. Our observation learns that a repeat expansion disorder like C9ORF72 should be considered in patients with a combination of young-onset dementia, psychiatric symptoms and/or photosensitive epilepsy. We advocate the occasional use of EEG in the dementia workup and in particular urge to consider provocative tests such as photic stimulation.