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.
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).
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