Background and Purpose-Because of a shortage of stroke specialists, many outlying or "spoke" hospitals initiate intravenous (IV) thrombolysis using telemedicine or telephone consultation before transferring patients to a regional stroke center (RSC) hub. We analyzed complications and outcomes of patients treated with IV tissue plasminogen activator (tPA) using the "drip and ship" approach compared to those treated directly at the RSC. Methods-A retrospective review of our Get With the Guidelines Stroke (GWTG-Stroke) database from 01/2003 to 03/2008 identified 296 patients who received IV tPA within 3 hours of symptom onset without catheter-based reperfusion. GWTG-Stroke definitions for symptomatic intracranial (sICH), systemic hemorrhage, discharge functional status, and destination were applied. Follow-up modified Rankin Score was recorded when available. Results-Of 296 patients, 181 (61.1%) had tPA infusion started at an outside spoke hospital (OSH) and 115 (38.9%) at the RSC hub. OSH patients were younger with fewer severe strokes than RSC patients. Patients treated based on telestroke were more frequently octogenarians than patients treated based on a telephone consult. Mortality, sICH, and functional outcomes were not different between OSH versus RSC and telephone versus telestroke patients. Among survivors, mean length of stay was shorter for OSH patients but discharge status was similar and 75% of patients walked independently at discharge. Conclusions-Outcomes in OSH "drip and ship" patients treated in a hub-and-spoke network were comparable to those treated directly at an RSC. These data suggest that "drip and ship" is a safe and effective method to shorten time to treatment with IV tPA. (Stroke. 2010;41:e18-e24.)Key Words: stroke Ⅲ telemedicine Ⅲ thrombolysis I ntravenous tissue plasminogen activator (IV tPA) is FDA approved for acute ischemic stroke (AIS) within the first 3 hours of symptom onset. 1 Previous studies have shown that IV tPA is underused and that only 3% to 4% of AIS patients receive thrombolytic treatment. 2 A majority of acute stroke patients present to hospitals that lack 24/7 availability of a stroke specialist, 3,4 are managed by generalists, 5 and many do not receive tPA at the presenting facility. 6,7 If practitioners opt for transfer to a regional stroke center (RSC) for initiation of tPA, delays may preclude delivery of tPA.Hub-and-spoke networks have been developed to allow IV tPA to be initiated at an outlying spoke hospital (OSH) under the supervision of a vascular neurologist at the designated RSC hub who provides assistance in the diagnosis and management of AIS via telephone 8 or telemedicine-enabled ("telestroke") 9 consultation before transfer. This practice has been referred to as "drip and ship." 10 The evidence supporting telemedicine for acute stroke care within a hub and spoke network has recently been reviewed and guideline recommendations published. 11,12 Limited data exist comparing the safety and feasibility of patients treated by "drip and ship" 13 versus patie...

BackgroundHyperglycemia has been associated with adverse outcomes in patients with acute ischemic stroke (AIS) and may influence outcomes after tissue plasminogen activator (tPA). We sought to analyze the association of acute and chronic hyperglycemia on clinical outcomes in tPA‐treated patients.Methods and ResultsWe identified 58 265 AIS patients from 1408 sites who received tPA from 2009 to 2013 in Get With The Guidelines‐Stroke. Acute hyperglycemia at admission was defined as a plasma glucose level >140 mg/dL. Chronic hyperglycemia was defined by plasma glycosylated hemoglobin (HbA1c) >6.5%. Post‐tPA outcomes were analyzed using logistic regression. Blood glucose >140 mg/dL and HbA1c >6.5 were associated with worse clinical outcomes (symptomatic intracranial hemorrhage [sICH], life‐threatening hemorrhage, and in‐hospital mortality and length of stay) in diabetic and nondiabetic patients. Among patients with documented history of diabetes, increasing admission glucose up to 200 mg/dL was associated with increased adjusted odds ratio (aOR) of in‐hospital mortality (aOR, 1.07) and sICH (aOR, 1.05) per 10 mg/dL increase in blood glucose. Increasing HbA1C to 8% was associated with increased odds of in‐hospital mortality (aOR, 1.19) and sICH (aOR, 1.16) per 1% increase in HbA1c. Similar findings were observed in patients without a documented history of diabetes. There was no further increase in poor outcomes above the blood glucose level of 200 mg/dL or HbA1c >8.ConclusionAcute and chronic hyperglycemia are both associated with increased mortality and worse clinical outcomes in AIS patients treated with tPA. Controlled trials are needed to determine whether acute correction of hyperglycemia can improve outcomes after thrombolysis.

Background: Symptomatic intracerebral hemorrhage (sICH) is the most devastating complication of thrombolytic therapy for acute stroke. It is not clear whether patients with sICH continue to bleed after diagnosis, nor has the most appropriate treatment been determined.Methods: We performed a retrospective analysis of our prospectively collected Get With the Guidelines-Stroke database between April 1, 2003, and December 31, 2007. Radiologic images and all procoagulant agents used were reviewed. Multivariable logistic regression was performed to identify factors associated with in-hospital mortality.Results: Of 2362 patients with acute ischemic stroke during the study period, sICH occurred in 19 of the 311 patients (6.1%) who received intravenous tissue plasminogen activator and 2 of the 72 (2.8%) who received intra-arterial thrombolysis. In-hospital mortality was significantly higher in patients with sICH than in those without (15 of 20 [75.0]% vs 56 of 332 [16.9%], PϽ .001). Eleven of 20 patients (55.0%) received therapy for co-

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PurposeHospital acquired pneumonia (HAP) is a major complication of stroke. We sought to determine associations between infarction of specific brain regions and HAP.Methods215 consecutive acute stroke patients with HAP (2003–2009) were carefully matched with 215 non-pneumonia controls by gender, then NIHSS, then age. Admission imaging and binary masks of infarction were registered to MNI-152 space. Regional atlas and voxel-based log-odds were calculated to assess the relationship between infarct location and the likelihood of HAP. An independently validated penalized conditional logistic regression model was used to identify HAP associated imaging regions.ResultsThe HAP and control patients were well matched by gender (100%), age (95% within 5-years), NIHSS (98% within 1-point), infarct size, dysphagia, and six other clinical variables. Right hemispheric infarcts were more frequent in patients with HAP versus controls (43.3% vs. 34.0%, p = 0.054), whereas left hemispheric infarcts were more frequent in controls (56.7% vs. 44.7%, p = 0.012); there was no significant difference between groups in the rate of brainstem strokes (p = 1.0). Of the 10 most infarcted regions, only right insular cortex volume was different in HAP versus controls (20 vs. 12 ml, p = 0.02). In univariate analyses, the highest log-odds regions for pneumonia were right hemisphere, cerebellum, and brainstem. The best performing multivariate model selected 7 brain regions of infarction and 2 infarct volume-based variables independently associated with HAP.ConclusionsHAP is associated with right hemispheric peri-insular stroke. These associations may be related to autonomic modulation of immune mechanisms, supporting recent hypotheses of stroke mediated immune suppression.

Anaphylaxis rarely manifests as a vasospastic acute coronary syndrome with or without the presence of underlying coronary artery disease. The variability in the underlying pathogenesis produces a wide clinical spectrum of this syndrome. We present three cases of anaphylactic acute coronary syndrome that display different clinical variants of this phenomenon. The main pathophysiological mechanism of the allergic anginal syndromes is the inflammatory mediators released during a hypersensitivity reaction triggered by food, insect bites, or drugs. It is important to appropriately recognize and treat Kounis syndrome in patients with exposure to a documented allergen.

There are few data on the risk of exercise and the role of exercise stress testing in Brugada syndrome. We sought to address this deficiency using a systematic literature review. We identified 98 English-language articles possibly addressing exercise in Brugada syndrome by searching PubMed and Google Scholar from January 1990 through November 2013 using the keywords ''Brugada syndrome,'' ''exercise,'' ''exercise testing,'' and ''syncope'' alone and in combinations. Abstracts were reviewed, and those articles pertaining to Brugada syndrome and exercise were reviewed in full. We identified 18 articles reporting on Brugada syndrome and exercise. This pool included 2 large studies of 93 and 50 Brugada subjects undergoing exercise testing, plus 16 case reports. There were no reports of exercise-related sudden death, but there were 4 cases of syncope after exercise. We identified 166 Brugada patients who underwent exercise testing. During exercise testing, there were 2 reports of ventricular tachycardia and 1 report of multiple ventricular extrasystoles. ST-segment elevation increased (ST augmentation) during the early recovery phase of exercise in 57% of patients. Exercise unmasked a Brugada electrocardiographic pattern in 5 patients. Exercise is associated with syncope and ST augmentation after exercise and may be helpful in unmasking Brugada syndrome. There are insufficient data on the risks of exercise in Brugada syndrome to make recommendations for exercise, but the observations that exercise can worsen the ST abnormalities in Brugada and produce ventricular arrhythmias suggest that patients with Brugada syndrome should be restricted from vigorous exercise.