In vivo imaging of glutamate uncovers the neuroprotective effects of nicotinamide riboside on excitotoxicity in an Alzheimer’s mouse model

 

 Hopefully your competent? doctor is fully aware of what this can do. No knowledge is grounds for firing! I take no prisoners in trying to get stroke solved. Incompetent persons need to be outed and fired! YOUR RESPONSIBILITY, since your stroke hospital is completely failing at getting stroke solved to 100% recovery, they are incompetent to the core!

• Nicotinamide riboside (3 posts to April 2016)

In vivo imaging of glutamate uncovers the neuroprotective effects of nicotinamide riboside on excitotoxicity in an Alzheimer’s mouse model

• Anshuman Swain, 
• Narayan Datt Soni, 
• Ryan B. Gaspar, 
• James G. Davis, 
• Fang Liu, 
• Halvor Juul, 
• Ravi Prakash Reddy Nanga, 
• Joseph A. Baur & 
• Ravinder Reddy 

• 3 Accesses

• Explore all metrics 

 We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply.

Abstract

Background

Nicotinamide adenine dinucleotide (NAD⁺) precursors, such as nicotinamide riboside (NR), have gained interest as potential therapeutics for alleviating Alzheimer’s disease (AD) pathology. Chemical exchange saturation transfer (CEST) magnetic resonance imaging (MRI) can provide insights into the effects of NR on AD by virtue of its sensitivity to monitoring the metabolic status of tissue in vivo.

Methods

This study used glutamate-weighted CEST (GluCEST) MRI to monitor glutamate-associated metabolic changes following NR treatment in the 5xFAD mouse model of AD. Drinking water was supplemented with NR or provided as is to animals over the course of expected disease progression prior to imaging experiments. Following imaging, an immunohistochemical assay to monitor the expression of glial fibrillary acidic protein (GFAP) and ionized calcium-binding adaptor molecule 1 (Iba1) was performed to assess the extent of neuroinflammatory glial responses. A two-way ANCOVA with interaction was performed for statistical analysis of both CEST and IHC data.

Results

Results from GluCEST revealed significantly higher glutamate levels in the hippocampal dentate gyrus of AD mice compared to WT, with a significant reduction following treatment. GFAP staining mirrored this trend, implicating reactive astrogliosis as a mechanism for elevated glutamate. Similar patterns were observed in the cerebral peduncles, a white matter bundle, in which GFAP and Iba1 supported GluCEST findings and suggested neuroinflammation in axonal tracts. Our findings are in concordance with studies reporting elevated glutamate associated with reactive gliosis and morphological changes disrupting glutamate imbalance. Interestingly, NR restores glutamate homeostasis and alleviates neuroinflammatory processes, thus rescuing tissue from excitotoxic insults.

Conclusion

Overall, this study demonstrates the potential of NR to mitigate glutamate-driven excitotoxicity in AD pathology, and highlights GluCEST as a sensitive in vivo, clinically translatable biomarker for neuroinflammation and excitotoxicity.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AD:

Alzheimer’s disease

NR:

Nicotinamide riboside

NAM:

Nicotinamide

NAD⁺ :

Nicotinamide adenine dinucleotide

CEST:

Chemical exchange saturation transfer

MRI:

Magnetic resonance imaging

GFAP:

Glial fibrillary acidic protein

WT:

Wild–type

MT:

Magnetization transfer

APT:

Amide proton transfer

rNOE:

Relayed nueclar Overhauser effect

ANOVA:

Analysis of variance

ANTs:

Advanced Normalization tools

Aβ:

Amyloid beta

IHC:

Immunohistochemistry

GluCEST:

Glutamate–weighted chemical exchange saturation transfer

Wash. judge dismisses stroke patient’s DUI protocol lawsuit

 You're going to have to be cognizant and capable enough to inform others that you're having a stroke. Obviously whatever training was provided here was totally inadequate!

Wash. judge dismisses stroke patient’s DUI protocol lawsuit

A judge dismissed a lawsuit against Puyallup police and Central Pierce Fire & Rescue filed by a woman who was misdiagnosed with DUI but was later found to have suffered a massive stroke

One for the Road: Stroke care missing the mark?

By Shea Johnson
The News Tribune

PUYALLUP, Wash. — A Pierce County Superior Court judge has dismissed a lawsuit that accused local authorities of negligence after a Puyallup woman was arrested for DUI but actually had suffered a stroke.

Jane Carhuff and a family representative sued the city of Puyallup and Central Pierce Fire & Rescue more than three years after her November 2019 arrest for which charges were dismissed, alleging that Puyallup police ignored protocol for DUI testing and firefighters rendered a medical opinion without the necessary expertise.

As a result, the 54-year-old postal worker spent more than three hours in custody reportedly acting strangely. A day or so after Carhuff returned home and her condition — alleged to have been the product of drug intoxication — didn’t improve, her family took her to a local hospital where she was diagnosed with having suffered a massive stroke, according to the suit.

The delay in receiving medical care significantly worsened Carhuff’s chances of recovery, and she continued to suffer strokes until her death in September 2023, according to the suit and her obituary.

In separate motions filed in court, the city of Puyallup and Central Pierce Fire & Rescue denied wrongdoing and sought to dismiss the case. Earlier this month, Judge TaTeasha Davis granted their motions, ending the case before a scheduled April trial, court records show.

“We were all stunned,” attorney Darrell Cochran, one of the lawyers representing Carhuff and her family representative, said in an interview Tuesday.

Cochran said the plaintiffs’ legal counsel planned to appeal Davis’ decision and, if successful, the case’s trial date would be reset.

The case hinged on whether Carhuff exhibited obvious signs of a stroke after she caused at least two crashes on her way to a doctor’s appointment. Attorneys for the city argued the plaintiffs’ own experts admitted she was not clearly showing such signs and that her behaviors were consistent with intoxication.

In a statement Wednesday, Puyallup City Attorney Joseph Beck expressed “deepest condolences” to Carhuff’s family on behalf of the city, calling her death “a profound tragedy.”

“We are grateful that the court, after a thorough review of all the facts presented, has determined that the City met the highest standard of care expected of law enforcement,” Beck said.

Central Pierce Fire & Rescue, which examined Carhuff prior to her arrest, argued in a court filing that emergency medical technicians acted appropriately.

“Central Pierce Fire & Rescue is committed to providing the highest standard of emergency medical care to our community,” a department spokesperson said in a statement Wednesday. “Our focus remains on serving with professionalism and compassion.”

Morning drive turns frantic

On Nov. 11, 2019, feeling ill, Carhuff embarked on a roughly 20-minute drive to a doctor’s appointment after eating breakfast with her brother’s wife and daughter, both of whom described her as acting normally, according to the lawsuit.

En route to her doctor, Carhuff suffered a medical emergency, inadvertently causing three crashes that badly damaged her vehicle before she arrived at her doctor’s office, a clinic at 610 S. Meridian, where she entered through the reception area and waited to be seen, the suit said.

All the while, Puyallup police frantically sought a hit-and-run driver, spurred by 911 calls from crash victims, including one who provided license plate information, according to the suit. Officers identified Carhuff as the suspect and learned her whereabouts from family upon visiting her home, leading police to respond to her doctor’s office, the suit said.

Central Pierce Fire & Rescue (CPFR) personnel also arrived at the scene.

The lawsuit alleged that Carhuff was mistreated by police and firefighters, despite purportedly being confused, disoriented and manifesting the effects of someone having a stroke.

Fire personnel conducted their own medical assessment, instead of consulting with Carhuff’s doctor or taking her to a local hospital roughly 300 yards away, according to the suit. Only Carhuff’s blood sugar was tested after she reportedly referenced being diabetic, the suit said, adding that CPFR concluded that she wasn’t in medical distress but under the influence of an unknown intoxicant.

In arresting Carhuff, police officers were accused of failing to follow standard DUI protocol by not conducting field-sobriety tests or contacting a drug-recognition expert, according to the suit.

In a response filed in court, the city of Puyallup did not dispute that Carhuff had been unsteady on her feet and unable to follow simple instructions; that three EMTs who examined her had reported finding no medical problem; or that she was later diagnosed with a stroke.

However, the city said it was reasonable for officers to conclude that Carhuff was intoxicated. In particular, Carhuff told officers she had taken the prescription sedative Ambien and severe-cold medication that morning, the city’s defense counsel said, noting that an expert witness for the plaintiffs acknowledged that Carhuff’s symptoms aligned with the effects of the sedative.

“It is undisputed she had something dry and crusty on her lips, had bloodshot and watery eyes, and her face was flushed,” the city’s legal counsel wrote in a court filing. “It is undisputed she acted confused.”

The plaintiffs’ legal counsel denied that Carhuff had taken prescription or other medication that would have impaired her ability to drive.

Other details were in dispute or later changed.

For instance, the two sides disagreed on the number of crashes Carhuff had been involved in on the way to her doctor’s appointment: The city said two, but Cochran told The News Tribune that it was indeed three.

The city also noted that Carhuff had been in custody in the Puyallup Jail for fewer than three hours before she bailed herself out. The original and amended lawsuits said bail was posted roughly eight hours after her arrest, but plaintiffs later reduced that time frame to three-plus hours in a subsequent filing, which Cochran said resulted from further investigation.

“We consider it a very strong case and one that’s very solidly on legal grounds,” he said Tuesday, insisting that there had been “absolutely no basis” for Carhuff’s arrest.

Law enforcement has an obligation to not worsen the health condition of people with whom it interacts, he said, “which is exactly what happened in this situation.”

Beck said the city of Puyallup would remain dedicated to fostering a safe and supportive environment for all of its residents.

“We understand the impact this case has had on the Carhuff family, and we continue to extend our heartfelt sympathies,” he said.

State hit with $12M judgment after rookie trooper arrests stroke victim

 

 It is YOUR RESPONSIBILITY  to have the proper stroke indicators(drooping smile, inability to lift arm). You can't do the slurred speech or dizziness one either.

 What is your stroke hospital misdiagnosis rate on strokes?

Have they prevented these problems from happening?

Auckland man dies from stroke after being misdiagnosed with a migraine

 

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

 

Factors Associated With Misdiagnosis of Acute Stroke in Young Adults

 

Pediatric Stroke Often Misdiagnosed, Treatment Delayed

 

Younger Stroke Patients Often Misdiagnosed

 

 Among 821 consecutive patients admitted to an acute stroke unit, the initial diagnosis of stroke proved incorrect in 108 (13%)

 

The latest here:

State hit with $12M judgment after rookie trooper arrests stroke victim

An Essex County jury has handed down a $11.5 million verdict against a New Jersey State Police trooper who mistook a motorist’s stroke for inebriation and arrested her, delaying medical treatment so long she’s now permanently disabled.

Cheryl Rhines of Jersey City was on her way to work in October 2017 when she began feeling ill and pulled to the shoulder of a highway in Newark, according to the lawsuit her mother later filed.

The responding state trooper, Jennifer Albuja, misinterpreted Rhines’ failure to respond to commands, communicate coherently, or stand upright as intoxication — even though Albuja found no smell or sign of substance use and Rhines had facial drooping and other signs of a stroke, was dressed in business attire at 8 a.m. on a weekday, and had no prior offenses, her lawsuit says.

Albuja failed to get Rhines treatment at a hospital 5 minutes away and instead searched her car and hauled her, handcuffed, to the state police’s Somerville station, delaying treatment by two and half hours, according to the complaint.

A sergeant at the station finally called EMTs, but troopers still left Rhines shackled on the floor even after they determined she was in medical distress, her attorney, Dennis M. Donnelly, told the New Jersey Monitor.

“I don’t think the jury liked that much,” he said.

Donnelly attributed the botched police response to state troopers’ “us-versus-them militaristic mentality,” saying they approach their job as warriors instead of guardians.

“They see everybody in the public as a danger,” Donnelly said. “They treated this woman like she was a criminal when she was helpless.”

Rhines spent nearly two weeks in the hospital and another month in a rehabilitation center, her lawsuit says.

Now 56, she had to leave her job as an event planner and move in with her mother in Nashville because she’s unable to speak or understand what people say to her — a language disorder called global aphasia that’s caused by stroke-related brain damage, Donnelly said.

“Her work life and her abilities to live as a normal human being are over,” he said.

The case went through remediation, but the state’s attorneys refused to resolve the case for more than $1 million — and Rhines’ care expenses had exceeded that, Donnelly said. 

  Jurors decided the case Jan. 29 after a nearly month-long trial — and made a much higher initial finding of $19.1 million to cover Rhines’ future medical care, emotional distress, pain and suffering, and loss of income.

But they blamed 60% of Rhines’ disabilities on the delayed treatment and 40% on the stroke itself, which the trooper didn’t cause. So they reduced their initial award by 40%, following Superior Court Judge Thomas Vena’s guidance.

State police spokespeople did not respond to a request for comment Wednesday. Allison Inserro, a spokeswoman for the state Attorney General’s Office, declined to comment on the case or whether the agency had tweaked policies or training in response.

Donnelly said Albuja, who had been a trooper for only two years when she arrested Rhines, was counseled by her supervisors about the incident — but only after he sued the state on Rhines’ behalf in 2019.

A $11.5 million payout is unusually high for lawsuits filed against the state. In 2023, when the state paid out $121 million to settle 364 claims, only 23 resulted in payouts of over $1 million, according to a recent New Jersey Monitor analysis.

Ind. stroke survivor, considered intoxicated by police, pushes awareness for first responders

 It is YOUR RESPONSIBILITY  to have the proper stroke indicators(drooping smile, inability to lift arm). You can't do the slurred speech or dizziness one either.

 What is your stroke hospital misdiagnosis rate on strokes?

Have they prevented these problems from happening?

Auckland man dies from stroke after being misdiagnosed with a migraine

 

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

 

Factors Associated With Misdiagnosis of Acute Stroke in Young Adults

 

Pediatric Stroke Often Misdiagnosed, Treatment Delayed

 

Younger Stroke Patients Often Misdiagnosed

 

 Among 821 consecutive patients admitted to an acute stroke unit, the initial diagnosis of stroke proved incorrect in 108 (13%)

 

The latest here:

Ind. stroke survivor, considered intoxicated by police, pushes awareness for first responders

VALPARAISO, Ind. — Pat Ingram remembers leaving a Valparaiso Noon Kiwanis meeting held at First Christian Church a little more than a year ago but after that, things got fuzzy.

The Valparaiso woman, 67, has vague memories of someone tapping on the window of her car, which she pulled into a snow bank in the parking lot of a pediatrician’s office a few blocks west of the church. She recalls the cold of metal handcuffs around her wrists and seeing her husband Steve and son Aaron when she was placed in an ambulance.

And Ingram remembers waking up hours later, early the morning of Jan. 18, 2024, at Community Hospital in Munster and subsequently finding out that she had had a stroke and undergone emergency brain surgery.

For the most part, Ingram has recovered from the stroke and has been able to piece together what happened on Jan. 17 of last year. What she and her husband Steve are still unable to understand is why Valparaiso Police officers who responded to the scene spent so much time focusing on whether she was intoxicated without evaluating her for a stroke.

“We would have loved to meet with the city two weeks after this happened,” Steve Ingram said, adding they would have liked an apology and assurance from officials that police were properly trained to recognize the symptoms of a stroke.

Per an email from Patrick Lyp, Valparaiso’s city attorney, all of the city’s police officers receive “general first aid training and basic life support as part of their initial recruitment and basic training instruction,” as well as training on CPR, the use of AEDs and the administration of the opioid antidote naloxone, and other measures.

“Many officers decide to extend their basic medical response knowledge, to include the certifications of Emergency Medical Responder (EMR) or Emergency Medical Technician (EMT). The Valparaiso Police Department currently has 16 EMR-certified officers and three EMT-certified officers,” Lyp said in the email. The training, which ranges from 80 to 160 hours depending on the level of certification, addresses patients suffering from strokes.

“Within the past year, the Valparaiso Police Department has completed refresher training in medical response, to include CPR, AED, and patient assessment,” Lyp said in the email. “Additional officers have been added to the Emergency Medical Response team, as certification in this area is extremely important to the well-being of our community. VPD continues to offer training courses biennially to increase the number of officers who have this expertise.”

Police officers in Indiana are required to have training in Basic Life Support and Basic First Aid as part of their initial training, Lyp said, adding that training is set forth by department and may include specialty training and/or refresher training in those basic skills.

“VPD was the first law enforcement agency in Porter County to incorporate an emergency medical specialty, starting the program in 2020,” Lyp said.

Because Pat Ingram filed a tort claim notice, indicating the possible filing of a lawsuit, Lyp said there were limitations on how the city could respond to media questions.

Attorney Jessica Smithey filed the tort claim notice on June 4.

“Patricia’s No. 1 goal has always been to have a conversation about what occurred and what she went through,” Smithey said, adding she filed a notice of tort claim act “to preserve Patricia’s rights moving forward.”

The Ingrams note that Pat’s car came to rest in a physician’s parking lot and the Valparaiso Medical Center, a facility that’s part of the Northwest Health system, was directly across the street.

“This would have turned out differently if a firefighter had pulled up instead of a cop,” Steve Ingram said.

The Ingrams have lived in Valparaiso since 1987 and have long been active in the community.

“I dislike doing this because I love this city,” Pat Ingram said.

Ingram’s ordeal was captured on police body and squad car cameras; the couple paid the requisite fee of $150 per video, for a total of $750, per the invoice, to the police department to get the footage a week after she had the stroke.

One of those videos is about an hour long and begins as an officer is on his way to the parking lot of Associated Pediatricians at 1111 E. Glendale Boulevard for a call of “a possibly intoxicated subject,” according to the police report, and ends when she is placed in an ambulance headed to Northwest Health-Porter. She was later transported by medical helicopter to Munster .

Throughout much of the video, Pat Ingram speaks so softly that when she speaks at all, she is difficult to hear or understand. She appears confused by instructions she receives from police to lower her car radio and step out of her car, and is unsteady on her feet.

When police transport her to the sallyport at the police station and take her out of the squad car to again try to assess what’s going on, an officer hands her a pad of paper and a pen to write down where she had been before she crashed into the snowbank on but Ingram is unable to hold the objects in her right hand. Sometimes, she sighs and closes her eyes instead of responding to officers.

They ask her numerous times if she’s had a drink; she answers yes then later says no. They ask if she’s on any medication and she says no, unable to communicate that, according to her and her husband, she’s on an assortment of medications for various health issues. Police ask if Pat Ingram is diabetic; again, she is not able to articulate what’s going on.

Police appear genuinely puzzled by her condition. Once they make contact with Steve Ingram and call for an ambulance while they’re in the police department’s sallyport, first responders deduce she’s having a stroke.

Pat Ingram told her husband she was getting groceries ahead of a predicted snowstorm after the Kiwanis meeting, which wrapped up around 1:15 p.m. or so. When Steve Ingram couldn’t reach her on her cellphone after repeated attempts, he called their son.

Widen the Window, Close the Gap: Revolutionizing Stroke Care in Alaska

 

 This is the whole problem in stroke enumerated in one word; 'care' NOT RECOVERY!

YOU have to get involved and chance this failure mindset of 'care' to 100% RECOVERY!

Because of the distances involved it is more important than ever that 100% RECOVERY PROTOCOLS ARE CREATED REGARDLESS OF THE TIME PRESENTED TO THE HOSPITAL!

LEADERS WOULD TACKLE SUCH A JOB! There are NO leaders in stroke; you're screwed!

Widen the Window, Close the Gap: Revolutionizing Stroke Care in Alaska

Key Takeaways

• Alaska's vast geography centralizes stroke care(NOT RECOVERY!) in Anchorage, complicating timely interventions due to long transport times.
• The ASC and RapidAI partnership aims to standardize stroke care(NOT RECOVERY!) across Alaska, leveraging AI technology to improve diagnosis and treatment speed.

SHOW MORE

A partnership between a stroke expert coalition and the technology offered by RapidAI has provided a potential roadmap for improving rural stroke care(NOT RECOVERY!) in remote areas of the United States.

Lucy He, MD, FAANS

Stroke Care(NOT RECOVERY!) in Alaska

Alaska, a state of fewer than 1 million people, is vastly different geographically than any of the other 49 states in America. It is one-fifth the size of the lower 48 states combined, 488 times larger than Rhode Island, 2.5 times larger than Texas, and larger than the next 3 largest states combined. Alaska has 0.93 square miles for each person in the state; by comparison, New York has 0.003 square miles per person.¹

With that in mind, it is safe to say the delivery of clinical care(NOT RECOVERY!), and specifically stroke care(NOT RECOVERY!), is unique and at many times, challenging. It doesn’t help that stroke is the fifth leading cause of death for Americans and its care(NOT RECOVERY!) needs are extremely time-sensitive. Every minute a stroke goes untreated, 1.9 million brain cells die, leading to more than 3 weeks of lost life.²

Much of the stroke care(NOT RECOVERY!) in Alaska is funneled through Anchorage, where nearly half of the state’s residents live.

"Essentially, all large vessel occlusions, medium vessel occlusions, anybody that’s a stroke thermodynamic candidate, they all have to come to Anchorage to get their intervention," Lucy He, MD, FAANS, told NeurologyLive^®. "There’s not the ability and obviously not enough providers to go elsewhere. One of the frustrating things has always been how long it takes to get the patient from the outside hospital to Anchorage for stroke intervention."

He, who moved to Alaska in 2023, serves as a neurosurgeon at Alaska Regional Hospital in Anchorage and as a physician sponsor of the Alaska Stroke Coalition (ASC). The ASC, a recently established nonprofit organization, is made up of a passionate community of hospitals, clinicians, healthcare workers, families, administrators, and emergency services aimed at saving lives and improving stroke care(NOT RECOVERY!) outcomes. He, along with other members of the ASC, were integral pieces in the recent incorporation of a new stroke care(NOT RECOVERY!) system that holds potential in remodeling the landscape of acute stroke management in the state.

In September, the ASC announced its partnership with RapidAI, a technology company, on the “Rapid AK” project, a 3-year initiative focused on advancing health equity for Alaskans affected by stroke. As part of its launch, 6 hospitals across the state were given access to RapidAI’s core stroke imaging and workflow products to help overcome roadblocks associated with rural care(NOT RECOVERY!).² At the time, 4 Alaskan hospitals, including He’s, were already leveraging the technology to improve stroke identification and treatment. Their prior exposure and success with the technology platform led to the advancement of this partnership, which has already and will continue to provide more equitable and timely care(NOT RECOVERY!) for residents across the state.

What RapidAI Offers

David Stoffel, MD, MBA

RapidAI is considered a pioneer in artificial intelligence (AI)-aided imaging diagnostics. The company’s platform utilizes AI and machine learning from more than 14 million scans to analyze medical images, helping clinicians make faster and more accurate decisions.³

A key features of the platform includes automated image analysis of CT and MRI scans to identify critical conditions such as hemorrhages or blockages. The platform also provides real-time decision support, is designed to integrate seamlessly with existing hospital systems and workflows, and also helps with data collection for understanding future trends in stroke care and research.⁴

"It’s been a game-changer in terms of speed and accuracy of diagnosis," David Stoffel, MD, MBA, chief business officer at RapidAI, told NeurologyLive. "This system not only streamlines communication but also gives smaller hospitals access to advanced stroke care(NOT RECOVERY!)without the usual delays."

Dr. He added to Stoffel’s sentiment by noting that the group is seeing early promise. “Stroke treatment timelines are shortening, and it’s allowing us to intervene earlier. In some cases, where minutes matter, RapidAI has been instrumental," she said.

The RapidAI interface allows for visualization and integration with a variety of devices and technologies.

RapidAI’s comprehensive stroke platform includes several different products, including Rapid NCCT, Rapid Hypodensity, Rapid ASPECTS, Rapid CTA, Rapid LVO, Rapid CTP, Rapid MRI, Rapid ICH, Rapid Hyperdensity, Rapid SHD, and AngioFlow by RapidAI. The software is all centrally connected through a phone (and web) app, which provides access to results in minutes from receipt of a scan. Through this app, clinicians can preview source images, have full screen zoom functionality of a scan, and rotate images for axial, coronal, and sagittal views. In addition, the app also has convenient windowing presets, including intracranial, skull, brain, bone, stroke, subdural, and bleed.

In the app, clinicians also have access to a centralized list of patient events, messages, and results. In addition, there is a “Go Notification” that allows for quicker coordination of stroke teams for critical cases. Clinicians may also use in-app calling for quicker communication, as well as integrate electronic health records, which can automatically retrieve the most current patient clinical data. Above all, as a patient is being triaged through RapidAI, the app will build a summary of their journey from prehospital routing, emergency room triage, imaging diagnostics, communication and workflow activation, and outcomes.⁵

RapidAI's interface displayed on a tablet.

Public health and cost consequences of time delays to stroke treatments, such as endovascular thrombectomy, can be burdensome for a healthcare system. This is especially true in a state like Alaska, where there is nearly 5 times the amount of shoreline as there is coastline. Since its origin, RapidAI software has been involved in more than 400 published pieces of research, some testing its specific effects on certain stroke outcomes while others used it as a tool to conduct research. One notable 2021 study showed that the use of the Rapid Mobile App resulted in a 33-minute reduction in door to groin puncture time (P = .02), 35-minute reduction in door to first pass time (P = .02), and a 37-minute reduction in door to recanalization time (P = .02) in univariate analyses when compared with patients treated pre-app. That study, published in the Journal of NeuroInterventional Surgery, also showed that patients who used the Rapid app had significantly lower National Institutes of Health Stroke Scale scores after procedure and at discharge (P = .03).⁶

"One of our guiding principles is that we want a patient to be able to walk into any hospital, whether it’s in rural Alaska or downtown Chicago, and receive the best care(NOT RECOVERY!) humanly possible," Stoffel added. "That means being connected with the experts and having access to the best type of decision-making possible. We really feel that RapidAI is the vehicle that can deliver that at equal access for healthcare for anyone across the country."

The Partnership

Kevin Myrick, RN

The foundation of the partnership between the ASC and RapidAI was laid during discussion between the ASC’s leadership and stakeholders familiar with successful stroke care(NOT RECOVERY!) models, particularly the Hawaii Stroke Coalition. Kevin Myrick, RN, a stroke coordinator who relocated from Hawaii, took charge of establishing the ASC. Myrick, who now serves as the director of Trauma and Stroke at the Alaska Regional Hospital, quickly filed the necessary paperwork, marking the coalition’s official formulation.

"When I started talking to Rapid about what other locations were doing, I learned that a statewide stroke coalition in Hawaii had gotten a grant to implement similar technology," He noted. "This highlighted the need for funding to make something like that happen here in Alaska."

To Myrick, Hawaii and Alaska aren’t that different. The remoteness of both states, the lack of access to care(NOT RECOVERY!) outside of the metropolitan hubs, and the respect for the dedicated lands of preserved groups across generations are just a few of the parallels drawn. When he lived in Hawaii, he was a part of building the Hawaii Stroke Coalition in a state where stroke care(NOT RECOVERY!) ranked towards the bottom nationally.

Recognizing the needs and fragmented healthcare system in Alaska, with numerous hospitals acting independent of one another, the coalition aimed to create a unified approach to stroke care(NOT RECOVERY!). The group moved quickly, forming in a little over 2 weeks. At the time, Myrick had reached out to stroke coordinators at various hospitals, looking to foster collaboration among them to discuss stroke care improvements statewide.

"When we first heard about RapidAI, there was some skepticism. But after seeing how it improves image-sharing and decision-making speed, it was clear this could revolutionize how we handle stroke care(NOT RECOVERY!), especially in remote areas."

As the coalition explored implementing RapidAI’s technology, they faced financial hurdles, as smaller hospitals were reluctant to invest without guaranteed returns on their investment. Then, the coalition identified external funding from a private family foundation, which enabled them to leverage RapidAI’s technology for 3 years.

A helicopter used to transport patients from remote areas to stroke centers.

Myrick added, "Alaska is unique in terms of healthcare delivery. The vast distances and limited resources mean we need to be creative. RapidAI helps bridge that gap by offering remote hospitals the tools they need to provide first-rate care(NOT RECOVERY!)."

In exchange for the technology, participating hospitals will use the “Get With The Guidelines” database for patients with stroke, ensuring standardized data collection and quality improvement. Get With The Guidelines is a quality improvement initiative by the American Heart Association and American Stroke Association aimed at enhancing care(NOT RECOVERY!) for cardiac and stroke patients. It is based on evidence and guidelines for secondary prevention, helping healthcare providers deliver consistent, guideline-driven treatment.

Data collection was a critical selling point to the partnership, considering there were little to no data captured in the state prior to the technology. At the time he arrived in Alaska, Myrick said that only “3 of the 17 hospitals put data into the registry. So, it looked like Alaska was a pretty healthy state, if not the healthiest state, but we know that’s not true. We know access to care(NOT RECOVERY!) is difficult. In Hawaii, we measured transfers by minutes. In Alaska, we measured transfers by hours."

Integrating Rapid’s Tools Into Clinical Care

Amber Simonetti, RN

As with most new opportunities in life, there is a period of integration and adjustment. The same can be said for the new RapidAI system in a state where, in certain parts, patients would be transferred to nearby hospitals via dogsled or snow machine. It may sound farfetched, but it’s true.

"We’ve seen great momentum in bringing RapidAI into hospitals across Alaska," Amber Simonetti, RN, a chest pain and stroke coordinator at Mat-Su Regional Medical Center in Palmer, Alaska, told NeurologyLive. "The biggest hurdle was helping everyone understand that this technology could work on equipment that may not be state-of-the-art. Each hospital setup is different, so adjustments to the workflow and a lot of trial and error go into figuring out the most efficient process. It’s just a matter of adapting RapidAI to what each hospital already has in place."

The ability to tinker and adjust the RapidAI system to fit the needs of each hospital has been critical for its implementation. For Simonetti and many others, being able to modify the system over time, instead of a fast, all-or-nothing approach, has allowed for more natural adoption and more stress-free, long-term buy in.

"For us, learning how to marry this technology with your clinical observations of your patient, and not relying on all one or all the other [is key]," she added. "We also need to recognize that we need to break down these silos of waiting for each next step before we move along in the process, and understanding that you can run things in parallel, which will improve our patient care(NOT RECOVERY!)."

Building a New Future of Hope

A patient being transported from ambulance to plane for travel to a stroke center.

The partnership between the ASC and RapidAI has infused new life into the stroke system in Alaska, with a promising future ahead. Going forward, the partnership allows for a push for standardization across Alaska’s healthcare facilities, ensuring uniformity in stroke care(NOT RECOVERY!) and reducing the cognitive and physical burden on healthcare providers.

"Fundamentally, what we’re trying to do—and we’re just starting to get there—is to protocolize and automate what happens with stroke patients across the state," He said. "Even if timing or telestroke involvement differs slightly by facility, the goal is for everyone to get the same images, engage early, and act consistently. This reduces the manual labor and fatigue that comes with these cases."

Through RapidAI, the state will be able to generate and leverage more consistent stroke data, an afterthought issue for several years. In addition to the general advantages data collection brings, the hope is that this software may help support clinicians who are seeking federal or state research grants. Above all, the partnership continues to help raise awareness about strokes and allows the ASC to refine selection criteria for interventions.

"Just because we live here doesn’t give us an excuse that we shouldn’t perform excellently," she added. "In fact, I think it provides more of a drive that we should be doing better, because we want to make sure that we give people the best chance of returning back to their baseline in their homes, instead of ending up in a long term care facility."

As the system becomes more widely integrated across the state, the vision of transitioning from reactive to preventive stroke care becomes clearer.

"Eventually we’ll reach a steady state for inpatient stroke cases,” He added. "Then the question becomes: 'What can we do to outpatient to reduce strokes overall?' In an ideal world, I’d love to see fewer stroke interventions because people are having fewer strokes, but that’s a broader issue we need to tackle after we stabilize inpatient protocols and technology."

The state has already begun to see the early progress and success of RapidAI, but for many, the long-term impact lies within the shift in mindset of the entire healthcare system. Simonetti added, “It’s about creating a culture of preparedness and precision."

Stroke patients could face 'four-hour round trip' UK

 Which means YOU have to demand a plan B; 100% recovery protocols regardless of time since stroke. YOUR RESPONSIBILITY; your government and stroke medical 'professionals' will not do one damn thing. So it is all up to you to get plan B accomplished!

Stroke patients could face 'four-hour round trip'

An MP said patients in his constituency could face "major difficulties" if proposed changes to stroke care services go ahead.

Sir John Whittingdale, the MP for Maldon, said proposals to close St Peter's Hospital in the town and move beds to Brentwood could leave his constituents facing long journeys to access rehabilitation.

The plans could also leave stroke survivors in south Essex needing to travel to Brentwood, which the patient group Healthwatch Southend said would be a four-hour round trip on public transport.

Dr Matt Sweeting, executive medical director of NHS Mid and South Essex, said he and his team were reviewing all the feedback received during a recent public consultation.

The two options offered during the consultation included running a 50-bed stroke rehabilitation unit in Brentwood which would serve the whole of mid and south Essex.

The second involved a smaller ward in Brentwood alongside a centre in Rochford.

Kate Bradbrook/BBC

Sir John Whittingdale said he planned to meet a government minister to discuss the proposed closure of St Peter's Hospital

Sir John said people living in villages like Southminster and Tillingham, who already drive about 30 minutes to Maldon, could be among the hardest hit.

"If people then have to travel to Brentwood instead, you're looking at double that amount of time and that's if people have cars, but a lot of people rely on public transport," he said.

Conservative MP Sir John previously debated the closure of St Peter's Hospital in Parliament and is due to meet local NHS leaders and the Department of Health and Social Care with Witham MP Dame Priti Patel.

Owen Richards, chief officer at Healthwatch Southend, said he was unable to support either of the proposed options.

"Getting to Brentwood from Southend is far from easy if you use public transport," he said.

"One of our volunteers tested the journey, which took two hours each way and could have cost up to £28."

Four out of five respondents rejected both options with objections including concerns about extra travel time and costs for patients, families, and carers.

There was marginally more support from Southend residents for the second option.

Dr Sweeting said: "While no decisions have been made at this stage, I want to reassure people that our priority is to ensure that any changes we consider are in the best interests of all patients."

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Comparative study of venous thromboembolic prophylaxis strategies in hemorrhagic stroke: a systematic review and network meta-analysis

 With this uncertainty, it is YOUR RESPONSIBILITY NOT TO HAVE THIS TYPE OF STROKE! I bet you can be assured your doctor and hospital are not pushing for research to solve this problem.

Do you prefer your  doctor and hospital incompetence NOT KNOWING? OR NOT DOING?

Comparative study of venous thromboembolic prophylaxis strategies in hemorrhagic stroke: a systematic review and network meta-analysis

Giorgio Maraziti https://orcid.org/0000-0002-9252-1297, Maria Giulia Mosconi https://orcid.org/0000-0002-0456-9160 mariagiulia98581@yahoo.it, and Maurizio PaciaroniView all authors and affiliations

Accepted Manuscripts

https://doi.org/10.1177/17474930241248542

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Abstract

Background:

Venous thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are frequent complications in patients with intracerebral hemorrhage (ICH). Various prophylactic strategies have been employed to mitigate this risk, such as heparin, intermittent pneumatic compression (IPC), and graduated compression stockings (GCS). The optimal thromboembolic prophylaxis approach remains uncertain due to the lack of randomized controlled trials (RCTs) comparing all interventions.

Aims:

We conducted a network meta-analysis and meta-analysis to systematically review and synthesize evidence from RCTs and non-randomized studies on the efficacy and safety of thromboembolic prophylaxis strategies in hospitalized ICH patients.

Summary of findings:

Our study followed registered protocol (PROSPERO CRD42023489217) and PRISMA guidelines incorporating the extension for network meta-analyses. Search for eligible studies was performed up to December 2023. We considered the occurrence of DVT, PE, hematoma expansion (HE), and all-cause mortality as outcome measures. A total of 16 studies, including 7 RCTs and 9 non-randomized studies, were included in the analysis. Network meta-analysis revealed that IPC demonstrated the highest efficacy in reducing DVT incidence (OR 0.30, 95% CI 0.08-1.16), particularly considering only RCTs (OR 0.33, 95% CI 0.16-0.67). GCS showed the highest safety profile for HE (OR 0.67, 95% CI 0.14-3.13), but without efficacy. Chemoprophylaxis did not reduce the risk of PE events (OR 1.10, 95% CI 0.17-7.19) with a higher occurrence of HE (OR 1.33, 95% CI 0.60-2.96), but the differences were not significant.

Conclusion:

Our study supports the use of IPC as the primary thromboembolic prophylaxis measure in ICH patients. Further research, including head-to-head RCTs, is needed to strengthen the evidence base and optimize clinical decision-making for thromboembolic prophylaxis in this vulnerable patient population.

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Endovascular treatment of acute ischemic stroke patients with tandem lesions: antegrade versus retrograde approach

 So your doctor doesn't know what to do with this type of stroke. Your responsibility is either to not have this stroke or get your doctor to initiate research to solve the problem. Is your doctor competent enough to get research started?

Endovascular treatment of acute ischemic stroke patients with tandem lesions: antegrade versus retrograde approach 

Milagros Galecio-Castillo MD

,

Michael Abraham MD

,

Mudassir Farooqui MD, MPH

,

Ameer E. Hassan DO

,

Afshin A. Divani PhD

,

Mouhammad A. Jumaa MD

,

Marc Ribo MD, PhD

,

Nils Petersen MD

,

Johanna Fifi

 MD

,

Waldo R. Guerrer MD

,

Amer M. Malik MD, MBA

,

James E. Siegler MD

,

Thanh N. Nguyen MD

,

Sunil A. Sheth MD

,

Albert J. Yoo MD, PhD

,

Guillermo Linares MD

,

Nazli Janjua MD

,

Darko Quispe-Orozco MD

,

Abid Qureshi MD

,

Wondwossen G. Tekle MD

,

Asad Ikram MD

,

Syed F. Zaidi MD

,

Cynthia B. Zevallos MD

,

Belen Taborda MD

,

Alex Devarajan BS

,

Linda Zhang BS

,

Mohamad Abdalkader MD

,

Sergio Salazar-Marioni MD

,

Jazba Soomro MD

,

Weston Gordon MD

,

Aaron Rodriguez-Calienes MD

,

Juan Vivanco-Suarez MD

,

Katrina Woolfolk RN

,

Maxim Mokin MD

,

Dileep R. Yavagal MD

, and

Santiago Ortega-Gutierrez MD, MSc

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Publication Date:

29 Dec 2023

Page Range:

1–10

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DOI link:

https://doi.org/10.3171/2023.10.JNS231702

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• ABSTRACT
• SUPPLEMENTARY MATERIALS

OBJECTIVE

The optimal technique for treating tandem lesions (TLs) with endovascular therapy is debatable. The authors evaluated the functional, safety, and procedural outcomes of different approaches in a multicenter study.

METHODS

Anterior circulation TL patients treated from January 2015 to December 2020 were divided on the basis of antegrade versus retrograde approach and included. The evaluated outcomes were favorable modified Rankin Scale (mRS) score (mRS score 0–2) at 3 months, ordinal shift in mRS score, successful recanalization, excellent recanalization, first-pass effect (FPE), time from groin puncture to successful recanalization, symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

RESULTS

Among 691 patients treated at 16 centers, 286 patients (174 antegrade and 112 retrograde approach patients) with acute stenting were included in the final analysis. There were no significant differences in mRS score 0–2 at 90 days (52.2% vs 50.0%, adjusted odds ratio [aOR] 0.83, 95% CI 0.42–1.56, p = 0.54), favorable shift in 90-day mRS score (aOR 1.03, 95% CI 0.66–1.29, p = 0.11), sICH (4.0% vs 4.5%, aOR 0.64, 95% CI 0.24–1.51, p = 0.45), successful recanalization (89.4% vs 93%, aOR 0.49, 95% CI 0.19–1.28, p = 0.19), excellent recanalization (51.4% vs 58.9%, aOR 0.59, 95% CI 0.40–1.07, p = 0.09), FPE (58.3% vs 69.7%, aOR 0.62, 95% CI 0.44–1.15, p = 0.21), and mortality at 90 days (16.6% vs 14.0%, aOR 0.94, 95% CI 0.35–2.44, p = 0.81) between the groups. The median (interquartile range) groin puncture to recanalization time was significantly longer in the antegrade group (59 [43–90] minutes vs 49 [35–73] minutes, p = 0.036).

CONCLUSIONS

The retrograde approach was associated with faster recanalization times with a similar functional and safety profile when compared with the antegrade approach in patients with acute ischemic stroke with TL.

ABBREVIATIONS

AIS = acute ischemic volume; aOR = adjusted odds ratio; ASPECTS = Alberta Stroke Program Early Computed Tomography Score; ENI = early neurological improvement; EVT = endovascular therapy; FPE = first-pass effect; ICA = internal carotid artery; IQR = interquartile range; IVT = intravenous thrombolysis; LVO = large vessel occlusion; mRS = modified Rankin Scale; mTICI = modified Thrombolysis in Cerebral Infarction; NIHSS = National Institutes of Health Stroke Scale; SEIMLESS = simultaneous extracranial, intracranial management of tandem lesions in stroke; sICH = symptomatic intracranial hemorrhage; TL = tandem lesion.