High Variability in Neuronal Loss Time Is Brain, Requantified

We still don't know the rate of neuronal death during the neuronal cascade of death or the hemorrhage cascade of death. If it is not quantified the stroke medical world will ignore that problem. Out of sight, out of mind. 

High Variability in Neuronal Loss - Time Is Brain, Requantified

Shashvat M. Desai

,

Marcelo Rocha

,

Tudor G. Jovin

,

Ashutosh P. Jadhav

Originally published18 Dec 2018https://doi.org/10.1161/STROKEAHA.118.023499Stroke. 2018;50:34–37

Abstract

Background and Purpose—

In the setting of acute ischemic stroke because of large-vessel occlusion (LVO) there is progressive loss of brain tissue which occurs in a time-dependent fashion previously quantified to be ≈1.9 million neurons per minute. However, this number represents an average and accumulating evidence suggests large individual variation. In this study, we aim to quantify the distribution and range in the rate of loss brain tissue across the entire spectrum of clinical phenotypes of anterior circulation LVO strokes encountered in clinical practice.

Methods—

Retrospective review of a prospectively acquired database of consecutive patients with anterior circulation stroke because of proximal LVO and appropriate ischemic core imaging was performed. Ischemic core volume was measured using automated software processing and time from last known well to imaging was recorded. Applying previously published methodology for brain loss quantification, we computed rate of brain tissue elements loss in proximal LVO stroke patients.

Results—

We studied 415 patients with internal carotid artery or middle cerebral artery (M1 segment) occlusion. Mean ischemic core volume was 50.4 mL and mean time to imaging from time from last known well (TLKW) was 8.7 hours, which is similar to previously published data, translates into a mean loss per minute of 2.03 million neurons, 14.8 billion synapses, and 12.8 km of myelinated fibers. However, the distribution of neuron loss was highly variable, ranging from <35 000 to >27 million cells per minute.

Conclusions—

Widely spread rates of infarct growth are observed in acute ischemic stroke because of proximal LVO with rate of neuron loss per minute ranging from <35 000 per minute in slow progressors to >27 million per minute in fast progressors, with a mean and median of 2 million and 0.9 million, respectively.

Stroke unit care, inpatient rehabilitation and early supported discharge

Should be titled; 'Get the survivors out of our hair faster so we don't have to look at our failure to get them fully recovered'. Out of sight, out of mind.
http://www.clinmed.rcpjournal.org/content/17/2/173.short

1. Helen Rodgers, professor of stroke care^A⇑ and
2. Chris Price, senior lecturer in stroke medicine^B

+ Author Affiliations

1. ^ANewcastle University and honorary consultant stroke physician, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
2. ^BNewcastle University and honorary consultant stroke physician, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK

1. Address for correspondence: Professor Helen Rodgers, Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne NE2 4AE, UK. Email: helen.rodgers@newcastle.ac.uk

ABSTRACT

Stroke units reduce death and disability through the provision of specialist multidisciplinary care for diagnosis, emergency treatments, normalisation of homeostasis, prevention of complications, rehabilitation and secondary prevention. All stroke patients can benefit from provision of high-quality basic medical care and some need high impact specific treatments, such as thrombolysis, that are often time dependent. A standard patient pathway should include assessment of neurological impairment, vascular risk factors, swallowing, fluid balance and nutrition, cognitive function, communication, mood disorders, continence, activities of daily living and rehabilitation goals. Good communication and shared decision making with patients and their families are key to high-quality stroke care. Patients with mild or moderate disability, who are medically stable, can continue rehabilitation at home with early supported discharge teams rather than needing a prolonged stay in hospital. National clinical guidelines and prospective audits are integral to monitoring and developing stroke services in the UK.