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Apple annuncia il nuovo iPad che pensa alla scuola: mila app a misura di classe Il video della settimana. Apple proposes new set of emoji aimed at representing people with to ban all bitcoin or cryptocurrency ads from June. Gioca con Koogeek e vinci un Apple HomePod oltre a tanti sconti sugli accessori.

Apple planeja bater de frente com gigantes do streaming e contrata nomes consagrados. Apple confirma que existe uma forma de desativar o ID de Rosto em caso de assalto. For Educational Purposes! Mi occupo di corsi e consulenze in ambito impaginazione grafica sviluppo web Sono Adobe Certified Instructor e Apple Certified Associate.

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Apple refocuses on the classroom looking to grab market share back from Google Microsoft. Start your day with a glass of all-natural cold-pressed juice made with your favorite fruits vegetables or nuts Raw nutrients are easily absorbed into your body giving you energy throughout the day Add a banana or avocado if you prefer a smoothie Add an apple or pear when juicing fibrous vegetables Add some ginger for an immune-boosting kick The possibilities are endless.

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Chain length 16inch. Presentation boxed Cat. Necklet length 16 inch Presentation boxed. Chain length 18 inch. Presentation boxed.

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A Computed tomography CT perfusion imaging showing an area of decreased cerebral blood flow matching the arterial territory of the right middle cerebral artery MCA. C Follow-up head CT showing interval development of a large early subacute ischemic infarct with midline shift.

Admission to the designated neurointensive care unit is indicated, with close monitoring by the neurosurgery team should this patient require hemicraniectomy. A patient was brought to the hospital after the family found him unresponsive at home. The patient was very difficult to arouse. While in the ED, he had several episodes of emesis and fluctuating degree of mild bilateral weakness was noted on exam. A Computed tomography angiography and B digital subtraction angiography, left vertebral artery injection showing occlusion of the basilar artery at its very distal segment arrow.

The clinical presentation can be quite variable and may include one or more of the following: altered level of consciousness, behavioral abnormalities, diplopia, gaze palsy, and pupillary abnormalities. Mortality in the United States, NCHS data brief, no Talwalkar A, Sayeedha U. Trends in emergency department visits for ischemic stroke and transient ischemic attack: United States, — Transient ischemic attack—Proposal for a new definition.

New Engl J Med. Prevalence and knowledge of transient ischemic attack among US adults. Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack. Can Med Assoc J. Validation and refinement of scores to predict very early stroke risk after transient ischemic attack. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare.

Saver J. Time is brain—quantified. Fisher CM. Lacunes: Small, deep cerebral infarcts. Cholesterol embolism as a cause of transient ischemic attacks and cerebral infarction. Clinical presentation and frequency of potential sources of embolism in acute ischemic stroke patients: the experience of the Rome Acute Stroke Registry.

Cerebrovascular Dis. Embolic stroke of undetermined source. Mechanisms of sporadic cerebral small vessel disease: insights from neuroimaging. Lancet Neurol. A population-based study of the incidence and prognosis of lacunar stroke. Testing the validity of the lacunar hypothesis: the Northern Manhattan Stroke Study experience. Clinical-computed tomographic correlations of lacunar infarction in the Stroke Data Bank.

Caplan L. Basic pathology, anatomy, and pathophysiology of stroke. Philadelphia: Saunders Elsevier; Hemispheric differences in ischemic stroke: is left-hemisphere stroke more common? J Clin Neurol. Geschwind N.

The apraxias: neural mechanisms of disorders of learned movement: the anatomical organization of the language areas and motor systems of the human brain clarifies apraxic disorders and throws new light on cerebral dominance.

Am Sci. Microsurgical anatomy of the middle cerebral artery. J Neurosurg. Foix C, Levy M. Les ramollissements sylviens. Revue Neurologique ;11 Arch Neurol. Stroke syndromes. New York: Cambridge University Press; Aphasia in acute stroke. A deficit of spatial remapping in constructional apraxia after right- hemisphere stroke. Brain ;— Carotid plaques increase the risk of stroke and subtypes of cerebral infarction in asymptomatic elderly: the Rotterdam study.

Fischer E. Zentralbl Neurochir. Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol. Stroke or transient ischemic attacks with basilar artery stenosis or occlusion: clinical patterns and outcome.

Anterior choroidal artery-territory infarction: Report of cases and review. Cerebellar infarction: clinical and neuroimaging analysis in patients: the Tohoku Cerebellar Infarction Study Group. Amarenco P, Hauw JJ. Cerebellar infarction in the territory of the anterior and inferior cerebellar artery: a clinicopathological study of 20 cases.

Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Controversies in cardioembolic stroke. Curr Treat Option N. The risk of subarachnoid and intracerebral hemorrhages in blacks as compared with whites.

Incidence of spontaneous intracerebral hemorrhage among Hispanics and non-Hispanic whites. Incidence of stroke in Shibata, Japan: — Management patterns and health care use after intracerebral hemorrhage.

Cerebrovasc Dis. Long-term mortality after intracerebral hemorrhage. Long term survival after primary intracerebral haemorrhage: a retrospective population based study.

J Neurol Neurosur Ps. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. Stroke volume—outcomes relationship 3. Lessons from the acute trauma model 3.

Development of modern stroke systems of care: the Brain Attack Coalition 5. Telestroke 5. Stroke system levels of care 6. Triaging the stroke patient 8. Clinical cases Case 2. Stroke is the fifth leading cause of death in the United States and accounts for around 1 in every 20 deaths in the United States.

For every minute of ischemia, approximately 2 million neurons are irreversibly lost. In , after the Food and Drug Administration approval, intravenous IV tissue plasminogen activator alteplase, tPA was established as the standard of care therapy for patients presenting with acute ischemic stroke within three hours from symptom onset. However, large vessel occlusions or severe strokes only account for a small minority of patients presenting with ischemic stroke 24 per , person-years.

How do we ensure that individuals in rural communities without access to large stroke centers continue to receive state-of-the-art stroke care as rapidly as possible?

Given the time sensitivity of stroke, is it better to have a greater number of less experienced lower patient volume hospitals or triage to a smaller number of hospitals with greater volume and expertise? This chapter will serve to outline such stroke systems of care and EMS providers and Emergency Department ED physicians and personnel in evaluating, managing, and triaging patients with different types stroke Figure 2.

We will discuss the reasoning behind the development of stroke centers and provide example cases of patients best managed at the various hospital subtypes. Figure 2. Question 2. There is robust literature demonstrating a direct relationship between cerebrovascular and endovascular patient volume and favorable patient outcomes, both for individual practitioners and for institutions.

In fact, mortality was significantly lower for patients transferred to high-volume centers for thrombectomy compared to those directly admitted to low- volume centers, suggesting the benefit of treatment at a high-volume center may outweigh any detrimental consequences related to transfer delays. Studies evaluating outcomes at various stroke centers based on volume have strongly suggested that lower-volume stroke centers have lower rates of good outcomes when compared to higher- volume centers.

It is worth noting that the recent randomized controlled trials that demonstrated a benefit for EVT over medical management were conducted at high-volume stroke centers. This fact was underscored in an editorial authored by several of the principle investigators that emphasized that the results were only generalizable to other established, efficient stroke systems staffed with highly experienced neurointerventionists, neurologists, intensivists, and supporting staff.

Therefore, increasing the numbers of low- volume centers to help improve stroke care access, rather than supporting high-volume regionalized systems of care, may potentially be harmful to patients as it may result in a higher percentage of patients with poor outcomes.

Following this call to arms, there was an expansion of ambulance and helicopter services for trauma patients, revamping of emergency medical care systems, and the emergence of statewide trauma systems.

In , the American Medical Association detailed a hierarchical classification scheme for hospitals based on their size, expertise, and ability to care for trauma patients. Later, trauma hospitals became required to participate in regionalized trauma systems and became regulated under certain requirements proposed by the Committee on Trauma. The emergence and success of trauma systems is largely related to governmental funding and supportive legislation leading to a more structured organization and implementation of detailed systems of care.

Trauma systems of care focus on the principle of timely and appropriate patient triage to facilities that are capable of managing traumatic injuries based on the severity of the injury.

In the acute trauma model, trauma patients may be stabilized at lower levels of care and, if the severity of trauma is low, remain at these centers for treatment. Those patients with more severe injuries may either be transported directly to tertiary care centers or may be stabilized at local facilities and then transported to higher-level facilities based on injury severity and complexity.

There is robust evidence supporting the importance of regionalized trauma systems in reducing mortality and improving outcomes following traumatic injury. Field assessment of patients includes evaluation of alertness, vital signs, anatomic factors of injury, mechanism of injury, and individual patient considerations pregnancy, burns, age.

These standardized classifications influence the immediate management of patients and direct transfer by EMS to the appropriate level of care. Although the finite time for large vessel occlusions has recently been expanded by randomized controlled trials showing benefit beyond 6 hours, there is a well-described relationship between timely treatment and good outcome.

Early recognition in the field is therefore critical Case 2. For stroke care to successfully follow a similar model, an organized system of triage revolving around standardized assessment scales must be organized and implemented to guide triage to proper levels of stroke care.

Another important consideration includes the sequelae of stroke, which may require higher levels of care following acute stabilization. For instance, complications following a stroke such as hemorrhagic conversion,. This is largely due to its development in an uncoordinated manner lacking systemic oversight and control. The current model may lead to patients getting inappropriate care due to lack of expertise in local hospitals or due to inappropriate and arbitrary triage.

The establishment and implementation of stroke care requires that governing bodies develop true regionalized care models, proven triage assessment tools, effective means of transportation, and a hierarchal system of care to manage both the acute stroke as well as sequelae from the insult. Fortunately, regionalized care is rapidly evolving through expansion of telestroke, the development of advanced certification for hospitals, and with improved guidelines for stroke care.

Some states also provide local stroke certification programs. Understanding the need for a hierarchical organization to facilitate stroke patient care, the Brain Attack Coalition BAC provided recommendations for the establishment of primary stroke centers PSCs in The BAC itself encompasses of a group of various professional, voluntary, and governmental organizations that work to set direction, advance knowledge, and communicate the best practices to prevent and treat stroke.

The coalition contains members that represent groups like the AHA and the Centers for Disease Control, as well as professionals in the fields of neurosurgery, neurology, diagnostic and interventional neuroradiology, and emergency medicine. Certification for each level of stroke care can be achieved via independent groups that offer certification programs, including the Joint Commission. For example, laws may require that stroke patients be taken to a certain PSC within a certain distance, providing regulations on where and when to transport patients.

In a more tangible example, state legislation has already shown to improve the general availability of stroke centers and leaves room for the standardization of care, which might help to organize transport to and treatment at PSCs. Recommendations from the BAC are derived from evidence-based literature and strive to improve the.

In the future, analysis of outcome and performance metrics may be used to compare individual centers and level of certification to optimize patient triage and management. Two frequent barriers to stroke care include geographic hurdles and absence of around the clock readily available acute stroke expertise. Hospitals with no alteplase use were more likely to contain less than 95 beds, be located in a rural setting, and specifically be located in the South or Midwest.

Forty percent of the US population lives in a county that treated less than 2. In the wake of widespread alteplase use, the late s and early s brought utilization of telestroke. Patients can present via their own vehicle or via EMS in which prehospital notification may occur. On arrival, the patient is evaluated by the ED provider and an acute stroke is suspected with time of onset within the window for acute intervention.

A computed tomography CT scan is performed, and a telestroke consultation is called. A recommendation is then made to the ED provider. The first is a distributed model where care is delivered by physicians at multiple distant locations. These physicians are typically employed on a contractual basis, and patients treated who require transfer typically move to an unrelated, geographically close, tertiary care center. The second model is the hub and spoke model in which the hub is typically an academic medical center and the spoke sites are hospitals in the region.

If transfer results from these consultations, patients are typically transferred to the hub site. Collectively, the BAC created a model to provide an organized and improved methodology for caring for stroke patients everywhere. The highlights of each level of qualification include:. Throughout this section, designations of the three types of stroke centers will be outlined for comparison using the elements previously listed.

Importantly, all hospitals with certification are required to collect and report performance metrics outcomes, complications, etc. In light of this, the BAC created the ASRH designation, which has the capabilities to diagnose, stabilize, treat with alteplase utilizing telestroke expertise, and transfer stroke patients that are not within 60 minutes of a PSC.

When directly compared to a PSC Box 2. Certification must be performed at least every two to three years, but with annual data collection and analysis. Recommendations for a PSC can be examined in Box 2. The main differences between a PSC and CSC center around the amount of physician specialists available and the imaging modalities utilized in the hospital Case 2. The BAC mandates that PSC certification requires a certifying body be administratively and financially independent of the hospital; inclusion of an assessment of infrastructure, personnel, protocols, and programs; a site visit at least every 2 years; and a well-defined and quantifiable disease performance measures developed and assessed on a regular basis with mandatory reporting to a stroke data registry.

The level of care provided requires highly trained specialty physicians and complex treatment programs, such as neurosurgery, neurocritical care, and neurointerventional physicians. These are all vital in the management of large ischemic and hemorrhagic strokes Cases 2. With the advancement of stroke levels of care, more data will become available to determine the efficacy of certain requirements of a CSC and can be adjusted as these come forth.

New performance measures for a CSC are currently in development. The Joint Commission has requested comment on minimum thrombectomy volume requirements. Currently, The Joint Commission has suggested TSC certification eligibility mandates that an institution perform a minimum of 12 thrombectomy procedures during the previous year, or 24 procedures over the last 2 years.

Many strokes are identified by EMS in the prehospital setting. When a potential acute stroke is identified the patient will ideally be taken to the nearest hospital that has the capabilities to administer thrombolytic therapy, unless the patient is medically unstable. After an evaluation by a stroke expert, which may occur in person, remotely via telephone consultation, or remotely via telestroke, the patient may need to be transferred to a higher level of care CSC given the outcome of the consultation.

Circumstances that would warrant transfer include but are not limited to administration of IV alteplase which would occur prior to transfer , need for evaluation for EVT, need for neurointensive care unit, need for neurosurgical evaluation, or may be dependent on imaging findings or stroke severity.

Concern for a large vessel occlusion would warrant further evaluation for EVT. An year-old female with hyperlipidemia was shopping with her daughter when she became acutely hemiplegic. She was able to speak but had neglect and gaze deviation. Non- contrast CT head Figure 2. The Alberta stroke program early CT score is 9. B Computed tomography perfusion, mean transit time MTT demonstrating slowed mean transit time in the right internal carotid artery distribution.

C Digital subtraction angiography DSA , antero-posterior view demonstrating complete large vessel occlusion of the right supraclinoid internal carotid artery arrow. D DSA, antero-posterior view demonstrating complete recanalization of the right internal carotid artery thromboembolism. This patient underwent emergent mechanical thrombectomy with complete revascularization 3 hours, 4 minutes from symptom onset.

Figures 2. The BAC and Joint Commission have designated advanced certification for hospitals that meet appropriate criteria, which allows for appropriate triage based on stroke severity. Those patients with large vessel occlusions or large territory infarcts require transfer to CSCs, where neurointerventional, neurocritical care, and neurosurgical specialists are present.

A year-old female with a history of hypertension and hyperlipidemia called EMS after noticing right-sided weakness and slurred speech. The patient arrived 4 hours from onset of symptoms and a CT head showed no hemorrhage.

The ED paged their Telestroke partners, and a stroke neurologist was able to review the imaging and examine the patient over the next 7 minutes. IV alteplase was given at 4 hours and 20 minutes, and the patient was admitted to the PSC for the rest of her stroke workup. CT angiography showed no large vessel occlusion nor carotid stenosis. The patient spent the night in the medical intensive care unit and was discharged home on aspirin after 4 days with 1-week follow-up with her primary physician for optimization of blood pressure control and follow-up in 2 weeks with stroke neurology.

However, not all strokes are equal, as many patients with minor strokes do not require transfer to tertiary care facilities, while those with large vessel occlusions require urgent transfer to facilities capable of performing rescue endovascular therapies or management of malignant intracranial hypertension. Telestroke has also been critical in providing expertise to hospitals receiving acute stroke patients that do not have in-house neurologists or neurosurgeons. Ultimately, the strengthening of regionalized, evidence-based and protocol-driven stroke care systems will be necessary to further reduce mortality and improve outcomes among stroke patients in the future.

Case 2. A year-old female with past medical history of hypertension and controlled diabetes mellitus was found unresponsive at home. She had last been seen by her family 3 hours earlier.

She was transferred to a CSC for emergency neurosurgical evaluation. There is 8 mm of midline shift with brainstem compression. This patient underwent a craniotomy and evacuation of hematoma. Heart disease and stroke statistics update: a report from the American Heart Association. Saver JL. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. Thrombolysis with alteplase 3 to 4.

A randomized trial of intraarterial treatment for acute ischemic stroke. Endovascular therapy for ischemic stroke. Randomized assessment of rapid endovascular treatment of ischemic stroke. Thrombectomy within 8 hours after symptom onset in ischemic stroke.

Stent-retriever thrombectomy for stroke. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke THRACE : a randomised controlled trial. Aspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone. A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA. J Neurointerv Surg. Recombinant tissue-type plasminogen activator use for ischemic stroke in the United States: a doubling of treatment rates over the course of 5 years.

Geographic access to acute stroke care in the United States. Patient outcomes are better for unruptured cerebral aneurysms treated at centers that preferentially treat with endovascular coiling: a study of the national inpatient sample — Outcomes after nontraumatic subarachnoid hemorrhage at hospitals offering angioplasty for cerebral vasospasm: a national level analysis in the United States.

Neurocrit Care. In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the United States, — effect of hospital and physician volume. Am J Neuroradiol. High subarachnoid hemorrhage patient volume associated with lower mortality and better outcomes. Caseload as a factor for outcome in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

Circ Cardiovasc Qual Outcomes. Operator experience and carotid stenting outcomes in Medicare beneficiaries. Experience matters more than specialty for carotid stenting outcomes. J Vasc Surg.

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