ImportanceInternational guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC).ObjectiveTo determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion.Design, Setting, and ParticipantsThis international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021.ExposuresPrior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation.Main Outcomes and MeasuresThe main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses.ResultsOf 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion.Conclusions and RelevanceIn this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic infection associated with high morbidity and mortality. The Korean city of Daegu endured the first large COVID-19 outbreak outside of China. Since the report of the first confirmed case in Daegu on February 18, 2020, a total of 6,880 patients have been reported until May 29, 2020. We experienced five patients with ischemic stroke and COVID-19 during this period in four tertiary hospitals in Daegu. The D-dimer levels were high in all three patients in whom D-dimer blood testing was performed. Multiple embolic infarctions were observed in three patients and suspected in one. The mean time from stroke symptom onset to emergency room arrival was 22 hours. As a result, acute treatment for ischemic stroke was delayed. The present case series report raises the possibility that the coronavirus responsible for COVID-19 causes or worsens stroke, perhaps by inducing inflammation. The control of COVID-19 is very important; however, early and proper management of stroke should not be neglected during the epidemic.

Objectives: This study aimed to assess image biomarkers of early neurological deterioration in single subcortical infarction (SSI) without any relevant artery stenosis. Methods: Between June 2005 and December 2009, consecutive patients with SSI within 24 h of symptom onset were enrolled. Magnetic resonance angiography of the brain and neck was obtained from all patients to confirm the absence of any stenosis of relevant arteries. We defined early neurological deterioration (END) as neurological worsening by ≥ 2 points based on the initial National Institutes of Health Stroke Scale score during the first week post admission or prior to hospital discharge. A multiple logistic regression analysis was used to evaluate the independent predictors of END in SSI. Results: A total of 205 patients (109 males; aged 63.9 ± 11.0 years, range 39–90 years) were enrolled, of whom 158 (77%) remained stable or improved, while 47 (23%) showed neurological worsening. There were significant differences in the maximum diameter of the largest area on an axial view and in the number of slices showing cerebral infarction on a transverse plane between patients with and without END. A adjusting for age, hypercholesterolemia, hemoglobin, NIHSS on admission and these magnetic resonance imaging characteristics, the occurrence of having three or more slices showing the cerebral infarction on a transverse plane was an independent predictor of END in SSI without relevant artery stenosis (1 vs. 3; OR 14.281; 95% CI 1.76–115.8; p = 0.013, 1 vs. 4; OR 14.04; 95% CI 1.65–119.57; p = 0.016). Conclusion: The longitudinal length of the infarcted lesion along the perforating artery predicts END in cases of acute SSI without any relevant artery stenosis.

The expected growth of stroke burden in Korea in early 2000s led to the initiation of a government-funded clinical research project with the goal of development and implementation of national stroke guidelines. The CRCS-K (Clinical Research Collaboration for Stroke in Korea) began as a part of this project. For stroke epidemiology and quality of care research, the CRCS-K developed a multicenter, prospective, stroke registry and began collection of data in 2008. Now, about 100 000 cases have been registered at 17 university hospitals or regional stroke centers and about 200 articles have been published based on the registry experience. The analysis of the 10-year secular trends showed overall improvement of stroke care and outcomes and areas for improvement. This large-scale, high-quality dataset provides opportunities to explore and compare treatment disparities using the comparative effectiveness research methods, design and conduct a registry-based randomized clinical trial, connect the registry data with other data sources including the national claims data and neuroimaging or genetic data, and collaborate with other international researchers. An international stroke registry consortium may be a viable future direction.

Now, coronavirus disease (COVID-19) is worldwide threatening. Medical staff 's efforts and sacrifices against COVID-19 are still ongoing. The purpose of this study was to investigate the mental health of the medical staff who have fought against the COVID-19 in hub hospitals. Methods: The medical staff underwent an evaluation of psychiatric and sleep status between March 23rd and April 3rd, 2020. Based on the evaluation, we retrospectively analyzed depression, anxiety, and sleep quality of the medical staff, who worked more than 7 days for fighting against the COVID-19. Results: This study included a total of 101 medical staff. Approximately 1/4 of the medical staff showed depressive mood and low quality of sleep, and more than 1/3 reported anxiety. The nurses reported more severe psychiatric symptoms and poorer sleep quality. Conclusions: This study demonstrated the mental and sleep status of the medical staff against COVID-19. Medical and social support should be considered for them.