Blood pressure management in acute stroke

Blood pressure (BP) is elevated in 75% or more of patients with acute stroke and is associated with poor outcomes. Whether to modulate BP in acute stroke has long been debated. With the loss of normal cerebral autoregulation, theoretical concerns are twofold: high BP can lead to cerebral oedema, haematoma expansion or haemorrhagic transformation; and low BP can lead to increased cerebral infarction or perihaematomal ischaemia. Published evidence from multiple large, high-quality, randomised trials is increasing our understanding of this challenging area, such that BP lowering is recommended in acute intracerebral haemorrhage and is safe in ischaemic stroke. Here we review the evidence for BP modulation in acute stroke, discuss the issues raised and look to on-going and future research to identify patient subgroups who are most likely to benefit

Results from the tranexamic acid for primary intracerebral haemorrhage-2 (TICH-2) trial

Background: Haematoma expansion leads to worse outcome in intracerebral haemorrhage (ICH). Tranexamic acid (TXA) is a promising haemostatic agent to prevent haematoma expansion and improve outcome after ICH. Methods: TICH-2 is a multicentre prospective double blind randomised controlled trial, which recruited patients presenting within 8 hours of primary ICH to receive intravenous TXA or placebo. Primary outcome is modified Rankin Scale at day 90 and will be analysed using ordinal logistic regression, adjusted for minimisation criteria. Secondary outcomes will be analysed using adjusted binary logistic regression and multiple linear regression; these include haematoma expansion at 24 hours, day 7 National Institute of Health Stroke Scale (NIHSS), day 90 Barthel Index, quality of life, cognition and mood. Results: A total of 2325 patients were recruited between 14th March 2013 and 30th September 2017, from 12 countries: United Kingdom (n= 1910), Italy, Georgia, Switzerland, Malaysia, Hungary, Poland, Ireland, Turkey, Sweden, Denmark and Spain. Randomisation characteristics included: age 68.9 (13.8) years; male 1301 (56.0%); time from onset to randomisation 3.6 hours [2.6, 5.0]; NIHSS 13 (7.5); Glasgow coma scale 13.4 (2.1); systolic blood pressure 172.6 (27.2) mmHg; intraventricular haemorrhage 745 (32.0%) and prior antiplatelet use 610 (26.2%). Conclusion: TICH-2 is the largest trial of TXA in spontaneous ICH and recruited over its original target of 2000 patients. The results will be available in May 2018 and will inform whether TXA should be recommended for the treatment of acute spontaneous ICH

The Great Observatories All-Sky LIRG Survey: Comparison of Ultraviolet and Far-Infrared Properties

The Great Observatories All-sky LIRG Survey (GOALS) consists of a complete sample of 202 Luminous Infrared Galaxies (LIRGs) selected from the IRAS Revised Bright Galaxy Sample (RBGS). The galaxies span the full range of interaction stages, from isolated galaxies to interacting pairs to late stage mergers. We present a comparison of the UV and infrared properties of 135 galaxies in GOALS observed by GALEX and Spitzer. For interacting galaxies with separations greater than the resolution of GALEX and Spitzer (2-6"), we assess the UV and IR properties of each galaxy individually. The contribution of the FUV to the measured SFR ranges from 0.2% to 17.9%, with a median of 2.8% and a mean of 4.0 +/- 0.4%. The specific star formation rate of the GOALS sample is extremely high, with a median value (3.9*10^{-10} yr^{-1}) that is comparable to the highest specific star formation rates seen in the Spitzer Infrared Nearby Galaxies Survey sample. We examine the position of each galaxy on the IR excess-UV slope (IRX-beta) diagram as a function of galaxy properties, including IR luminosity and interaction stage. The LIRGs on average have greater IR excesses than would be expected based on their UV colors if they obeyed the same relations as starbursts with L_IR < 10^{11}L_0 or normal late-type galaxies. The ratio of L_IR to the value one would estimate from the IRXg-beta relation published for lower luminosity starburst galaxies ranges from 0.2 to 68, with a median value of 2.7. A minimum of 19% of the total IR luminosity in the RBGS is produced in LIRGs and ULIRGs with red UV colors (beta > 0). Among resolved interacting systems, 32% contain one galaxy which dominates the IR emission while the companion dominates the UV emission. Only 21% of the resolved systems contain a single galaxy which dominates both wavelengths.Comment: 37 pages, 10 figures, accepted for publication in Ap

Consent procedures and relationship with outcome in the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2)

Background: Obtaining consent in emergency situations is challenging. Proxy consent allows patients to be recruited when they lack capacity, a common scenario in stroke patients. The rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 (RIGHT-2) recruits patients in the pre-hospital setting within 4 hours of stroke onset. Methods: In RIGHT-2, informed or proxy consent is taken in the ambulance. A brief assessment of capacity is performed by the paramedic. Patients with capacity provide consent and in patients without capacity, proxy consent is obtained from a relative, carer or friend, or by the paramedic, witnessed by a crew member. Results: Of 879 participants enrolled into RIGHT-2 as of 15th December 2017, 468 (53.2%) participants gave their own consent; proxy consent was given by a relative/carer/friend for 325 (37%) and by a paramedic for 85 (9.7%). Participants who consented themselves were younger, had less dependency and had less severe strokes than those with proxy consent. Participants who gave their own consent had a lower rate of intracerebral haemorrhage (9% vs 16%) and a higher rate of non-stroke (20% vs 13%) as their final diagnosis than those who gave proxy consent. Consenting patients had better scores for dependency, cognition, disability and quality of life at day 90 than those recruited via proxy consent. Conclusion: Proxy consent can ensure participants are enrolled rapidly into emergency clinical trials where they may otherwise be excluded due to lack of capacity. These patients have more severe strokes and therefore poorer clinical outcomes

Serum amyloid protein is associated with outcome following acute ischaemic stroke: data from the REmote ischaemic Conditioning After Stroke Trial (RECAST)

Background: Remote ischaemic per-conditioning (RIC) in experimental ischaemic stroke is neuroprotective. Several neurohumoral, vascular and inflammatory mediators are implicated. Methods: The REmote ischaemic Conditioning After Stroke Trial (RECAST) was a pilot blinded sham-controlled trial in patients with ischaemic stroke, randomised to receive four 5-minute cycles of RIC within 24 hours of ictus. Plasma taken pre-intervention, immediately post-intervention and on day 4 was analysed for nitric oxide (nitrate/nitrite) levels using chemiluminescence and other biomarkers were analysed by enzyme-linked immunosorbent assay (ELISA): alpha-2-macroglobulin (A2M), serum amyloid protein (SAP), e-selectin, vascular endothelial growth factor (VEGF). Biomarkers were correlated with outcome (Day 90 National Institutes of Health Stroke Scale [NIHSS], modified Rankin scale [mRS], Barthel index [BI]) using Pearson’s correlation coefficient. Results: In all 26 patients, an increase in SAP (pre- to post-intervention) positively correlated with worse day 90 mRS (r=0.429, p=0.029) and negatively with worse BI (r=-0.392, p=0.048), whilst an increase in SAP from day 0 to 4 positively correlated with worse day 90 NIHSS (r=0.400, p=0.043), mRS (r=0.505, p=0.008) and negatively with worse BI (r=-0.439, p=0.025). RIC reduced SAP levels from pre- to post-intervention (n=13, 2-way ANOVA, p<0.05), whilst sham did not. No significant changes over time or by treatment, or correlations with outcome were seen for A2M, e-selectin, nitric oxide or VEGF. Conclusion: Increased plasma levels of SAP are associated with worse clinical outcomes after ischaemic stroke. RIC reduced SAP levels from pre- to post-intervention. Larger studies assessing biomarkers and efficacy of RIC in acute ischaemic stroke are warranted

The Insulin Resistance Intervention after Stroke trial: a perspective on future practice and research

The prevention of recurrent events after ischaemic stroke and transient ischaemic attack is well established and based on lifestyle changes, antithrombotics, statins, antihypertensives and carotid surgery. The international IRIS trial assessed whether pioglitazone, a glucose-lowering insulin-sensitizing drug, would reduce recurrent vascular events in patients with ischaemic stroke or transient ischaemic attack. After 4.8 years, pioglitazone therapy was associated with reduced vascular events and new diabetes, and an increase in weight, oedema and bone fractures. Pioglitazone may add to the strategies for preventing further events in patients with stroke or transient ischaemic attack

The Great Observatories All-Sky LIRG Survey: Herschel Image Atlas and Aperture Photometry

Far-infrared (FIR) images and photometry are presented for 201 Luminous and Ultraluminous Infrared Galaxies [LIRGs: log$(L_{\rm IR}/L_\odot) = 11.00 - 11.99$, ULIRGs: log$(L_{\rm IR}/L_\odot) = 12.00 - 12.99$], in the Great Observatories All-Sky LIRG Survey (GOALS) based on observations with the $Herschel$ $Space$ $Observatory$ Photodetector Array Camera and Spectrometer (PACS) and the Spectral and Photometric Imaging Receiver (SPIRE) instruments. The image atlas displays each GOALS target in the three PACS bands (70, 100, and 160 $\mu$m) and the three SPIRE bands (250, 350, and 500 $\mu$m), optimized to reveal structures at both high and low surface brightness levels, with images scaled to simplify comparison of structures in the same physical areas of $\sim$$100\times100$ kpc$^2$. Flux densities of companion galaxies in merging systems are provided where possible, depending on their angular separation and the spatial resolution in each passband, along with integrated system fluxes (sum of components). This dataset constitutes the imaging and photometric component of the GOALS Herschel OT1 observing program, and is complementary to atlases presented for the Hubble Space Telescope (Evans et al. 2017, in prep.), Spitzer Space Telescope (Mazzarella et al. 2017, in prep.), and Chandra X-ray Observatory (Iwasawa et al. 2011, 2017, in prep.). Collectively these data will enable a wide range of detailed studies of AGN and starburst activity within the most luminous infrared galaxies in the local Universe.Comment: Accepted for publication in ApJS, 270 pages, 216 figures, 4 table