Some patients with large vessel occlusion (LVO) are first evaluated at primary stroke centers (PSCs) before transfer to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). A subgroup of these patients experiences rapid infarct growth, also known as “imaging decay,” during transfer, limiting the benefit from intervention. We evaluated the incidence, predictors and outcomes of imaging decay in this subgroup.

The present study was an analysis of all patients with anterior circulation LVO at PSCs in Northern Alberta and transferred to the CSC in the University of Alberta Hospital in Edmonton for EVT. The Alberta Stroke Program Early CT Score (ASPECTS) decay was defined as ≥ 2 ASPECTS points decrement at CSC compared to PSC. The primary outcome was 90-day home time.

182 patients were included. Median time between baseline and follow-up CTs was 250.5 (IQR 163–324.25) minutes. Out of the 182 patients, 66 patients (36%) had ASPECTS decay, and 32 of 66 patients (48%) underwent EVT. Poor collateral score was strongly associated with ASPECTS decay (OR = 0.35, [0.21–0.59], p < 0.001). Patients with ASPECTS decay have a significantly lower 90-day home time (β = –0.32, [–4.6 to –36.4], P < 0.001) and higher risk of 90-day mortality (OR = 4.9, [2.4–10.0], P < 0.001) and in-hospital death (OR = 3.8, [1.2–12.3], P = 0.03).

For patients with LVO transferred for thrombectomy, a third of our patients developed ASPECTS decay. Collateral blood flow was the main determinant of ASPECTS decay during interfacility transfers. Decay is strongly associated with poor functional outcomes.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disorder leading to vascular malformations in different organ systems. Approximately 10% of patients with HHT have brain vascular malformations (BVMs). Due to the negative health consequences related to BVMs, screening with MRI is recommended. There are no health jurisdictional standards for medical imaging protocols in North America or elsewhere. The objective of this project is to adopt a provincial standardized operating protocol (SOP) to improve diagnostic accuracy and reduce inappropriate imaging in patients with and without HHT in Alberta.

Multiple fora were held among the five Alberta Health Services zones with stakeholders from urban, suburban and rural radiology groups, neurology, pulmonology and hematology. The consensus process took five years to complete between 2015 and 2020. The content of the fora was approved by all participants.

The SOP was implemented in February 2020 and defines that screening for BVMs must include standard unenhanced brain MRI (sagittal T1, axial fluid-attenuated inversion recovery and axial T2) with susceptibility-weighted imaging (SWI), a 3T or 1.5T magnet strength and minimum imaging standards to include 3 mm contiguous slice thickness.

Incorporation of SWI allowed for the elimination of MR contrast to improve access to the local performance of studies within the province, facilitating virtual care.

A provincial SOP for BVM screening in patients with suspected or confirmed HHT was successfully implemented in Alberta. Gadolinium was avoided, as it was felt to be unnecessary for screening purposes and might complicate imaging at more remote sites.

Adjunctive intraarterial (IA) thrombolysis after endovascular thrombectomy may improve clinical outcomes in patients with large vessel occlusion (LVO) stroke possibly due to improvement in microvascular reperfusion.

We conducted a meta-analysis of randomized controlled trials (RCTs) evaluating IA thrombolysis with tenecteplase, alteplase or urokinase in anterior or posterior circulation LVO stroke after successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3). Efficacy outcomes were excellent functional outcome (modified Rankin Scale [mRS] 0–1), functional independence (mRS 0–2) and recovery without any disability (mRS 0) at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (ICH), any ICH and death. Odds ratios (OR) and 95% confidence intervals (CI) were pooled using random-effects models.

Seven RCTs (n = 2,130; 2022–2025) were included. IA thrombolytic drugs used were alteplase, tenecteplase and urokinase with doses ranging from 10 % to 50% of recommended IV dosage. IA thrombolysis significantly improved excellent functional outcome (mRS 0–1: OR 1.45, 95% CI 1.19–1.76) and recovery without any disability (mRS 0: OR 1.34, 95% CI 1.09–1.64), without safety risks (symptomatic ICH: 5.05% with IA thrombolytics vs. 4.49% in standard). Paradoxically, there was no difference in functional independence (mRS 0–2) (OR 1.09, 95% CI 0.99–1.20). Additionally, tenecteplase or alteplase at doses equivalent to 25% or 50% of recommended IV dosage significantly improved excellent functional outcome.

IA thrombolysis offered immediately following EVT with successful reperfusion improved excellent functional outcome and recovery without disability at 90 days with an acceptable safety profile.

Historically, it has been proposed that functional neurological symptoms occur more frequently on the left side of the body due to a distinct body representation and emotional processing of the right hemisphere, yet objective imaging data to support this are lacking. We aimed to investigate whether patients with acute left-sided symptoms (right hemisphere) suspected of having a minor stroke are more likely to show negative diffusion-weighted imaging (DWI) compared to those with right-sided symptoms.

Data are from the SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment) multicenter prospective cohort study conducted between 2013 and 2017. Patients with mild persistent unilateral hemiparesis and/or hemisensory symptoms (National Institute of Health Stroke Scale ≤ 3) and available DWI were included. The primary outcome was the proportion of patients with a negative DWI.

Of 1731 patients, 584 (30.8%) were included. Of these, 310 (53.1%) patients presented with left-sided symptoms and 274 (46.9%) with right-sided symptoms. Overall, 214 (36.6%) patients had a negative DWI, 126 (58.9%) with left-sided symptoms and 88 (41.1%) with right-sided symptoms: risk ratio (RR) 1.27 (95% CI = 1.02–1.57). Left-sided hemiparesis was associated with negative DWI (RR 1.42 [95% CI = 1.08–1.87]), while left-sided hemisensory symptoms were not (RR 1.11 [95% CI = 0.87–1.41]). There was no effect modification by age or sex on this association (Pinteraction 0.787 and 0.057, respectively).

Unilateral left-sided neurological symptoms were more frequently associated with negative DWI compared to right-sided symptoms in suspected minor stroke patients. This observation is exploratory, as the final diagnosis in DWI-negative cases was not established.

Tenecteplase has been shown to be non-inferior to alteplase for the treatment of acute ischemic stroke within 4.5 hours of stroke onset. While not formally approved by regulatory authorities, many jurisdictions have transitioned to using tenecteplase for routine stroke treatment because it is simpler to use and has cost advantages.

We report a three-phase time-series analysis over 2.5 years and the process for transition from use of alteplase to tenecteplase for the routine treatment of acute ischemic stroke from a system-wide perspective involving an entire province. The transition was planned and implemented centrally. Data were collected in clinical routine, arising from both administrative sources and a prospective stroke registry, and represent real-world outcome data. Data are reported using standard descriptive statistics.

A total of 1211 patients were treated with intravenous thrombolysis (477 pre-transition using alteplase, 180 transition period using both drugs, 554 post-transition using tenecteplase). Baseline characteristics, adverse events and outcomes were similar between epochs. There were four dosing errors with tenecteplase, including providing the cardiac dose to two patients. There were no instances of major hemorrhage associated with dosing errors.

The transition to using intravenous tenecteplase for stroke treatment was seamless and resulted in identical outcomes to intravenous alteplase.

The best prehospital transport strategy for patients with suspected stroke due to possible large vessel occlusion varies by jurisdiction and available resources. A foundational problem is the lack of a definitive diagnosis at the scene. Rural stroke presentations provide the most problematic triage destination decision-making. In Alberta, Canada, the implementation and 5-year experience with a rural field consultation approach to provide service to rural patients with acute stroke is described.

The protocols established through the rural field consultation system and the subsequent transport patterns for suspected stroke patients during the first 5 years of implementation are presented. Outcomes are reported using home time and data are summarized using descriptive statistics.

From April 2017 to March 2022, 721 patients met the definition for a rural field consultation, and 601 patients were included in the analysis. Most patients (n = 541, 90%) were transported by ground ambulance. Intravenous thrombolysis was provided for 65 (10.8%) of patients, and 106 (17.6%) underwent endovascular thrombectomy. The median time from first medical contact to arterial access was 3.2 h (range 1.3–7.6) in the direct transfers, compared to 6.5 h (range 4.6–7.9) in patients arriving indirectly to the comprehensive stroke center (CSC). Only a small proportion of patients (n = 5, 0.8%) were routed suboptimally to a primary stroke center and then to a CSC where they underwent endovascular therapy.

The rural field consultation system was associated with shortened delays to recanalization and demonstrated that it is feasible to improve access to acute stroke care for rural patients.

The Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial demonstrated that minimally invasive surgery to treat spontaneous lobar intracerebral hemorrhage (ICH) improved functional outcomes. We aimed to explore current management trends for spontaneous lobar ICH in Canada to assess practice patterns and determine whether further randomized controlled trials are needed to clarify the role of surgical intervention.

Neurologists, neurosurgeons, physiatrists and trainees in these specialties were invited to complete a 16-question survey exploring three areas: (1) current management for spontaneous lobar ICH at their institution, (2) perceived influence of ENRICH on their practice and (3) perceived need for additional clinical trial data. Standard descriptive statistics were used to report categorical variables. The χ2 test was used to compare responses across specialties and career stages.

The survey was sent to 433 physicians, and 101 (23.3%) responded. Sixty-eight percent of participants reported that prior to publication of the ENRICH trial, spontaneous lobar ICH was primarily managed conservatively, with surgery reserved for life-threatening situations. Forty-three percent of participants did not foresee a significant increase in surgical intervention at their institution. Of neurosurgical respondents, 33% remained hesitant to offer surgical intervention beyond lifesaving operations. Only 5% reported routinely using specifically designed technologies to evacuate ICH. Seventy percent reported that another randomized controlled trial comparing nonsurgical to surgical management for spontaneous lobar ICH is needed.

There is significant practice variability in the management of spontaneous lobar ICH across Canadian institutions, stressing the need for additional clinical trial data to determine the role of surgical intervention.

In acute ischemic stroke, a longer time from onset to endovascular treatment (EVT) is associated with worse clinical outcome. We investigated the association of clinical outcome with time from last known well to arrival at the EVT hospital and time from hospital arrival to arterial access for anterior circulation large vessel occlusion patients treated > 6 hours from last known well.

Retrospective analysis of the prospective, multicenter cohort study ESCAPE-LATE. Patients presenting > 6 hours after last known well with anterior circulation large vessel occlusion undergoing EVT were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes were good (mRS 0–2) and poor clinical outcomes (mRS 5–6) at 90 days, as well as the National Institutes of Health Stroke Scale at 24 hours. Associations of time intervals with outcomes were assessed with univariable and multivariable logistic regression.

Two hundred patients were included in the analysis, of whom 85 (43%) were female. 90-day mRS was available for 141 patients. Of the 150 patients, 135 (90%) had moderate-to-good collaterals, and the median Alberta Stroke Program Early CT Score (ASPECTS) was 8 (IQR = 7–10). No association between ordinal mRS and time from last known well to arrival at the EVT hospital (odds ratio [OR] = 1.01, 95% CI = 1.00–1.02) or time from hospital arrival to arterial access (OR = -0.01, 95% CI = -0.02–0.00) was seen in adjusted regression models.

No relationship was observed between pre-hospital or in-hospital workflow times and clinical outcomes. Baseline ASPECTS and collateral status were favorable in the majority of patients, suggesting that physicians may have chosen to predominantly treat slow progressors in the late time window, in whom prolonged workflow times have less impact on outcomes.

Stroke clinical registries are critical for systems planning, quality improvement, advocacy and informing policy. We describe the methodology and evolution of the Registry of the Canadian Stroke Network/Ontario Stroke Registry in Canada.

At the launch of the registry in 2001, trained coordinators prospectively identified patients with acute stroke or transient ischemic attack (TIA) at comprehensive stroke centers across Canada and obtained consent for registry participation and follow-up interviews. From 2003 onward, patients were identified from administrative databases, and consent was waived for data collection on a sample of eligible patients across all hospitals in Ontario and in one site in Nova Scotia. In the most recent data collection cycle, consecutive eligible patients were included across Ontario, but patients with TIA and those seen in the emergency department without admission were excluded.

Between 2001 and 2013, the registry included 110,088 patients. Only 1,237 patients had follow-up interviews, but administrative data linkages allowed for indefinite follow-up of deaths and other measures of health services utilization. After a hiatus, the registry resumed data collection in 2019, with 13,828 charts abstracted to date with a focus on intracranial vascular imaging, identification of intracranial occlusions and treatment with thrombectomy.

The Registry of the Canadian Stroke Network/Ontario Stroke Registry is a large population-based clinical database that has evolved throughout the last two decades to meet contemporary stroke needs. Registry data have been used to monitor stroke quality of care and conduct outcomes research to inform policy.

In June of 2024, Becton Dickinson experienced a blood culture bottle shortage for their BACTEC system, forcing health systems to reduce usage or risk exhausting their supply. Virginia Commonwealth University Health System (VCUHS) in Richmond, VA decided that it was necessary to implement austerity measures to preserve the blood culture bottle supply.

VCUHS includes a main campus in Richmond, VA as well as two affiliate hospitals in South Hill, VA (Community Memorial Hospital (CMH)) and Tappahannock Hospital in Tappahannock, VA. It also includes a free-standing Emergency Department in New Kent, VA.

Blood cultures from both pediatric and adult patients were included in this study.

VCUHS intervened to decrease blood culture utilization across the entire health system. Interventions included communication of blood culture guidance as well as an electronic health record order designed to guide providers and discourage wasteful ordering.

Post-implementation analyses showed that interventions reduced overall usage by 35.6% (P < .0001) and by greater than 40% in the Emergency Departments. The impact of these changes in utilization on positivity were analyzed, and it was found that the overall positivity rate increased post-intervention from 8.8% to 12.1% (P = .0115) and in the ED specifically from 10.2% to 19.5% (P < .0001).

These findings strongly suggest that some basic stewardship interventions can significantly change blood culture practice in a manner that minimizes the impact on patient care.

Mobile health has been shown to improve quality, access, and efficiency of health care in select populations. We sought to evaluate the benefits of mobile health monitoring using the KidsHeart app in an infant CHD population.

We reviewed data submitted to KidsHeart from parents of infants discharged following intervention for high-risk CHD lesions including subjects status post stage 1 single ventricle palliation, ductal stent or surgical shunt, pulmonary artery band, or right ventricular outflow tract stent. We report on the benefits of a novel mobile health red flag scoring system, mobile health growth/feed tracking, and longitudinal neurodevelopmental outcomes tracking.

A total of 69 CHD subjects (63% male, 41% non-white, median age 28 days [interquartile range 20, 75 days]) were included with median mobile health follow-up of 137 days (56, 190). During the analytic window, subjects submitted 5700 mobile health red flag notifications including 245 violations (mean [standard deviation] 3 ± 3.96 per participant) with 80% (55/69) of subjects submitting at least one violation. Violations precipitated 116 interventions including hospital admission in 34 (29%) with trans-catheter evaluation in 15 (13%) of those. Growth data (n = 2543 daily weights) were submitted by 63/69 (91%) subjects and precipitated 31 feed changes in 23 participants. Sixty-eight percent of subjects with age >2 months submitted at least one complete neurodevelopment questionnaire.

In our initial experience, mobile health monitoring using the KidsHeart app enhanced interstage monitoring permitting earlier intervention, allowed for remote tracking of growth feeding, and provided a means for tracking longitudinal neurodevelopmental outcomes.

Agriculture has been dominated by annual plants, such as all cereals and oilseeds, since the very beginning of civilization over 10,000 years ago. Annual plants are planted and uprooted every year which results in severe disturbance of the soil and disrupts ecosystem services. Science has shown that it is possible to domesticate completely new perennial grain crops, i.e. planted once and harvested year after year. Such crops would solve many of the problems of agriculture, but their development and uptake would be at odds with the current agricultural technology industry.

Agriculture is arguably the most environmentally destructive innovation in human history. A root cause is the reliance on annual crops requiring uprooting and restarting every season. Most environmental predicaments of agriculture can be attributed to the use of annuals, as well as many social, political, and economic ones. Advances in domestication and breeding of novel perennial grain crops have demonstrated the possibility of a future agricultural shift from annual to perennial crops. Such a change could have many advantages over the current agricultural systems which are to over 80% based on annual crops mainly grown in monocultures. We analyze and review the prospects for such scientific advances to be adopted and scaled to a level where it is pertinent to talk about a perennial revolution. We follow the logic of E.O. Wright's approach of Envisioning Real Utopias by discussing the desirability, viability, and achievability of such a transition. Proceeding from Lakatos' theory of science and Lukes' three dimensions of power, we discuss the obstacles to such a transition. We apply a transition theory lens to formulate four reasons of optimism that a perennial revolution could be imminent within 3–5 decades and conclude with an invitation for research.