Stroke is the second leading non-communicable cause of death and third leading cause of death and disability worldwide with prevalence expected to rise 120

INTRODUCTION:Platform trials are an efficient trial design which enables testing of multiple interventions simultaneously. They could advance knowledge of treatments for intracerebral haemorrhage (ICH). We aimed to investigate the views of clinicians involved in stroke research on recruitment to a future platform trial for ICH. METHODS:Between April and July 2025, we conducted a UK-wide online survey of clinicians actively involved in stroke research using convenience sampling through professional organisations. Participants considered factors related to the consent process and research environment and could provide optional free text responses about additional barriers or facilitators to recruitment. We used descriptive statistics for quantitative data and content analysis for qualitative data. RESULTS:Among 73 respondents, 46 (63%) were female, 36 (49%) were stroke physicians, 24 (33%) nurses, 6 (8%) allied health professionals, and 7 (10%) were in other roles. A total of 35 (48%) had >20 years' clinical experience, 44 (60%) reported spending <10% of their role in research. 66 (90%) thought that a platform trial would be a good option for testing interventions for patients with stroke due to ICH. Across 11 modifiable factors, clinicians most frequently rated the perceived importance of the research question and a research-positive culture in the clinical team as facilitators of recruitment (both 92%), while clinician preference for specific treatments was most frequently rated as a barrier (48%). Two themes emerged from free text responses: study design and infrastructure. Regarding study design, respondents perceived consent procedures (n = 9), study materials (n = 8), study procedures (n = 8), eligibility assessment (n = 6), the research question (n = 3), and randomisation (n = 3) as important for a future platform trial. Regarding infrastructure, emergent factors were staffing (n = 17), local research culture and capacity (n = 9), research governance and delivery (n = 6), and training (n = 6). CONCLUSION:The overwhelming majority of respondents from the UK clinical stroke community supported a platform trial for ICH, although the influence of survey responder bias is unknown.

Abstract Background and aims Recruiting people with intracerebral haemorrhage (ICH) to clinical trials remains challenging. We did a feasibility study for a platform study for ICH (PLINTH). Methods Adults with incident ICH (or the legal representative of adults with incapacity) in NHS Lothian and Lanarkshire, Scotland, were shown (i) a <3-minute narrated video about this feasibility study before verbal consent, then (ii) personalised information about their ICH and uncertainties about their care before written consent. Researchers conducted semi-structured interviews at days 3 and 14 after written consent to obtain participants’ views about the two-stage consent process and taking part in a future PLINTH. The primary outcome is the proportion of people with incident ICH for whom there was at least one management uncertainty, consent to participate in this feasibility study, and willingness to consider participating in a future PLINTH. Results We screened 320 adults with ICH between 1 Oct 2023 to 30 Jun 2025. Of these, 200 (63%) were eligible, 197 (62%) were approached, 169 (53%) gave verbal consent, 165 (52%) gave written consent, and 140 (44%) met the primary outcome. Among 169 participants who gave verbal consent, 109 (64%) were from Lothian, median age was 73 years (IQR 59-83), 83 (49%) were female, 109 (64%) were diagnosed outside of usual office hours, and 164/168 (98%) with complete data had two or more relevant uncertainties about their care suitable for investigation in a future PLINTH. Conclusions The results of this feasibility study will culminate in a proposal for the most efficient design of a future PLINTH. Conflict of interest Tom Moullaali: nothing to disclose

Abstract Background and aims Recruitment of people with spontaneous intracerebral haemorrhage (ICH) into clinical trials remains challenging. In this feasibility study, we aimed to evaluate the feasibility and acceptability of a proportionate consent process for a future platform trial for ICH. Methods We approached adults with incident ICH and sought verbal consent before written consent, using paper and multimedia materials and delivered face-to-face or by telephone, according to participant preference. Multimedia resources included a 3-minute narrated video about the study at verbal consent and a presentation with personalised information about the patient’s ICH and uncertainties about their care at written consent. We conducted semi-structured interviews on days 3 and 14 after written consent to explore acceptability and experiences of the consent process. Results Between October 2023 and June 2025, we approached 196 adults with ICH or their representatives. 168 (86%) provided verbal consent and 163 (83%) provided written consent (median age 72 years, 49% female, median ICH score 1 [IQR 0-2]). Most participants found giving verbal consent before written consent acceptable at both assessments (154/159, 97% and 149/152, 98%). Most (126/154, 82%) reported that the consent process supported their decision-making. Qualitative analysis dentified two preliminary themes: the multimedia materials were viewed as clear and educational; personalisation and dialogue increased relevance and value. Conclusions In this feasibility study, a proportionate consent process starting with verbal consent was acceptable to the vast majority of people with ICH or their representatives. Use of multimedia materials and flexible delivery methods may support recruitment of a broad and representative ICH population. Conflict of interest

BACKGROUND:Providing equitable health care to rural stroke patients is challenging and associated with less intervention and poorer outcomes. We assessed how several distinct patient-related geographic classifications influenced stroke care and outcomes in Scotland, United Kingdom. METHODS:We conducted a population-level data-linkage study of ischemic stroke patients admitted to the hospital (2010-2018). Geographic classifications included 2 binary (urban versus rural; accessible versus remote) and 1 six-category classification encompassing both rurality and accessibility (large urban areas, other urban areas, accessible small towns, remote small towns, accessible rural areas, and remote rural areas). Process outcomes included achievement of a stroke care bundle and thrombolysis administration. Clinical outcomes included 30-day discharge from hospital care, 90-day home time, inpatient and 1-year all-cause mortality. RESULTS:We included 42 917 ischemic stroke patients (35 766 urban and 7151 rural). Binary classifications of rurality or accessibility missed important differences in stroke care and outcomes revealed using 6-category classification. Using the latter, compared with large urban areas, patients in accessible rural areas were more likely to receive a complete stroke care bundle (adjusted odds ratio, 1.21 [95% CI, 1.12-1.31]); patients in remote rural areas were less likely (adjusted odds ratio, 0.85 [95% CI, 0.78-0.93]). Compared with large urban areas, 30-day discharge from hospital care was more likely for patients residing elsewhere (eg, remote rural areas adjusted subdistribution hazards ratio, 1.11 [95% CI, 1.05-1.17]); home time within 90 days was higher for other urban areas (adjusted incidence rate ratio, 1.05 [95% CI, 1.03-1.07]) and accessible rural areas (adjusted incidence rate ratio, 1.03 [95% CI, 1.01-1.06]); and 1-year mortality was less likely in other urban areas (adjusted hazard ratio, 0.93 [95% CI, 0.88-0.98]) and remote small towns (adjusted hazard ratio, 0.89 [95% CI, 0.80-0.99]). CONCLUSIONS:When considering geographic disparities in stroke care and outcomes across Scotland, it is important to account for both home location and accessibility of care. Despite patients residing in remote rural areas being less likely to achieve a complete stroke care bundle, this did not translate into poorer outcomes.

BackgroundStroke survivor's goals reflect their individual priorities and hopes for the future. Person-centred goal setting is recommended in rehabilitation clinical guidelines, but evidence-based training to support its implementation in practice is limited. We aimed to develop, describe and evaluate a new Goal setting and Action Planning (G-AP) rehabilitation training resource to support person-centred goal setting practice in community neuro-rehabilitation settings.MethodsA clinical-academic team, advisory group and web-design company were convened to co-develop the G-AP training resource. G-AP training was then delivered to multi-disciplinary staff (n = 48) in four community neuro-rehabilitation teams. A mixed methods evaluation utilising a staff questionnaire and focus group discussion was conducted to investigate staff experiences of G-AP training and their early G-AP implementation efforts. Questionnaire data were analysed descriptively; focus group data were analysed using a Framework approach. An integrated conceptual overview of data was developed to illustrate findings.ResultsA fully online G-AP training resource comprising a training website and two interactive webinars was developed. Following training, 41/48 (85%) staff completed the online questionnaire and 8/48 (17%) participated in the focus group. Nearly all staff rated the training website as excellent (n = 25/40; 62%) or good (n = 14/40; 35%) and the webinars as excellent (n = 26/41; 63%) or good (n = 14/41; 34%). Following training, staff agreed they were knowledgeable about G-AP (37/41; 90%) and had the confidence (35/40; 88%) and skills (35/40; 88%) to use it in practice. Within one month of training, staff described implementing G-AP individually, but transitioning to implementation at a team level required more time to develop new working practices. Team context including staff beliefs about G-AP, leadership support and competing demands impacted (positively and negatively) on staff training engagement, learning experience and implementation efforts.ConclusionsThe new G-AP training resource was positively evaluated and supported early G-AP implementation efforts. This study advances our understanding of training evaluation by highlighting the training—context interaction the temporal nature of training effects. A follow up study evaluating longer term G-AP implementation is underway.

ImportanceThe net clinical effect of early vs later direct oral anticoagulant (DOAC) initiation after atrial fibrillation–associated ischemic stroke is unclear.ObjectiveTo investigate whether early DOAC treatment is associated with a net clinical benefit (NCB).Design, Setting, and ParticipantsThis was a post hoc analysis of the Early Versus Late Initiation of Direct Oral Anticoagulants in Post–Ischaemic Stroke Patients With Atrial Fibrillation (ELAN) open-label randomized clinical trial conducted across 103 sites in 15 countries in Europe, the Middle East, and Asia between November 6, 2017, and September 12, 2022, with a 90-day follow-up. Participants included patients with atrial fibrillation–associated acute ischemic stroke, excluding those with therapeutic anticoagulation at stroke onset or with severe hemorrhagic transformation of the ischemic infarct.InterventionEarly DOAC initiation (<48 hours after minor and moderate stroke, 6-7 days after major stroke) vs later initiation (3-4 days after minor stroke, 6-7 days after moderate stroke, and 12-14 days after major stroke).Main Outcomes and MeasuresThe main measure was the NCB of early treatment over later treatment, calculated by subtracting the weighted rate of excess bleeding events (major extracranial or intracranial hemorrhage) attributable to early treatment from the rate of excess ischemic events (recurrent stroke or systemic embolism) possibly prevented by early treatment within 30 days (main analysis) or 90 days (ancillary analysis). An established weighting scheme was used to account for the different clinical impact of bleeding relative to ischemic outcomes. Event rates were derived from adjusted logistic models. The analysis included all evaluable randomized ELAN participants.ResultsOf the original 2013 ELAN participants, 1966 were eligible for analysis (977 [49.7%] assigned to early DOAC initiation, 989 [50.3%] assigned to later DOAC initiation; median [IQR] age 77 [70-84] years; 1075 [54.7%] male). The 30-day NCB of early treatment over later treatment ranged from 1.73 (95% CI, 0.06-3.40) to 1.72 (95% CI, −0.63 to 3.98) weighted events possibly prevented per 100 participants for intracranial hemorrhage weights 1.5 to 3.3. The 90-day NCB ranged from 2.16 (95% CI, 0.30-3.87) to 2.14 (95% CI, −0.26 to 4.41) weighted events per 100 participants.Conclusions and RelevanceThis post hoc analysis of a randomized clinical trial estimated a sizeable NCB of early anticoagulation for patients after atrial fibrillation–associated ischemic stroke. Although estimates cannot exclude the possibility of no benefit or small net harm, the findings suggest that early treatment may be more favorable.Trial RegistrationClinicalTrials.gov Identifier: NCT03148457

Background: In 2023, the National Clinical Guidelines for Stroke revised the recommended daily multidisciplinary therapy dose from 45 minutes per therapy to 3 hours of therapy overall. To monitor the achievement of these guidelines, there is a need for accurate measurement. This study introduces a novel co-designed digital dosage tracking system that uses Near Field Communication technology to log rehabilitation activities and demonstrates its feasibility and accuracy in a clinical setting through comparison with the current clinical method of manual recording. Objective: This study aimed to assess the validity, feasibility, and usability of a novel co-designed digital tracker using Near Field Communication technology to automatically log rehabilitation dosage in people with stroke history, providing an objective and low-burden solution for clinical environments. Methods: This pilot mixed methods study included 2 phases. Phase 1 involved a usability trial with 9 participants conducted at a university research center, assessing usability with the System Usability Scale (SUS) and Intrinsic Motivation Inventory (IMI). Phase 2 consisted of a clinical trial in a National Health Service stroke ward with 15 inpatients, comparing the digital tracker with manual therapist recordings for validity and feasibility using paired t tests, Cohen d, and Bland-Altman plots. An acceptable discrepancy range was set at +/- 5%-10%. Results: The digital tracker demonstrated high usability with a mean SUS score of 91.43 (SD 9.53) and strong user satisfaction (IMI score 6.29/7, SD 1.50). Clinical trial results showed a strong agreement between the digital and manual methods (t206=-1.60; P=.11; Cohen d=-0.06), with a small mean time discrepancy of 1.23 (SD 11.01) minutes across 207 activities. The Bland-Altman plot indicated good accuracy and consistency between methods, with limits of agreement within the clinically acceptable range. Conclusions: The co-designed digital tracker has been shown to agree with a manual method for recording rehabilitation dosage. This development presents the opportunity for objective, automated, and low-burden recording of rehabilitation dose to support prescription, monitoring, and research. Trial Registration: ClinicalTrials.gov NCT05981729; https://clinicaltrials.gov/study/NCT05981729

ObjectiveTo assess the feasibility of a multi-technology, group based, approach to increasing rehabilitation dose early after stroke.MethodsMixed methods design reporting recruitment, dropout, safety, dose and acceptability.SettingAcute Hospital Stroke UnitParticipantsSixty stroke patients, 9.0 median (IQR 12.8) days after stroke, referred for rehabilitation, without contraindications to light exercise.InterventionPersonalised rehabilitation delivered in supervised groups, using a multi-technology rehabilitation gym, in addition to usual care.Main measuresFeasibility was based on achieving recruitment rates over 3.2 per month, dropout rates below 6%, absence of suspected unexpected serious adverse reactions and shoulder pain prevalence below 60%. Acceptability was derived from interviews with the clinical team. Dose (rehabilitation time) was recorded manually. Function was measured with the modified Rivermead Mobility Index and Therapy Outcome Measure.ResultsFeasibility was satisfactory with high recruitment rates (6 per month), low dropout (2%), no suspected unexpected serious adverse reactions and low prevalence (19%) of shoulder pain. Thematic analysis of interview data indicated the clinical team (n = 9) found the intervention acceptable and identified organisational constraints to higher doses. Participants attended an average of 9.1 (1-32) sessions during their hospital stay (23.0 days, SD 19.7), with sessions lasting 52 min (SD 15.7), on average. The modified Rivermead Mobility Index and Therapy Outcome Measure increased by 17.9 (SD 8.6) and 5.7 points (SD 2.4), respectively.ConclusionsStrong feasibility findings support future trials of multi-technology, group-based rehabilitation. This novel approach is an encouraging step toward achieving recommended doses of rehabilitation after stroke but needs further investigation.

Background Clinical decisions made early after stroke can make the difference between survival with disability or death. We aimed to develop, implement and evaluate a new Shared decision making (SDM) process for severe stroke into a regional 36 bedded stroke unit.Methods We developed the process through four coproduction workshops, attempted its implementation then its impact on death at 6 months, discharge destination and tube feeding. We also explored patients, families and staff views about SDM.Results Eleven people (staff and people with lived experience of stroke) attended the first co-production workshop, eight the second, seven the third and six the fourth. The new SDM process incorporated Tailored Talks (a digital platform with information about stroke and its prognosis) and an implementation plan (including staff training). We implemented this process on 1st August 2022.Only 8/1020 patients received Tailored Talks (4 before and 4 after implementation). For the entire group there was no change tube feeding, discharge destination or death. The proportion of people with severe strokes dead at six months was higher before implementation. Twenty-one patients or family members provided views about SDM quality, but the sample size was too small to draw conclusions. Staff interviews suggested that insufficient time, lack of a ‘human touch’ and inadequate leadership explained the lack of implementation.Conclusion Our co-produced SDM was not effectively implemented into a stroke unit and there was no change in the use of tube feeding or death in 1020 patients.Key points Shared decision making after severe stroke is complex.A co-produced new process for shared decision making after severe stroke was not effectively implemented into clinical practice.There was no change in tube feeding, death or institutionalisation.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis work was supported by Edinburgh and Lothian Health Foundation Reference 1339### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Ethics approval was given by Scotland A research ethics committee (21/SS/0044)I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll data produced in the present work are contained in the manuscript

The past decade has seen a growing recognition of the role of supported self‐management in the provision of long‐term care and support for stroke survivors in primary and community care. However, its implementation and delivery across different contexts and models of community stroke care is inconsistent and patchy. This realist evaluation explored how and in which circumstances supported self‐management is enacted and delivered within community stroke rehabilitation. Specifically, the study aimed to identify and explore contexts, mechanisms, and outcomes related to the delivery of collaborative supported self‐management. It comprised a realist synthesis, Q‐methodology study, and realist‐informed interviews and focus groups with stroke survivors (n = 20), community‐based stroke practitioners (n = 20), and community service delivery managers/clinical leads (n = 8) in stroke. The findings revealed that delivering supported self‐management effectively and consistently in community stroke rehabilitation starts with embedding the ethos of collaborative supported self-management across staff, teams, and the organisation and involves collaborative relationships with stroke survivors that aim to build trust, confidence, and resilience. The findings identified specific mechanisms and facilitatory and inhibitory contexts that influence how well this is enacted and achieved in practice. A realist approach in this study is novel and has helped to generate new insights and perspectives how and when supported self‐management approaches work in community stroke rehabilitation. The findings expand on and complement existing research on the efficacy of supported self‐management in stroke and are of clinical importance for informing how collaborative, relational supported self‐management approaches can be implemented, personalised, and tailored to people’s needs and evaluated within current healthcare systems.

Blood Pressure Variability (BPV) is associated with cardiovascular risk and serum uric acid level. We investigated whether BPV was lowered by allopurinol and whether it was related to neuroimaging markers of cerebral small vessel disease (CSVD) and cognition. We used data from a randomised, double-blind, placebo-controlled trial of two years allopurinol treatment after recent ischemic stroke or transient ischemic attack. Visit-to-visit BPV was assessed using brachial blood pressure (BP) recordings. Short-term BPV was assessed using ambulatory BP monitoring (ABPM) performed at 4 weeks and 2 years. Brain MRI was performed at baseline and 2 years. BPV measures were compared between the allopurinol and placebo groups, and with CSVD and cognition. 409 participants (205 allopurinol; 204 placebo) were included in the visit-to-visit BPV analyses. There were no significant differences found between placebo and allopurinol groups for any measure of visit-to-visit BPV. 196 participants were included in analyses of short-term BPV at week 4. Two measures were reduced by allopurinol: the standard deviation (SD) of systolic BP (by 1.30 mmHg (95% confidence interval (CI) 0.18–2.42, p = 0.023)); and the average real variability (ARV) of systolic BP (by 1.31 mmHg (95% CI 0.31–2.32, p = 0.011)). There were no differences in other measures at week 4 or in any measure at 2 years, and BPV was not associated with CSVD or cognition. Allopurinol treatment did not affect visit-to-visit BPV in people with recent ischemic stroke or TIA. Two BPV measures were reduced at week 4 by allopurinol but not at 2 years.

In 2023, the National Clinical Guidelines for Stroke revised the recommended daily multidisciplinary therapy dose from 45 minutes to 3 hours. To monitor the achievement of these guidelines there is a need for accurate measurement. This study introduces a novel co-designed digital dosage tracking system that utilises Near Field Communication (NFC) technology to log rehabilitation activities and demonstrates its feasibility and accuracy in a clinical setting through comparison with the current clinical method of manual recording. This study aimed to assess the validity, feasibility, and usability of a novel co-designed digital tracker using Near Field Communication (NFC) technology to automatically log rehabilitation dosage in stroke patients, providing an objective and low-burden solution for clinical environments. This pilot mixed-methods study included two phases. Phase 1 involved a usability trial with nine participants conducted at a university research centre, assessing usability with the System Usability Scale (SUS) and Intrinsic Motivation Inventory (IMI). Phase 2 consisted of a clinical trial in an NHS stroke ward with 15 inpatients, comparing the digital tracker with manual therapist recordings for validity and feasibility using paired t-tests, Cohen's D, and Bland-Altman plots. An acceptable discrepancy range was set at ±5-10%. The digital tracker demonstrated high usability with a mean SUS score of 91.43 (SD = 9.53) and strong user satisfaction (IMI score 6.29/7, SD = 1.50). Clinical trial results showed a strong agreement between the digital and manual methods (t(207)=-1.55, P=.12, Cohen’s D=-0.06), with a small mean time discrepancy of 1.18 minutes (SD = 10.98) across 208 activities. The Bland-Altman plot indicated good accuracy and consistency between methods, with limits of agreement within the clinically acceptable range. The co-designed digital tracker has been shown to agree with a manual method for recording rehabilitation dosage. This development presents the opportunity for objective, automated and low-burden recording of rehabilitation dose to support prescription, monitoring and research. ClinicalTrials.gov: NCT05981729 IRAS ID No. 329156

Background Anti-inflammatory therapy with long-term colchicine prevented vascular recurrence in coronary disease. Unlike coronary disease, which is typically caused by atherosclerosis, ischaemic stroke is caused by diverse mechanisms including atherosclerosis and small vessel disease or is frequently due to an unknown cause. We aimed to investigate the hypothesis that long-term colchicine would reduce recurrent events after ischaemic stroke. Methods We did a randomised, parallel-group, open-label, blinded endpoint assessed trial comparing long-term colchicine (05 mg orally per day) plus guideline-based usual care with usual care only. Hospital-based patients with non-severe, non-cardioembolic ischaemic stroke or high-risk transient ischaemic attack were eligible. The primary endpoint was a composite of first fatal or non-fatal recurrent ischaemic stroke, myocardial infarction, cardiac arrest, or hospitalisation (defined as an admission to an inpatient unit or a visit to an emergency department that resulted in at least a 24 h stay [or a change in calendar date if the hospital admission or discharge times were not available]) for unstable angina. The p value for significance was 0048 to adjust for two prespecified interim analyses conducted by the data monitoring committee, for which the steering committee and trial investigators remained blinded. The trial was registered at ClinicalTrials.gov (NCT02898610) and is completed. Findings 3154 patients were randomly assigned between Dec 19, 2016, and Nov 21, 2022, with the last follow-up on Jan 31, 2024. The trial finished before the anticipated number of outcomes was accrued (367 outcomes planned) due to budget constraints attributable to the COVID-19 pandemic. Ten patients withdrew consent for analysis of their data, leaving 3144 patients in the intention-to-treat analysis: 1569 (colchicine and usual care) and 1575 (usual care alone). A primary endpoint occurred in 338 patients, 153 (98%) of 1569 patients allocated to colchicine and usual care and 185 (117%) of 1575 patients allocated to usual care alone (incidence rates 332 vs 392 per 100 person-years, hazard ratio 084; 95% CI 068-105, p=012). Although no between-group difference in C-reactive protein (CRP) was observed at baseline, patients treated with colchicine had lower CRP at 28 days and at 1, 2, and 3 years (p<005 for all timepoints). The rates of serious adverse events were similar in both groups. Interpretation Although no statistically significant benefit was observed on the primary intention-to-treat analysis, the findings provide new evidence supporting the rationale for anti-inflammatory therapy in further randomised trials. Copyright (c) 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.

Introduction: There is evidence that sex differences exist in stroke presentation, risk factors, severity, treatment, and outcomes. To further understand this, we explored how sex differences influence acute stroke management, secondary prevention prescribing, and mortality outcomes in a well-characterised cohort of first-ever stroke patients in Scotland. Methods: This is a retrospective, population-based, data-linkage study of stroke admissions to acute care hospitals in Scotland between January 1, 2011, and December 31, 2018. Data sources included the Scottish Stroke Care Audit (SSCA), the Prescribing Information System (PIS), the Scottish Morbidity Record 01 (SMR01), and the National Records of Scotland (NRS) death records. Multivariable logistic regression was used to explore the association between patient sex, acute stroke care, and secondary prevention prescribing, while Cox proportional hazards models were used to explore the association between patient sex and all-cause mortality up to 1 year after index event. Results: This study included 5,901 patients with a first-ever intracerebral haemorrhage (ICH) and 47,087 patients with a first-ever acute ischaemic stroke (AIS). After an ICH, women had significantly lower odds of receiving all components of the stroke care bundle (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.69-0.87) and were less likely to be prescribed antihypertensives within 90 days after discharge to the usual place of residence (aOR, 0.78; 95% CI, 0.63-0.97). There was no sex difference in stroke care bundle achievement for those admitted with AIS; however, women had significantly lower odds of receiving antihypertensives, lipid-lowering drugs, or oral anticoagulants after discharge. The risk of all-cause mortality was lower in women at 1 year after both ICH (adjusted hazard ratio [aHR], 0.90; 95% CI, 0.83-0.98) and AIS (aHR, 0.91; 95% CI, 0.87-0.95) after adjusting for potential confounders. Conclusion: The sex differences in stroke treatment and outcomes may be partly explained by the older age of women at the time of stroke, which influences stroke presentation, severity, and prognosis. However, following adjustment, women had a reduced risk of all-cause mortality after both ICH and AIS. (c) 2024 The Author(s).Published by S. Karger AG, Basel

AbstractBackgroundAlthough morbidity and mortality from COVID-19 have been widely reported, the indirect effects of the pandemic beyond 2020 on other major diseases and health service activity have not been well described.Methods and resultsAnalyses used national administrative electronic hospital records in England, Scotland, and Wales for 2016–21. Admissions and procedures during the pandemic (2020–21) related to six major cardiovascular conditions [acute coronary syndrome (ACS), heart failure (HF), stroke/transient ischaemic attack (TIA), peripheral arterial disease (PAD), aortic aneurysm (AA), and venous thromboembolism(VTE)] were compared with the annual average in the pre-pandemic period (2016–19). Differences were assessed by time period and urgency of care.In 2020, there were 31 064 (−6%) fewer hospital admissions [14 506 (−4%) fewer emergencies, 16 560 (−23%) fewer elective admissions] compared with 2016–19 for the six major cardiovascular diseases (CVDs) combined. The proportional reduction in admissions was similar in all three countries. Overall, hospital admissions returned to pre-pandemic levels in 2021. Elective admissions remained substantially below expected levels for almost all conditions in all three countries [−10 996 (−15%) fewer admissions]. However, these reductions were offset by higher than expected total emergency admissions [+25 878 (+6%) higher admissions], notably for HF and stroke in England, and for VTE in all three countries. Analyses for procedures showed similar temporal variations to admissions.ConclusionThe present study highlights increasing emergency cardiovascular admissions during the pandemic, in the context of a substantial and sustained reduction in elective admissions and procedures. This is likely to increase further the demands on cardiovascular services over the coming years.

Background: After a stroke, inpatients often receive less than the recommended dose of therapy. Telerehabilitation may assist by providing personalised rehabilitation programmes without face-to-face therapy time. This study aimed to evaluate the acceptability and feasibility of an individualised programme of upper-limb rehabilitation that is delivered via an online rehabilitation platform for inpatient stroke survivors. Methods: Stroke survivors were recruited from three stroke units in one NHS Board in Scotland and randomised to the intervention (personalised upper-limb exercise programme delivered via an online physiotherapy platform for four weeks, up to 30 min five times per week, in addition to usual care) or the control group (usual care). The main outcomes are related to recruitment, attrition, adherence and safety. The clinical measures were the Action Research Arm Test, Trunk Impairment Scale and Modified Ashworth Scale. The intervention participants, their carers and physiotherapists completed questionnaires on the acceptability of the intervention. Results: Twenty-six participants, 42% males, were recruited around three weeks post-stroke, on average. There were 13 participants in each group, with a mean age of 69 years (SD of 12) and 67 years (SD of 11) for the control and intervention groups, respectively. Overall, 47% of those screened for eligibility were randomised, and attrition was 23% in the intervention group mainly due to discharge before the end of the intervention. Participants who adhered to their programme (completed more than two-thirds), generally those with an engaged carer, demonstrated a trend toward improved clinical outcomes. Overall, the patients, carers and physiotherapists were positive regarding the intervention. There was a total of five reported adverse events, none of which were related to the study. Conclusion: An upper-limb unsupervised exercise intervention using an online physiotherapy platform for inpatient stroke survivors is feasible, safe and acceptable to patients, carers and physiotherapists. A fully powered RCT is warranted to investigate the clinical- and cost-effectiveness of such interventions for this patient group.

BACKGROUND AND AIMS: Over the last decade, there have been significant advances in stroke prevention and care, including the use of the direct oral anticoagulants (DOACs) and the implementation of an acute stroke care bundle.This study aims to describe trends in hospital admissions for first-ever non-traumatic intracerebral haemorrhage (ICH), prior anticoagulation use, acute stroke care, discharge destination and mortality in a national Scottish cohort. METHODS:A national data linkage study using routinely collected health data in the Scottish Stroke Care Audit, the Prescribing Information System, inpatient and day-case discharges in the Scottish Morbidity Record 01, and mortality data in the National Records of Scotland between January 2011 and December 2018 with follow-up data to 90 days.Multivariable logistic regression models were adjusted for year of admission, sociodemographic factors, comorbidity burden, stroke severity and care bundle. RESULTS:Between 2011 and 2018, there were 5901 hospital admissions for a first-ever ICH (women 52.2%; mean age 74.26 [±12.70]years).Admissions for ICH rose from 10% (515 cases) of all stroke admissions in 2011 to 11.2% (857 cases) in 2018.Prescriptions for OAC within 90 days before admission doubled from 9.7% to 19.4% of patients.While warfarin prescriptions remained consistent (9.5% to 9.3%; p=0.851), prescriptions for DOACs increased from 1.0% in 2014 to 10.3% in 2018.Acute care also improved during the study period (stroke unit admission [65.4% to 74.6%]; brain scan within 12h [88.2% to 96.6%]; and early swallow screen [80.8% to 93.7%]).Discharge to usual place of residence within 30 days (adjusted Odds Ratio (aOR), 1.00; 95% confidence interval (CI), 0.97 -1.04) and 90 days (aOR, 1.00 [0.97 -1.04]) remained consistent between 2011 and 2018, while all-cause mortality within 30 days after stroke increased slightly (aOR, 1.05 [1.01 -1.08]), but not at 90 days after stroke (aOR, 1.03 [1.00 -1.06]). CONCLUSIONS:Although acute care measures improved over time, corrected 30-day, but not 90-day all-cause mortality increased over time.This might reflect better data collection, realistic medicine in frailer patients or worsening of haemorrhage related to anticoagulation and requires further explorations.

Background:People who experience an ischaemic stroke are at risk of recurrent vascular events, progression of cerebrovascular disease, and cognitive decline. We assessed whether allopurinol, a xanthine oxidase inhibitor, reduced white matter hyperintensity (WMH) progression and blood pressure (BP) following ischaemic stroke or transient ischaemic attack (TIA). Methods:In this multicentre, prospective, randomised, double-blinded, placebo-controlled trial conducted in 22 stroke units in the United Kingdom, we randomly assigned participants within 30-days of ischaemic stroke or TIA to receive oral allopurinol 300 mg twice daily or placebo for 104 weeks. All participants had brain MRI performed at baseline and week 104 and ambulatory blood pressure monitoring at baseline, week 4 and week 104. The primary outcome was the WMH Rotterdam Progression Score (RPS) at week 104. Analyses were by intention to treat. Participants who received at least one dose of allopurinol or placebo were included in the safety analysis. This trial is registered with ClinicalTrials.gov, NCT02122718. Findings:Between 25th May 2015 and the 29th November 2018, 464 participants were enrolled (232 per group). A total of 372 (189 with placebo and 183 with allopurinol) attended for week 104 MRI and were included in analysis of the primary outcome. The RPS at week 104 was 1.3 (SD 1.8) with allopurinol and 1.5 (SD 1.9) with placebo (between group difference -0.17, 95% CI -0.52 to 0.17, p = 0.33). Serious adverse events were reported in 73 (32%) participants with allopurinol and in 64 (28%) with placebo. There was one potentially treatment related death in the allopurinol group. Interpretation:Allopurinol use did not reduce WMH progression in people with recent ischaemic stroke or TIA and is unlikely to reduce the risk of stroke in unselected people. Funding:The British Heart Foundation and the UK Stroke Association.