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Publication Initial testing of an electronic application of the simplified modified Rankin Scale questionnaire (e-smRSq)(Elsevier, 2020-06-20) Dutta, Dipankar; Foy, Christopher; Ramadurai, Gopinath; Obaid, Mudhar; Bruno, Askiel; Dutta, Dipankar; Foy, Chris; Ramadurai, Gopinath; Obaid, Mudhar; Medical and Dental; Additional Professional Scientific and TechnicalIntroduction and purpose: To facilitate modified Rankin scale (mRS) assessments, we developed and tested a smartphone/web application of the simplified mRS questionnaire (e-smRSq). The e-smRSq guides raters towards a final score according to the smRSq algorithm, and offers hints for scoring based on the conventional mRS concepts. Methods: Initially, three experienced mRS certified raters prepared 30 vignettes of unstructured stroke patient interviews, and determined consensus reference scores. Using the e-smRSq, 16 raters of varied professional backgrounds without mRS training scored the mRS for 24 randomly selected vignettes. Subsequently, 5 certified and 5 uncertified raters using the e-smRSq scored 23 mRS certification vignettes developed and used in the Strategies to Innovate Emergency Care Clinical Trials Network-Neurological Emergencies Treatment Trials (SIREN-NETT). Cohen's and Fleiss's kappa (κ), weighted kappa (κw), and intra-class correlation (ICC) compared rater scores with reference scores and assessed interrater reliability. Results: For the 16 initial raters using the e-smRSq with 24 vignettes, the κ (Fleiss) was 0.62 and ICC 0.87 (CI 0.80-0.93). Comparing raters' scores with reference scores, Cohen's κ was 0.68 and κw 0.90. For the 10 subsequent raters using the e-smRSq on SIREN-NETT vignettes, κ (Fleiss) was 0.8 and ICC 0.95 (CI 0.91-0.97). Comparing all 10 raters scores with SIREN-NETT reference scores, Cohen's κ was 0.88 and κw 0.97. There was no significant difference between certified and uncertified raters. Conclusions: The e-smRSq appears to have good reproducibility and validity metrics among both certified and non-certified mRS raters, possibly owing to its simplicity. Further testing in stroke patients in warranted.Publication The importance of early completion of cardiac investigations after ischaemic stroke: a case and systematic review of reperfusion therapy in stroke due to cardiac fibroelastoma(Elsevier, 2020-11) Helliwell, Henrietta; Desai, Aishwarya; McCole, Mark; Beale, Andy; Ramadurai, Gopinath; Chandrasekaran, Badrinathan; Yiin, Gabriel; Ramadurai, Gopinath; Medical and DentalNo abstract availablePublication Mechanical thrombectomy in stroke – planning for service expansion using discrete event simulation(Elsevier, 2020-02-29) Dutta, Dipankar; Parry, Frances; Obaid, Mudhar; Ramadurai, Gopinath; Dutta, Dipankar; Parry, Frances; Obaid, Mudhar; Ramadurai, Gopinath; Medical and DentalMechanical thrombectomy (MT) is a very effective, but highly time dependent, reperfusion technique in the management of acute ischaemic stroke caused by large artery occlusion. MT is provided by 24 neuroscience centres (NSCs) in the UK which receive patients directly ('mothership') and via transfer from district general hospitals (DGHs), the 'drip and ship' pathway. NSCs currently provide a within hours service but are working on service expansion to enable 24/7 availability. DGHs, too, will need to prepare for this service expansion to ensure good outcomes for their patients. We discuss options for service expansion in a DGH and regional stroke network in south-west England and use Sentinel Stroke National Audit Programme data and discrete event simulation to model and compare alternative workflow options to aid the planning process. We suggest that our modelled options could be considered by all NHS DGHs in their preparation for MT service expansion.Publication Posterior Cerebral Circulation Stroke Secondary to Foetal Origin of Posterior Communicating Artery: An Indication for Carotid Endarterectomy(Elsevier, 2020-12-16) Mann, Lydia; Preece, Ryan; Haslam, Liz; Paravastu, Sharath; bulbulia, richard; Kulkarni, Sachin; Mann, Lydia; Preece, Ryan; Haslam, Liz; Paravastu, Sharath; Bulbulia, Richard; Kulkarni, Sachin; Medical and DentalIntroduction: Posterior cerebral circulation strokes are most commonly caused by posterior vasculature in situ thrombosis, cardiac emboli, or arterial dissection. However, the foetal origin of the posterior communicating artery is an anatomical variant of the cerebral circulation that results in communication between the internal carotid and posterior cerebral circulation. Therefore, rarely this can result in posterior cerebral territory infarction from internal carotid artery thrombo-embolism. This is the report of a case in which a patient suffered posterior circulation stroke secondary to this anatomical variation of the circle of Willis. Report: A 71 year old male patient was admitted to the stroke team with seizures, headache, and confusion. Examination revealed a left sided homonymous hemianopia. Diffusion weighted magnetic resonance imaging (MRI) of the brain 36 hours into his admission revealed an acute right posterior circulation infarct with extensive haemorrhagic transformation. Duplex ultrasound three days later revealed a heavily calcified right internal carotid artery mixed echogenicity plaque with 80%-90% stenosis. Subsequent computed tomography angiography showed a large right foetal variant posterior communicating artery. Following improvement in functional status, the patient underwent uneventful carotid endarterectomy to reduce risk of future stroke. Discussion: In patients presenting with posterior circulation infarction, clinicians should consider embolism from an atheromatous internal carotid artery via the variant foetal origin of posterior communicating artery. If detected, consideration should be given to undertaking carotid endarterectomy to reduce future stroke risk if no other source is detected.Publication Cerebral venous sinus thrombosis after resolution of COVID-19 in a non-hospitalised patient(Oxford University Press, 2021-07-21) Saad, Toni; Golestani, Farhad; Saad, Toni; Golestani, Farhad; Medical and DentalNo abstract availablePublication Long-Term Risk of Stroke After Transient Ischemic Attack or Minor Stroke: A Systematic Review and Meta-Analysis(American Medical Association, 2025-05-06) Khan, Faizan; Yogendrakumar, Vignan; Lun, Ronda; Ganesh, Aravind; Barber, Philip; Vasileios-Arsenios, Lioutas; Emborg Vinding, Naja; Algra, Ale; Weimar, Christian; Ogren, Joachim; Edwards, Jodi; Swartz, Richard; Ois, Angel; Giralt-Steinhauer, Eva; Netland Khanevski, Andrej; Leng, Xinyi; Tian, Xuan; Leung, Thomas; Park, Hong-Kyun; Bae, Hee-Joon; Kamouch, Masahiro; Ago, Tetsuro; Verburgt, Esmee; Verhoeven, Jamie; de Leeuw, Frank-Erik; Berghout, Bernard; Ikram, Kamran; Kostev, Karel; Whiteley, William; Uehara, Toshiyuki; Minematsu, Kazuo; Ildstad, Fredrik; Fandler-Höfler, Simon; Aarnio, Karoliina; von Sarnowski, Bettina; Foschi, Matteo; Jing, Jing; Baik, Minyoul; Kim, Young Dae; Spampinato, Michele; Hasegawa, Yasuhiro; Perera, Kanjana; Purroy, Francisco; Dutta, Dipankar; Yang, Xiaoli; Lippert, Julian; Myers, Laura; Bravata, Dawn; Santos, Monica; Coveney, Sarah; Garcia-Esperon, Carlos; Levi, Christopher; Lorenzetti, Diane; Vatanpour, Shabnam; Wang, Yongjun; Albers, Gregory; Lavallee, Philippa; Amarenco, Pierre; Coutts, Shelagh; Hill, Michael; Dutta, Dipankar; Medical and DentalImportance After a transient ischemic attack (TIA) or minor stroke, the long-term risk of stroke is not well-known. Objective To determine the annual incidence rates and cumulative incidences of stroke up to 10 years after TIA or minor stroke. Data Sources MEDLINE, Embase, and Web of Science were searched from inception through June 26, 2024. Study Selection Prospective or retrospective cohort studies reporting stroke risk during a minimum follow-up of 1 year in patients with TIA or minor stroke. Data Extraction and Synthesis Two reviewers independently performed data extraction and assessed study quality. Unpublished aggregate-level data on number of events and person-years during discrete follow-up intervals were obtained directly from the authors of the included studies to calculate incidence rates in individual studies. Data across studies were pooled using random-effects meta-analysis. Main Outcomes and Measures The primary outcome was any stroke. Study-level characteristics were investigated as potential sources of variability in stroke rates across studies. Results The analysis involved 171 068 patients (median age, 69 years [IQR, 65-71]; median proportion of male patients, 57% [IQR, 52%-60%]) from 38 included studies. The pooled rate of stroke per 100 person-years was 5.94 events (95% CI, 5.18-6.76; 38 studies; I2 = 97%) in the first year, 1.80 events (95% CI, 1.58-2.04; 25 studies; I2 = 90%) annually in the second through fifth years, and 1.72 events (95% CI, 1.31-2.18; 12 studies; I2 = 84%) annually in the sixth through tenth years. The 5- and 10-year cumulative incidence of stroke was 12.5% (95% CI, 11.0%-14.1%) and 19.8% (95% CI, 16.7%-23.1%), respectively. Stroke rates were higher in studies conducted in North America (rate ratio [RR], 1.43 [95% CI, 1.36-1.50]) and Asia (RR, 1.62 [95% CI, 1.52-1.73]), compared with Europe, in cohorts recruited in or after 2007 (RR, 1.42 [95% CI, 1.23-1.64]), and in studies that used active vs passive outcome ascertainment methods (RR, 1.11 [95% CI, 1.07-1.17]). Studies focusing solely on patients with TIA (RR, 0.68 [95% CI, 0.65-0.71) or first-ever index events (RR, 0.45 [95% CI, 0.42-0.49]) had lower stroke rates than studies with an unselected patient population. Conclusions and Relevance Patients who have had a TIA or minor stroke are at a persistently high risk of subsequent stroke. Findings from this study underscore the need for improving long-term stroke prevention measures in this patient group.Publication Real-world management, resource use, patient-reported outcomes and adherence in patients receiving direct oral anticoagulants for first stroke attributed to non-valvular atrial fibrillation in secondary care: A UK mixed-methods observational study(Public Library of Science, 2025-05-23) Uprichard, James; Zhang, Liqun; Dixit, Anand; Bhat, Yaqoob; Mistri, Amit; Dutta, Dipankar; Rashed, Khalid; Karunatilake, Dumin; Hatton, Chris; Eva, Joe; Reed, Amelia; Dutta, Dipankar; Medical and DentalThis real-world study investigated the patient-related factors, characteristics, and outcomes of adult patients with non-valvular atrial fibrillation (NVAF) receiving a direct oral anticoagulant (DOAC) for secondary stroke prevention. This was a multi-centre, mixed-methods, non-interventional study conducted in 8 UK secondary care National Health Service centres. The study included adult patients who presented with first ischaemic stroke associated with NVAF without previous anticoagulants. Group 1 included all patients. Group 2 is comprised of prospectively enrolled patients who were initiated on apixaban (n = 49), edoxaban (n = 39) or rivaroxaban (n = 5) post-first stroke from Group 1. The primary objective (Group 1) was to describe patients’ demographics, clinical characteristics, and medical history, stratified by the anticoagulant prescribed. The secondary objectives (Group 2) were to describe the patient management pathways, hospital resource use and clinical assessments associated with DOAC treatment, and the patient-reported satisfaction and experience of DOAC treatment. 234 patients were recruited from 8 centres (Group 1). Baseline CHA2DS2-VASc risk scores ranged from 2–7; 70% (157/224) had a score of ≥4. 86% (n = 202/234) of patients presented with stroke at accident and emergency. For Group 2, the median time from stroke to first DOAC dose was 6 (IQR, 2.0–10.2; n = 88) days; 50% patients had ≥ 1 outpatient visit recorded related to AF or DOACs. At 3 and 6 months, 73% (46/63) and 83% (43/52) had high (score of 8) Morisky Medication Adherence Scale score (MMAS-8), respectively. No patients reported being dissatisfied at 3 or 6 months post-DOAC initiation. The study findings demonstrate high levels of adherence, persistence, and treatment satisfaction in the 6 months post-initiation of DOAC after first stroke attributable to NVAF in patients. The presented results provide clinicians with valuable insights into the experience of post-stroke patients with NVAF receiving treatment with a DOAC for secondary prevention of stroke during the 6 months post-stroke.Publication Perioperative Stroke(Nature Research, 2024-01-18) Fanning, Jonathon; Campbell, Bruce; Bulbulia, Richard; Gottesman, Rebecca; Ko, Sang-Bae; Floyd, Thomas; Messé, Steven; Bulbulia, Richard; Medical and DentalIschaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.