Serial NIHSS scores in patients with acute cerebral infarction

Observation on the short-term efficacy of inverse moxibustion at the Baihui point and Dazhui point in preventing post-stroke depression

OBJECTIVE

In this study, inverse moxibustion was performed at the Baihui and Dazhui points in patients with ischemic stroke, and the Hamilton Depression Rating Scale 17 (HAMD) score, National Institute of Health Stroke Scale (NIHSS) score, modified Barthel index (MBI) score, and incidence of post-stroke depression (PSD) were observed.

METHODS

Eighty patients with acute ischemic stroke were enrolled and randomly divided into two groups. All enrolled patients were given routine treatment for ischemic stroke, and those in the treatment group were also given moxibustion at the Baihui and Dazhui points. The course of treatment was four weeks. The HAMD, NIHSS, and MBI scores of the two groups were evaluated before and four weeks after the treatment. The differences between the groups and the incidence of PSD were evaluated to determine the effect of inverse moxibustion at the Baihui and Dazhui points on the HAMD, NIHSS, and MBI scores and prevention of PSD in patients with ischemic stroke.

RESULTS

After the four weeks of treatment, the HAMD and NIHSS scores of the treatment group were lower than those of the control group, their MBI was higher than that of the control group, and their incidence of PSD was statistically significantly lower than that of the control group.

CONCLUSION

Inverse moxibustion at the Baihui acupoint in patients with ischemic stroke can effectively promote the recovery of neurological function, improve depression, and reduce the incidence of PSD and should be considered for application in clinical practice.

Efficacy of Fuyuan Xingshen Decoction Combined with Butylphthalide Sodium Chloride Injection in the Treatment of Acute Cerebral Infarction and Its Effect on Hemodynamics

Objective. This study aims to determine the curative effect of Fuyuan Xingshen Decoction combined with butylphthalide sodium chloride injection in acute cerebral infarction (ACI) treatment and its effect on hemodynamics. Methods. In our hospital, a total of 84 ACI patients from May 2020 to February 2022 were randomly divided into two groups: observation and control (n = 42 each). Fuyuan Xingshen Decoction in combination with butylphthalide sodium chloride injection was provided to the observation group, while the control group received butylphthalide sodium chloride injection alone. Both groups’ clinical efficacy was observed. Before and after treatment, the neurological function of the two groups was evaluated using the National Institutes of Health Stroke Scale (NIHSS), while the daily living ability of both groups was determined using the Barthel index rating scale. Both groups were investigated for their cognitive function, before and after treatment, by using the Mini-Cog scale and Montreal Cognitive Assessment (MoCA) scale. The pulsatility index (PI), peak velocity (Vp), and mean velocity (Vm) of intracranial arteries were measured by transcranial Doppler ultrasonography before and after treatment. The levels of ubiquitin carboxy-terminal hydrolase-1 (UCH-L1), Fibulin-5, and visinin-like protein-1 (VILIP-1) in serum and the expression levels of miR-34c, miR-25, and miR-182 in peripheral blood of the two groups were compared. Both groups were observed for the incidence of adverse reactions. Results. Compared with the control (71.43%), the observation group exhibited a significantly higher effective rate of around 90.48%. In the observation group, the improvement in NIHSS, Barthel index, Mini-cog, and MoCA scores; hemodynamic indexes including Vp, PI, and Vm; serum UCH-L1, Fibulin-5, and VILIP-1 levels; and the miR-34c, miR-25, and miR-182 expression levels in peripheral blood was better than the control group, with significant difference (all $P<0.05$ ). The incidence of adverse reactions between the groups demonstrated no significant differences ( $P>0.05$ ). Conclusions. Fuyuan Xingshen Decoction combined with butylphthalide sodium chloride injection can effectively improve patients’ daily living ability, neurological function, cognitive function, and cerebral hemodynamics in the treatment of ACI, with good effect and safety.

Correlation between Collateral Compensation and Homocysteine Levels in Patients with Acute Cerebral Infarction after Intravenous Thrombolysis Based on Medical Big Data

Homocysteine is an amino acid present in plasma, which is an important intermediate product in the metabolism of methionine and cysteine. Acute cerebral infarction (CI) is called acute CI of stroke. It is one of the most common diseases in neurology and has a serious impact, affecting people's lives. This article is aimed at studying the effect of data mining algorithms based on medical big data and the improved apriori algorithm on the analysis of the correlation between collateral compensation and homocysteine levels in patients with acute CI. This article proposes that there are many factors in patients with acute CI, among which are collateral compensation and homocysteine levels that are not easily determined. From the data in the tables in the experiment of this article, it can be seen that the collateral circulation of patients with acute CI is 8%, and the collateral circulation of patients without acute CI is 35%. The results indicate that both collateral compensation and homocysteine levels affect patients with acute CI. The higher the homocysteine level, the greater the probability of acute CI, and the better the state of collateral circulation, the less likely it is to suffer from acute CI.

Intravenous Thrombolysis Combined with Arterial Thrombolysis (Bridging Therapy) Effectively Improves Vascular Recanalization Rate in Patients with Cerebral Infarction

Objective

To explore the efficacy of intravenous thrombolysis combined with arterial thrombolysis (bridging therapy) in patients with acute cerebral infarction and its effect on serum inflammatory factors.

Methods

The case data of 138 patients with acute cerebral infarction admitted to our hospital from February 2019 to February 2021 were retrospectively analyzed. According to the treatment plan they received, patients were assigned to two groups, namely, an observation group (n = 71) treated with bridging therapy and a control group (n = 67) treated with intravenous thrombolysis alone. The following indexes were recorded and compared between the two groups: treatment efficacy, National Institutes of Health Stroke Scale (NIHSS) score, activities of daily living, incidence rates of vascular recanalization, intracranial hemorrhage and reembolization after treatment, levels of inflammatory factors before and after treatment, levels of prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen (FIB) before and 1 week after treatment, and modified Rankin Scale scores 1, 3, and 6 months after treatment.

Results

Compared with the control group, the therapeutic efficacy, neurological function, activities of daily living, and vascular recanalization were markedly better in the observation group (P > 0.05). In addition, the incidence of intracranial hemorrhage and reembolization was statistically lower in the observation group (P < 0.05). No marked difference was found between the two groups in terms of pretreatment serum inflammatory factors and coagulation function (P > 0.05), while the above indicators improved statistically after treatment in both groups, with comparatively more obvious improvement in the observation group. It was also observed that, compared with the control group, the modified Rankin Scale score in the observation group was significantly better at 3 and 6 months after treatment (P < 0.05).

Conclusion

Bridging therapy can improve the vascular recanalization rate among patients suffering from acute cerebral infarction, reduce the incidence of intracranial hemorrhage and reembolization, and improve the prognosis and neurological function of patients, which is worthy of clinical application.

Effect of Danhong injection on neurological recovery and adverse events in patients with acute ischemic stroke: A protocol for a randomized, double-blind, placebo-controlled clinical study

BACKGROUND

Acute ischemic stroke (AIS) is characterized by high disabling and recurrent recurrence, and its severe neurological impairment and vascular adverse events (AEs) limit the recovery of patients. Danhong injection is a complementary alternative to the treatment of AIS, and previous studies have demonstrated its efficacy and safety. However, there is no long-term follow-up and rigorous clinical study to evaluate the effect of Danhong injection on neurological recovery and AEs in patients with AIS.

METHODS

This is a prospective randomized, double-blind, placebo-controlled trial investigating the effect of Danhong injection on neurological recovery and AEs in patients with AIS. Participants were randomly divided into treatment and control groups in a 1:1 ratio. The treatment group was treated with Danhong injection and the control group were treated with placebo under the guideline recommended basic treatment. After 14 days of continuous treatment, the follow-up period was 6 months. Observation indicators include: National Institute of Health Stroke Scale, modified Rankin scale, symptomatic intracranial hemorrhage, the incidence of new major vascular events within 6 months, and all-cause mortality. Finally, the data were analyzed statistically using the SPASS 22.0 software.

DISCUSSION

This study will evaluate the effect of Danhong injection on neurological recovery and AEs in AIS. The results will provide a reference for the clinical use of AIS.

Efficacy and safety of intravenous thrombolysis with alteplase for treating acute ischemic stroke at different time windows: A protocol for systematic review and meta-analysis

BACKGROUND

As the priority drug for treating acute ischemic stroke (AIS), alteplase is a thrombolytic drug with strong fibrin specificity. It can obviously treat AIS with high safety. However, the validity of its time window is controversial. This study focus on the efficacy and safety of intravenous thrombolysis with alteplase for treating AIS at different time windows.

METHODS

Retrieval of English database (PubMed, Embase, Web of Science, the Cochrane Library) and Chinese database was conducted (China National Knowledge Infrastructure, WAN FANG, VIP, China Biology Medicine disc) by computers. From the establishment of the database to October 2020, a retrospective study and case-control study on intravenous thrombolysis at different time windows for treating AIS were conducted. Two researchers independently conducted data extraction and quality evaluation of literature on the included studies, and RevMan5.3 was used for Meta-analysis on the included literature.

RESULTS

This study aims to evaluate the efficacy and safety of intravenous thrombolysis with alteplase at different time windows for treating AIS by National Institutes of Health Stroke Scale score, modified Rankin Scale rating scale, spontaneous intracerebral hemorrhage incidence rate, All-cause mortality, and so on.

CONCLUSIONS

This study will provide an evidence-based basis for the clinical efficacy of alteplase for treating AIS by thrombolytic therapy at different time windows.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval was not required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605 / OSF.IO / K7PHB.

Serum Occludin as a Biomarker to Predict the Severity of Acute Ischemic Stroke, Hemorrhagic Transformation, and Patient Prognosis

Blood-brain barrier (BBB) damage plays an important role in overall brain injury following acute ischemic stroke (AIS). We investigated the potential utility of serum occludin, a BBB damage biomarker, in predicting the severity of AIS, hemorrhagic transformation (HT) and patient prognosis. A total of 243 patients, suspected of suffering an AIS and admitted to the emergency room at Xuanwu Hospital between November 2018 to March 2019, were enrolled in this study. Serum occludin levels were measured by enzyme linked immunosorbent assay and clinical data were collected from each patient. Receiver operating characteristic curves (ROC) were used to analyze the relationship between serum occludin and AIS. Multiple logistic regression analysis was used to analyze the relationship between serum occludin and stroke prognosis. Serum occludin levels were significantly elevated in acute stroke cases compared with those with stroke-like symptoms (P<0.001). In the moderate and severe cerebral infarction (CI) groups, serum occludin levels were significantly higher than those in the mild CI group (P<0.001). Patients with HT had higher occludin levels than non-HT patients (P<0.05). In addition, serum occludin level of patients with poor prognosis was significantly higher than that of the patients with good prognosis for non-reperfusion therapy. The ROC curve showed that serum occludin could reasonably predict HT and poor prognosis. Moreover, serum occludin were independently associated with 90-day poor prognosis. These findings suggest that the serum occludin levels could be used to identify early acute stroke cases and may predict the severity of AIS and HT as well as the prognosis at 90 days.

Hyperbaric oxygen for severe traumatic brain injury: a randomized trial

OBJECTIVE

The present study aimed to explore the effects of hyperbaric oxygen therapy on the prognosis and neurological function of patients with severe traumatic brain injury.

METHODS

A prospective study was carried out in 88 patients diagnosed with severe brain injury at our hospital and they were enrolled as research participants and randomly assigned to control and experimental groups (n = 44 per group) using a random number table method. Both groups underwent routine treatment. Patients in the experimental group were administered hyperbaric oxygen therapy approximately 1 week after admission when their vital signs had stabilized.

RESULTS

No significant intergroup differences were observed in the Glasgow Coma Scale (GCS) and U.S. National Institutes of Health Stroke Scale (NIHSS) scores before treatment. However, after oxygen treatment, compared with the control group, the experimental group showed higher GCS and lower NIHSS scores. The GCS score at admission, tracheotomy status, and first hyperbaric oxygen therapy duration were independent prognostic factors in patients with severe traumatic brain injury.

CONCLUSION

Hyperbaric oxygen therapy may promote recovery of neurological function and improve the cognitive function and prognosis of patients with severe traumatic brain injury.

Clinical efficacy of aspirin combined with clopidogrel in treating cerebral infarction and its effect on serum hs-CRP, sICAM-1 and TNF-α

Clinical efficacy of aspirin combined with clopidogrel in treating cerebral infarction and its influence on serum high-sensitivity C-reactive protein (hs-CRP), soluble intercellular adhesion molecule-1 (sICAM-1) and tumor necrosis factor-α (TNF-α) were explored. Ninety patients with acute cerebral infarction treated in Yidu Central Hospital of Weifang were analyzed, and those treated with aspirin alone were group A (n=40) and those treated with aspirin and clopidogrel were group B (n=50) according to the different treatment plans. The NIHSS score, total effective rate and incidence rate of adverse reactions after treatment and admission were compared between the two groups. The expression level of hs-CRP was detected by enzyme-linked immunosorbent assay, and the expression levels of sICAM-1 and TNF-α were analyzed by radioimmunoassay before treatment and three weeks after surgery, respectively, and they were analyzed and compared. After treatment, the total effective rate of patients in group B was significantly higher than that of group A (P<0.05). The general clinical baseline information, NIHSS score, and the expression levels of hs-CRP, sICAM-1, and TNF-α of patients in group B were significantly improved after treatment compared with those before treatment (P<0.05), and the NIHSS score and the expression levels of serum hs-CRP, sICAM-1, and TNF-α of those in group B were significantly lower than those in group A (P<0.05). Combination therapy of aspirin and clopidogrel can improve cerebral infarction effectively, and inhibit the expression levels of hs-CRP, sICAM-1 and TNF-α more effectively than aspirin alone.

Stroke severity quantification by critical care physicians in a mobile stroke unit

BACKGROUND

Cerebral revascularization in acute stroke requires robust diagnostic tools close to symptom onset. The quantitative National Institute of Health Stroke Scale (NIHSS) is widely used in-hospital, whereas shorter and less specific stroke scales are used in the prehospital field. This study explored the accuracy and potential clinical benefit of using NIHSS prehospitally.

PATIENTS AND METHODS

Thirteen anesthesiologists trained in prehospital critical care enrolled patients with suspected acute stroke in a mobile stroke unit. NIHSS was completed twice in the acute phase: first prehospitally and then by an on-call resident neurologist at the receiving hospital. The agreement between prehospital and in-hospital NIHSS scores was assessed by a Bland-Altman plot, and inter-rater agreement for predefined clinical categories was tested using Cohen's κ.

RESULTS

This Norwegian Acute Stroke Prehospital Project study included 40 patients for analyses. The mean numerical difference between prehospital and in-hospital NIHSS scores was 0.85, with corresponding limits of agreement from - 5.94 to 7.64. Inter-rater agreement (κ) for the corresponding clinical categories was 0.38. A prehospital diagnostic workup (NIHSS and computed tomographic examination) was completed in median (quartiles) 10 min (range: 7-14 min). Time between the prehospital and in-hospital NIHSS scores was median (quartiles) 40 min (32-48 min).

CONCLUSION

Critical care physicians in a mobile stroke unit may use the NIHSS as a clinical tool in the assessment of patients experiencing acute stroke. The disagreement in NIHSS scores was mainly for very low values and would not have changed the handling of the patients.

Magnitude of Benefit of Combined Endovascular Thrombectomy and Intravenous Fibrinolysis in Large Vessel Occlusion Ischemic Stroke

Background and Purpose—

Quantifying the benefit magnitude of combined endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) versus nonreperfusion care in patients with acute ischemic stroke caused by large vessel occlusion would aid organization of regional stroke care systems.

Methods—

NINDS rt-PA Study (National Institute for Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator) and SWIFT PRIME trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment) patients were matched for prognosis (based on age and National Institutes of Health Stroke Scale) and definite/likely anterior circulation large vessel occlusion (based on National Institutes of Health Stroke Scale total score and item pattern), using optimal inverse variance matching, to determine comparative outcomes with nonreperfusion care alone, IVT alone, and IVT+EVT.

Results—

Matching yielded 240 patients, including 80 each treated with nonreperfusion care, IVT alone, and IVT+EVT, with, respectively, mean age 67.1, 67.1, and 66.9 and presenting deficit severity (National Institutes of Health Stroke Scale) mean 15.8, 15.9, and 15.9. Outcomes at 3 months for IVT+EVT versus nonreperfusion care included freedom from disability (modified Rankin Scale score, 0–1) 48.1% versus 21.3%, P =0.0004; functional independence (modified Rankin Scale score, 0–2) 62.9% versus 32.6, P =0.0001; and reduced disability over all 7 modified Rankin Scale levels, common odds ratio 3.34, P <0.0001. Outcomes for IVT alone versus nonreperfusion care included: freedom from disability 30.0% versus 21.3%, P =0.28 and reduced disability over all 7 modified Rankin Scale levels, common odds ratio 1.14, P =0.65. Compared with nonreperfusion care, the number needed to treat with EVT+IVT for 1 more patient to have reduced disability was 1.8.

Conclusions—

Matched patient analysis across randomized trials provides evidence that the strategy of combined IVT and mechanical thrombectomy is a highly beneficial treatment strategy for acute ischemic stroke caused by large vessel occlusion patients. A reasonable effect magnitude estimate is that, among every 100 patients treated, combined IVT+EVT reperfusion therapy, compared with no reperfusion therapy, reduces long-term disability in 57, including conferring functional independence upon 30.

Frequency of early rapid improvement in stroke severity during interfacility transfer

Background

As interfacility transfer of patients with stroke becomes increasingly common, understanding fluctuations in deficits during transfer may help predict resource needs. We sought to characterize changes in NIH Stroke Scale (NIHSS) scores during transfer and identify factors associated with early rapid improvement (ERI).

Methods

We used prospectively collected data from our Comprehensive Stroke Center's (CSCs) stroke and telestroke network databases. We calculated changes in NIHSS scores for all patients transferred to our CSC after an initial telestroke evaluation from January 2010 to December 2015. Logistic regression identified factors associated with ERI, controlling for patient characteristics available on arrival.

Results

Among the 505 patients included, the median initial NIHSS score was 11 (interquartile range [IQR] 5-18), and on CSC arrival, it was 9 (IQR 3-17), with a median change of 0 (-3 to -0). Of note, 74.5% of scores changed by fewer than 4 points (7% increased ≥4 points, and 19% decreased ≥4). In 85% of cases, the NIHSS score change did not cross a threshold to alter eligibility for thrombectomy. In multivariable modeling, ERI was associated with ability to ambulate before the index stroke (odds ratio [OR] 5.79, p = 0.02) and higher initial NIHSS (OR 1.06 per point, p = 0.001).

Conclusions

These findings may be valuable for resource planning and for inclusion in thrombectomy alert activation processes at the receiving hospital.

Endovascular Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Prospects

Intracranial atherosclerotic stenosis (ICAS) is a common cause of transient ischemic attack (TIA) and ischemic stroke. Endovascular treatment, including balloon angioplasty alone, balloon-mounted stents, and self-expandable stent placement with or without prior angioplasty, is an alternative to medical treatment for the prevention of recurrent TIA or ischemic stroke in patients with ICAS. Although the SAMMPRIS and VISSIT trials supported medical management alone against endovascular treatments, both randomized controlled trials (RCT) were criticized due to flaws relating to patient-, intervention-, and operator-related factors. In this review, we discuss the current debate regarding these aspects and suggest approaches to solve current controversies in the future. In our opinion, endovascular treatment in carefully selected patients, individualized choice of endovascular treatment subtypes, and an experienced multidisciplinary team managing the patient in the pre-, peri- and post-procedural period have the potential to provide safe and efficious treatment of patients with symptomatic ICAS.

Differences in Therapeutic Responses and Factors Affecting Post-Stroke Depression at a Later Stage According to Baseline Depression

Background and Purpose

The pathophysiology of post-stroke depression (PSD) is complex and may differ according to an individual’s mood immediately after stroke. Here, we compared the therapeutic response and clinical characteristics of PSD at a later stage between patients with and without depression immediately after stroke.

Methods

This study involved a post hoc analysis of data from EMOTION (ClinicalTrials.gov NCT01278498), a placebo-controlled, double-blind trial that examined the efficacy of escitalopram (10 mg/day) on PSD and other emotional disturbances among 478 patients with acute stroke. Participants were classified into the Baseline-Blue (patients with baseline depression at the time of randomization, defined per the Montgomery-Asberg Depression Rating Scale [MADRS] ≥8) or the Baseline-Pink groups (patients without baseline depression). We compared the efficacy of escitalopram and predictors of 3-month PSD (MADRS ≥8) between these groups.

Results

There were 203 Baseline-Pink and 275 Baseline-Blue patients. The efficacy of escitalopram in reducing PSD risk was more pronounced in the Baseline-Pink than in the Baseline-Blue group (p for interaction=0.058). Several risk factors differentially affected PSD development based on the presence of baseline depression (p for interaction <0.10). Cognitive dysfunction was an independent predictor of PSD in the Baseline-Blue, but not in the Baseline-Pink group, whereas the non-use of escitalopram and being female were more strongly associated with PSD in the Baseline-Pink group.

Conclusions

Responses to escitalopram and predictors of PSD 3 months following stroke differed based on the presence of baseline depression. Our data suggest that PSD pathophysiology is heterogeneous; therefore, different therapeutic strategies may be needed to prevent PSD emergence following stroke.

Circadian variation in clinical features and outcome of intracerebral hemorrhage: The INTERACT studies

Previous studies consistently reported a diurnal variation in the occurrence of intracerebral hemorrhage (ICH), with a morning peak. However, limited knowledge exists on the circadian pattern of ICH severity and outcome. This study aimed to determine possible associations between ICH onset time and admission severity and 90-day outcomes using the combined data set of the pilot and main-phase Intensive blood pressure (BP) reduction in an acute cerebral hemorrhage trial (INTERACT). The ICH onset time was categorized into three groups (1: 00:00-07:59; 2: 08:00-15:59; and 3: 16:00-23:59). We found an association between onset time and low Glasgow Coma Scale score: aOR (time 1: 1.72, 95% CI 1.12-2.66; time 3: 1.95, 95% CI 1.31-2.89, p = 0.003; in comparison to time 2). There was no association between onset time and volume of ICH (adjusted p = 0.354) or 90-day outcomes of death or major disability, and death and major disability separately (all adjusted p > 0.4). The results showed that more severe cases of ICH patients, defined by a reduced level of consciousness, had late afternoon to early morning stroke onset, but this was unrelated to baseline hematoma volume or location. There was no circadian influence on ICH clinical outcome.