Is the association of National Institutes of Health Stroke Scale scores and acute magnetic resonance imaging stroke volume equal for patients with right- and left-hemisphere ischemic stroke?

Malignant Brain Edema and Associated Factors in Large Hemispheric Infarction Following Reperfusion Therapy

OBJECTIVE

This study aimed to explore Malignant Brain Edema (MBE) and associated factors in patients with Large Hemispheric Infarction (LHI) following early reperfusion therapy.

METHODS

We consecutively and retrospectively enrolled a cohort of 114 LHI patients who had received early reperfusion therapy, including Intravenous Thrombolysis (IVT) or Endovascular Therapy (EVT) at the hyperacute stage of stroke between January 2009 and December 2018. MBE was defined as a midline shift ≥5 mm, accompanied by signs of herniation. Multivariate logistic analyses were conducted to identify independent factors associated with MBE in LHI patients following early reperfusion therapy.

RESULTS

Among the enrolled patients, 69 (60.53%) were treated with IVT alone and 45 (39.47%) with EVT. Successful recanalization was achieved in 56 (49.12%) patients, while complete recanalization was achieved in 38 (33.33%) patients. After early reperfusion therapy, 50 (43.86%) developed MBE in LHI patients. The MBE group showed higher rates of in-hospital death (54% vs. 4.69%), 3-month mortality (64% vs. 10.94%), and 3-month unfavorable outcomes (90% vs. 64.06%) (all p<0.01). Neither different reperfusion therapy (EVT vs. IVT alone) nor different recanalization status (complete recanalization or not) was independently associated with the development of MBE in LHI patients following reperfusion therapy in multivariate analyses. MBE was independently associated with age [Odds Ratio (OR) 0.953, 95% confidence interval (CI) 0.910-0.999, p =0.044], right hemisphere stroke (OR 4.051, 95% CI 1.035-15.860, p =0.045), previous ischemic stroke or TIA (OR 0.090, 95% CI 0.014-0.571, p =0.011), and hypodensity >1/3 MCA territory (OR 8.071, 95% CI 1.878-34.693, p =0.005). Meanwhile, patients with lower baseline Alberta Stroke Program Early CT Score (ASPECTS) had a trend of higher incidence of MBE following reperfusion therapy (OR 0.710, 95% CI 0.483-1.043, p =0.081).

CONCLUSION

MBE occurred in nearly one-half of LHI patients following early reperfusion therapy and was related to poor outcomes. An increased risk of MBE was found to be associated with younger age, right hemisphere stroke, absence of a history of ischemic stroke or TIA, and hypodensity >1/3 MCA region on baseline CT images.

Amide Proton Transfer-Weighted MRI, Associations with Clinical Severity and Prognosis in Ischemic Strokes

BACKGROUND

The National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale (mRS) scores have important shortcomings. Amide proton transfer-weighted (APTw) imaging might offer more valuable information in ischemic strokes assessment.

PURPOSE

To utilize APTw, apparent diffusion coefficient (ADC), and computed tomography perfusion (CTP) for the assessment of clinical symptom severity and 90-day prognosis in patients diagnosed with ischemic stroke.

STUDY TYPE

Prospective.

SUBJECTS

61 patients (mean age 63.2 ± 9.7 years; 46 males, 15 females) with ischemic strokes were included in the study.

FIELD STRENGTH/SEQUENCE

3T/turbo spin echo (TSE) T1-weighted imaging, T2-weighted imaging, T2-fluid attenuated inversion recovery (T2-FLAIR), diffusion-weighted imaging (DWI), and single-shot TSE APTw imaging.

ASSESSMENT

APTw, ADC, and CTP were used to compare patient subgroups and construct a prognostic nomogram model.

STATISTICAL TESTS

Kolmogorov-Smirnov test, t-test, Mann-Whitney U test, chi-square test, Pearson correlation analysis, multivariate logistic regression analysis, decision curve analysis (DCA), receiver operating characteristic curves (ROCs). The significance threshold was set at P < 0.05.

RESULTS

Correlation analysis revealed that APTw and NIHSS exhibit the highest correlation (r = -0.634, 95% confidence interval [CI] -0.418 to -0.782), surpassing that of ADC and lesion size. Multivariable analysis revealed APTw (odds ratio [OR] 0.905, 95% CI 0.845-0.970), ADC (OR 0.745, 95% CI 0.609-0.911), and infarct core-cerebral blood volume (IC-CBV) (OR 0.547, 95% CI 0.310-0.964) as potential risk factors associated with a poor prognosis. The nomogram model demonstrated the highest predictive efficacy, with an area under the curve (AUC) of 0.960 (95% CI 0.911-0.988), exceeding that of APTw, ADC, and IC-CBV individually.

DATA CONCLUSION

The APTw technique holds potential value in categorizing and managing patients with ischemic stroke, offering guidance for the implementation of clinical treatment strategies.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 2.

Early neurological deterioration as a predictor of outcomes after endovascular thrombectomy for stroke: A systematic review and meta-analysis

BACKGROUND

Early neurological deterioration (END) is a potential predictor for 90-day outcomes following mechanical thrombectomy for acute ischemic stroke (AIS). We performed a systematic review and meta-analysis to better understand whether END can be used as a surrogate for long-term outcomes.

METHODS

Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, MEDLINE, and Embase. END definition was cataloged for each included study. Outcomes of interest included 90-day modified Rankin Scale (mRS) 0-2, symptomatic intracranial hemorrhage (sICH), mortality, and thrombolysis in cerebral infarction (TICI) 2b-3. We calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI) for all definitions of END.

RESULTS

We included seven studies with 2992 patients in our analysis. There was a significant, inverse association with END and mRS 0-2 rates (OR = 0.15; 95% CI = 0.08-0.29; P-value< 0.001). Moreover, END was a significant predictor of increased odds for reported sICH rates (OR = 16.37; 95% CI = 7.66-34.99; P-value< 0.001). Furthermore, there was a significant association between END and increase in mortality rates (OR = 6.79; 95% CI = 2.62-17.62; P-value< 0.001). There was no significant association between END and rates of TICI 2b-3 (OR = 0.53; 95% CI = 0.27-1.05; p = 0.069).

CONCLUSIONS

Broadly defined, END holds value as a potential predictor of rates of mRS 0-2 at 90 days and is associated with higher rates of mortality and sICH, but had no correlation with TICI 2b-3.

Improving acute stroke assessment in non-enhanced computed tomography: automated tool for early ischemic lesion volume detection

BACKGROUND AND OBJECTIVES

ASPECTs is a widely used marker to identify early stroke signs on non-enhanced computed tomography (NECT), yet it presents interindividual variability and it may be hard to use for non-experts. We introduce an algorithm capable of automatically estimating the NECT volumetric extension of early acute ischemic changes in the 3D space. We compared the power of this marker with ASPECTs evaluated by experienced practitioner in predicting the clinical outcome.

METHODS

We analyzed and processed neuroimaging data of 153 patients admitted with acute ischemic stroke. All patients underwent a NECT at admission and on follow-up. The developed algorithm identifies the early ischemic hypodense region based on an automatic comparison of the gray level in the images of the two hemispheres, assumed to be an approximate mirror image of each other in healthy patients.

RESULTS

In the two standard axial slices used to estimate the ASPECTs, the regions identified by the algorithm overlap significantly with those identified by experienced practitioners. However, in many patients, the regions identified automatically extend significantly to other slices. In these cases, the volume marker provides supplementary and independent information. Indeed, the clinical outcome of patients with volume marker = 0 can be distinguished with higher statistical confidence than the outcome of patients with ASPECTs = 10.

CONCLUSION

The volumetric extension and the location of acute ischemic region in the 3D-space, automatically identified by our algorithm, provide data that are mostly in agreement with the ASPECTs value estimated by expert practitioners, and in some cases complementary and independent.

Differences in outcome between left-sided and right-sided mechanical thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Mechanical thrombectomy (MT) is a safe and effective treatment option for acute ischemic stroke due to large vessel occlusion. To investigate differences in outcomes between patients receiving left-sided and right-sided MT, we performed a systematic review and meta-analysis.

METHODS

A systematic literature review was performed using Embase, PubMed, Scopus, and Web of Science databases. Additional literature was searched for manually. Studies reporting safety and efficacy metrics for MT were included. Data regarding the modified Rankin scale (mRS), thrombolysis in cerebral infarction (TICI), symptomatic intracranial hemorrhage (sICH), and 90-day mortality were included. A random-effects model was used to calculate pooled odds ratios (ORs), mean differences (MDs), and 95% confidence intervals (CIs).

RESULTS

The literature search yielded 13 reports consisting of 19 studies ranging from 98 to 5590 patients. Patients presenting with left-sided stroke had a National Institutes of health stroke scale score 2.89 greater than patients presenting with right-sided stroke (MD = 2.89; 95% CI = 2.09-3.68; P-value < 0.001). There were no differences between left-sided and right-sided MT patients for mRS 0-2 (OR = 0.94; 95% CI = 0.85-1.04; P-value = 0.224), TICI 2b-3 (OR = 1.05; 95% CI = 0.88-1.25; P-value = 0.598), sICH (OR = 0.83; 95% CI = 0.61-1.14; P-value = 0.255), or 90-day mortality (OR = 1.06; 95% CI = 0.84-1.33; P-value = 0.610).

CONCLUSIONS

There does not appear to be a difference in outcomes for patients undergoing left-sided or right-sided thrombectomy.

Patient factors associated with treatment time for stroke before and after the onset of COVID-19

OBJECTIVES

Prior to our study, little was known about factors related to time-to-treatment for stroke pre- and post-COVID-19.

DESIGN

This was a retrospective cohort study to evaluate factors associated with delayed door-to-needle time among patients with acute ischemic stroke over two time-periods.

RESULTS

Final sample consisted of 932 charts with mean age of 68.1(±15.6). Significant factors associated with shorter door-to-needle time included ≤ four hours since symptom onset and stroke occurring during post-Covid-19 time-period. Those on anti-coagulants had 72 % higher odds of longer door-to-needle time. As patients got older and stroke symptoms were more severe, less time was spent in door-to-imaging.

CONCLUSION

Results highlight the importance of early recognition of stroke symptoms and rapid transport to the hospital. Faster response times in post-Covid-19 time-period may be attributable to systematic processes put in place to address pandemic-related challenges. Outcomes may depend on research to identify gaps in stroke treatment.

New Picture Stimuli for the NIH Stroke Scale: A Validation Study

BACKGROUND

The National Institutes of Health Stroke Scale is a widely accepted tool for structured graded neurological examination of stroke or suspected stroke in the hyperacute setting. Concerns have arisen about the use of its picture stimuli in a contemporary and global health context. Here, we present new stimuli prepared to serve the needs of stroke providers worldwide: the precarious painter image description and updated objects for naming.

METHODS

This was a validation study of 101 healthy fluent English speakers. Participants were reached by the Johns Hopkins Outpatient Center, the University of South Carolina, and Prisma Health from 2022 to 2023 and included residents of the United States, Germany, Canada, the United Kingdom, Australia, and Zambia. Participants were recorded in person or via video conferencing when asked to describe the new picture, while a subset named seven illustrations. Multivariate analyses of variance were used for primary analyses. In a complementary investigation, 299 attendees of the 2023 International Stroke Conference were asked about their preference for the existing or new stimuli and why.

RESULTS

Each of the 44 content units from the picture description was included by at least 5% of respondents in the demographically representative subsample. Performance was similar across healthy participants irrespective of age, sex, race, ethnicity, or education. Typical descriptions were characterized by an average of 23 content units (SD=5) conveyed with 167 syllables (SD=79). The new naming stimuli were recognized by 100% of participants from many countries as being familiar and identifiable, and names provided in response to the task were highly convergent. The majority of stroke health care providers preferred both the precarious painter and naming stimuli.

CONCLUSIONS

The description of the new National Institutes of Health Stroke Scale picture, the precarious painter, results in rich samples among healthy speakers that will provide an appropriate basis for the detection of language deficits.

Neglect scoring modifications in the National Institutes of Health Stroke Scale improve right hemisphere stroke lesion volume prediction

BACKGROUND

The National Institutes of Health Stroke Scale (NIHSS) does not equitably assess stroke severity in the two cerebral hemispheres. By attributing a maximum of two points for neglect and seven for language, it undervalues right hemisphere deficits. We aimed to investigate if NIHSS equally predicts right hemisphere lesion volumes in patients with and without neglect, and if a modification of the neglect scoring rules could increase its predictive capacity.

METHODS

We analyzed a prospective cohort of acute right middle cerebral artery ischemic stroke patients. First, we calculated the correlation between NIHSS scores and lesion volume and analyzed the partial correlation of neglect. Then, we applied different modifications in the neglect scoring rules and investigated how they interfered with lesion volume predictive capacity.

RESULTS

A total of 162 ischemic stroke patients were included, 108 with neglect and 54 without. The correlation between lesion volume and NIHSS was lower in patients with neglect (r = 0.540 vs. r = 0.219, p = 0.004) and neglect was a statistically significant covariate in the partial correlation analysis between NIHSS and lesion volume (p = 0.017). With the neglect score tripled and with the duplication or triplication of all neglect modalities, the correlation was significantly higher than with the standard NIHSS (p = 0.043, p = 0.005, p = 0.001, respectively). With these modifications, neglect was no longer a significant covariable in the partial correlation between lesion volume and NIHSS.

CONCLUSION

A modification of NIHSS neglect scoring might improve the scale's capacity to predict lesion volume.

The Pitfalls of NIHSS: Time for a New Clinical Acute Stroke Severity Scoring System in the Emergency?

Stroke is the second leading cause of death and a major cause of disability worldwide. Stroke severity scales serve as reliable means to track a patient's neurological deficit, predict outcome, and guide treatment decisions in clinical practice. The National Institute of Health Stroke Scale (NIHSS) was introduced over 30 years ago, marking a significant milestone in the field of stroke. Over the years, there have been notable advancements in acute stroke care. Despite several modifications made to NIHSS, none has yet succeeded in effectively capturing all the complex effects of a stroke. This review focuses on the pitfalls of NIHSS and emphasizes the need for a quick and comprehensive clinical and upgraded version of the stroke severity rating scale.

Death and ADL Dependency After Scoring Zero on the NIHSS: A Swedish Retrospective Registry-Based Study

Background and Objectives

Of all strokes, mild strokes (defined as 5 points or less on the National Institutes of Health Stroke Scale [NIHSS]) are in the majority. However, up to one-third of patients with mild strokes still exhibit significant deficits 3 months after the stroke. Studies on the presumably mildest strokes, defined by zero points on the NIHSS (0-NIHSS) at admission, are scarce. Hence, we aimed to study patient characteristics and outcomes among patients with 0-NIHSS strokes.

Methods

Our retrospective registry-based study included a total of 6,491 adult patients with stroke admitted to 3 different stroke units in Gothenburg, Sweden, from November 2014 to June 2019. Our main outcome was a composite measure including death and activities of daily living (ADL) dependency 3 months after the stroke. Analyses of patient characteristics were followed by adjusted analyses including multiple confounders.

Results

In total, 5,945 patients had data on NIHSS at admission, of whom 1,412 (24%) presented with a 0-NIHSS stroke. Among these, the median age was 72 years, 600 (42%) were female, and 86 (6%) had a hemorrhagic stroke. Among previously ADL-independent patients, 65 (6%) were either dead or ADL-dependent 3 months after the stroke. Prestroke physical inactivity (OR 2.48, 95% CI 1.40-4.38) and age (OR 1.05 per gained year, 95% CI 1.02-1.08) significantly increased the risk of death and ADL dependency.

Discussion

One of 17 patients has either died or become ADL-dependent 3 months after a 0-NIHSS stroke, stressing that these strokes are not always benign. Older and physically inactive patients are at greater risk of an adverse outcome.

Functional outcome in low-ASPECTS (0-5) acute ischemic stroke treated with mechanical thrombectomy: impact of laterality explored in a single-center study

Background

There is no consensus regarding the influence of infarct laterality in patients with acute ischemic stroke due to anterior large vessel occlusion (AIS-LVO) treated with mechanical thrombectomy (MT), particularly in low-ASPECT (0-5) patients who were excluded from the initial MT studies and that participated in dedicated randomized-controlled trials that do not consider the side of the occlusion. We aimed to evaluate the role of infarct laterality on the clinical outcome in low-ASPECT AIS patients treated with MT.

Material and methods

We retrospectively analyzed our institutional stroke database in our Thrombectomy-Capable Stroke Center (TCSC), including patient characteristics, procedural variables, and outcomes, between January 2015 and January 2022. Patients with acute intracranial ICA and/or proximal MCA occlusions with ASPECT ≤ 5 either on CT or MRI were included and divided into 2 groups according to the location of ischemia. The primary endpoint was a good clinical outcome at 90 days (modified Rankin Scale (mRS) score of 0-3).

Results

Between January 2015 and November 2021, 817 MT were performed, of which 82 were low-ASPECT (10.0%): 41 left-sided and 41 right-sided strokes. The rates of good clinical outcome were 30.8% (12/41) for the left-sided group and 43.6% (17/41) for the right-sided group, with a p-value of 0.349. The morality rate showed no significant difference between the two groups: 39.0% (16/41) in the right stroke group and 36.6% (15/41) in the left stroke group.

Conclusion

The clinical outcome was not significantly influenced by stroke laterality. The results of this single-center retrospective study indicate either a lack of strength or equal value in performing mechanical thrombectomy regardless of stroke laterality.

Clinical features of ischemic stroke in patients with nonvalvular atrial fibrillation combined with intracranial atherosclerotic stenosis

BACKGROUND

Nonvalvular atrial fibrillation (NVAF) and intracranial atherosclerotic stenosis (ICAS) are major causes of ischemic stroke. Relatively few studies have focused on the risk factors and clinical features of ischemic stroke caused by NVAF combined with ICAS.

METHOD

We retrospectively evaluated NVAF and/or ICAS in patients with acute ischemic stroke admitted within 72 h after stroke. All patients with acute ischemic stroke underwent diffusion-weighted magnetic resonance imaging (DWI), magnetic resonance angiography (MRA), computed tomography angiography (CTA), and/or digital subtraction angiography (DSA). NVAF was detected by routine electrocardiogram or 24-h Holter examination, Doppler echocardiography, and contrast echocardiography of the right heart.

RESULTS

Among the 635 enrolled patients, NVAF, ICAS, and NVAF+ICAS were diagnosed in 170 (26.77%), 255 (40.16%), and 210 (33.07%) patients, respectively. Patients in the NVAF+ICAS group were older (p < .001), specifically aged ≥75 years (p < .001). The admission time of the NVAF+ICAS group was shorter (p < .001) than that of the ICAS group. The admission NIHSS score of the NVAF group was higher than that of the NVAF+ICAS group (p < .001). HsCRP, NTpro-BNP, and LEVF levels were significantly different among the three groups (p < .001). NVAF+ICAS ischemic stroke occurred mainly in the right hemisphere (52.4%).

CONCLUSION

NVAF with ICAS ischemic stroke is more likely to occur in older patients. Infarctions occurred mainly in the right cerebral hemisphere. Neurological deficits in NVAF are more severe than those in NVAF combined with ICAS and in simple ICAS ischemic strokes. HsCRP, LEVF, andNTpro-BNP seem to be closely associated with NVAF+ICAS ischemic stroke.

Construction of a Nomogram Prediction Model for Prognosis in Patients with Large Artery Occlusion-Acute Ischemic Stroke

BACKGROUND

Patients with large artery occlusion-acute ischemic stroke (LAO-AIS) can experience adverse outcomes, such as brain herniation due to complications. This study aimed to construct a nomogram prediction model for prognosis in patients with LAO-AIS in order to maximize the benefits for clinical patients.

METHODS

Retrospective analysis of 243 patients with LAO-AIS from January 2019 to January 2022 with medical history data and blood examination at admission. Univariate and multivariate analyses were conducted through binary logistic regression equation analysis, and a nomogram prediction model was constructed.

RESULTS

Results of this study showed that hyperlipidemia (odds ratio [OR] = 2.849, 95% confidence interval [CI] = 1.100-7.375, P = 0.031), right cerebral infarction (OR = 2.144, 95% CI = 1.106-4.156, P = 0.024), D-Dimer>500 ng/mL (OR = 2.891, 95% CI = 1.398-5.980, P = 0.004), and neutrophil-lymphocyte ratio >7.8 (OR = 2.149, 95% CI = 1.093-4.225, P = 0.027) were independent risk factors for poor early prognosis in patients with LAO-AIS. In addition, hypertension (OR = 1.947, 95% CI = 1.114-3.405, P = 0.019), hyperlipidemia (OR = 2.594, 95% CI = 1.281-5.252, P = 0.008), smoking (OR = 2.414, 95% CI = 1.368-4.261, P = 0.002), D-dimer>500 ng/mL (OR = 3.170, 95% CI = 1.533-6.553, P = 0.002), and neutrophil-lymphocyte ratio >7.8 (OR = 2.144, 95% CI = 1.231-3.735, P = 0.007) were independent risk factors for poor long-term prognosis. The early prognosis nomogram receiver operating characteristic curve area under the curve value was 0.688 for the training set and 0.805 for the validation set, which was highly differentiated. The mean error was 0.025 for the training set calibration curve and 0.016 for the validation set calibration curve. Both the training and validation set decision curve analyses indicated that the clinical benefit of the nomogram was significant. The long-term prognosis nomogram receiver operating characteristic curve area under the curve values was 0.697 for the training set and 0.735 for the validation set, showing high differentiation. The mean error was 0.041 for the training set calibration curve and 0.021 for the validation set calibration curve. Both of the training and validation set decision curve analyses demonstrated a substantial clinical benefit of the nomogram.

CONCLUSIONS

The nomogram prediction model based on admission history data and blood examination are easy-to-use tools that provide an accurate individualized prediction for patients with LAO-AIS and can assist in early clinical decisions and in obtaining an early prognosis.

Diagnostic Evaluation of Stroke Etiology

OBJECTIVE

Precise therapies require precise diagnoses. This article provides an evidence-based approach to confirming the diagnosis of ischemic stroke, characterizing comorbidities that provide insights into the pathophysiologic mechanisms of stroke, and identifying targets for treatment to optimize the prevention of recurrent stroke.

LATEST DEVELOPMENTS

Identifying the presence of patent foramen ovale, intermittent atrial fibrillation, and unstable plaque is now routinely included in an increasingly nuanced workup in patients with stroke, even as ongoing trials seek to clarify the best approaches for treating these and other comorbidities. Multicenter trials have demonstrated the therapeutic utility of patent foramen ovale closure in select patients younger than age 60 years. Insertable cardiac monitors detect atrial fibrillation lasting more than 30 seconds in about one in ten patients monitored for 12 months following a stroke. MRI of carotid plaque can detect unstable plaque at risk of being a source of cerebral embolism.

ESSENTIAL POINTS

To optimize the prevention of recurrent stroke, it is important to consider pathologies of intracranial and extracranial blood vessels and of cardiac structure and rhythm as well as other inherited or systemic causes of stroke. Some aspects of the stroke workup should be done routinely, while other components will depend on the clinical circumstances and preliminary testing results.

Vagal Nerve Activity and Short-Term Clinical Outcomes after Stroke: What Is Left May Not Be Right

Stroke is a leading cause of death worldwide. Multiple factors influence the severity of stroke. Normal functional and biological differences seen between the hemispheres may also be related to stroke severity. In the present study, we examined the differences in the severity of stroke as a function of stroke side, and whether patients' vagal nerve activity moderated such differences. We included 87 patients with an ischemic stroke, whose medical records were retrospectively examined for background information (age, gender), stroke side and severity by NIHSS, length of stay in hospital, inflammation such as C-reactive protein, and vagal nerve activity. The vagal activity was indexed by patients' heart-rate variability (HRV), fluctuations in the intervals between normal heartbeats, derived from patients' ECG. Results revealed that patients with left-side stroke had significantly worse NIHSS scores (10.6) than those with right-sided stroke (7.6, p < 0.05). However, when dividing the sample into those with low versus high HRV (at the median), only when HRV was low, did patients with left-side stroke have a worse NIHSS score (10.9) compared to those with right-sided stroke (6.5, p < 0.05). In contrast, no differences in stroke severity were seen between left stroke (10.2) and right stoke (8.7, p > 0.05), when HRV was high. These results tended to remain the same when statistically controlling for age effects, which was related to NIHSS, but not to the stroke side. These findings suggest that patients with left-sided stroke may have more severe strokes than those with right-sided ones, but that adequate vagal nerve activity may protect against such differences. Possible mechanisms and suggestions for future directions are provided.

Location of Hyperintense Vessels on FLAIR Associated with the Location of Perfusion Deficits in PWI

Perfusion imaging is preferred for identifying hypoperfusion in the management of acute ischemic stroke, but it is not always feasible/available. An alternative method for quantifying hypoperfusion, using FLAIR-hyperintense vessels (FHVs) in various vascular regions, has been proposed, with evidence of a statistical relationship with perfusion-weighted imaging (PWI) deficits and behavior. However, additional validation is needed to confirm that areas of suspected hypoperfusion (per the location of FHVs) correspond to the location of perfusion deficits in PWI. We examined the association between the location of FHVs and perfusion deficits in PWI in 101 individuals with acute ischemic stroke, prior to the receipt of reperfusion therapies. FHVs and PWI lesions were scored as present/absent in six vascular regions (i.e., the ACA, PCA, and (four sub-regions of) the MCA territories). Chi-square analyses showed a significant relationship between the two imaging techniques for five vascular regions (the relationship in the ACA territory was underpowered). These results suggest that for most areas of the brain, the general location of FHVs corresponds to hypoperfusion in those same vascular territories in PWI. In conjunction with prior work, results support the use of estimating the amount and location of hypoperfusion using FLAIR imaging when perfusion imaging is not available.

Crossed Cerebellar Diaschisis Worsens the Clinical Presentation in Acute Large Vessel Occlusion

INTRODUCTION

Initial NIHSS in anterior large vessel occlusion (LVO) correlates partially with the hypoperfusion volume. We aimed at assessing the contribution of crossed cerebellar diaschisis (CCD) from the hypoperfused territory on LVO initial clinical deficit.

METHODS

CCD was retrospectively identified by brain CT perfusion imaging (CTP) in patients with anterior LVO treated by mechanical thrombectomy from January 2017 to July 2021. CCD was defined by CTP parameter alteration in the contralateral cerebellar hemisphere to the LVO. NIHSS, clinical/perfusion variables, and CCD were included in regression models to assess their interrelationships.

RESULTS

206 patients were included. CCD was present in 90 patients (69%). NIHSS scores were higher on admission and at stroke discharge among patients with CCD (17.90 ± 6.1 vs. 11.4 ± 8.4, p < 0.001; 9.6 ± 7.7 vs. 6.6 ± 7.9, p = 0.049; respectively). Patients with a CCD had higher stroke volumes (118.2 ± 60.3 vs. 69.3 ± 59.7, p < 0.001) and lower rate of known atrial fibrillation (22% vs. 41%, p = 0.021). On multivariable logistic regression, CCD independently worsened the initial NIHSS (OR 4.85 [2.37-7.33]; p < 0.001).

CONCLUSION

CCD is found in 69% of LVO on admission CTP, correlates with stroke volumes, and independently worsens initial NIHSS.

Independent Predictive Value of Elevated YKL-40 in Ischemic Stroke Prognosis: Findings from a Nationwide Stroke Registry

INTRODUCTION

Elevated circulatory concentrations of YKL-40 have been reported in patients with ischemic stroke. This study further investigated the association of plasma YKL-40 concentrations at admission and short, long-term prognosis after ischemic stroke.

METHODS

Based on a prospective, nationwide multicenter registry focusing consecutive patients of ischemic stroke and transient ischemic attack, plasma YKL-40 levels were detected by enzyme-linked immunosorbent assay at admission, and patients were stratified into percentile according to the plasma YKL-40 concentrations. The multivariate Cox or logistic regression model was used to investigate the association of YKL-40 concentration with death and functional outcomes at 3 months, 6 months, and 12 months after ischemic stroke, with potential confounders adjusted.

RESULTS

A total of 8,006 first-ever ischemic stroke patients, with the age of 61.7 ± 11.5, were included in this study. The mortality of 0-33%, 34-66%, 67-90%, and 91-100% groups at 12 months follow-up was 0.9%, 2.2%, 4.4%, and 9.4%, respectively (p < 0.0001), and the modified Rankin Scale 3-6 ratio was 6.8%, 10.5%, 15.7%, and 24.0%, respectively (p < 0.0001). In the multivariate regression, after adjusting for potential confounders, 91-100% group had higher risk of death (hazard ratio 2.99, 95% confidence interval 1.75-5.11)and modified Rankin Scale 3-6 (odds ratio 1.42, 95% confidence interval 1.08-1.88) at 12 months since onset of ischemic stroke compared to the 0-33% group.

CONCLUSIONS

The elevated YKL-40 at admission can potentially help predict death, functional prognosis after ischemic stroke, which may help further studies to explore the potential physiological and pathological mechanism including the effects of vulnerable plaque and collateral circulation.

Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management

BACKGROUND AND PURPOSE

Minor acute ischemic stroke (AIS) patients-defined by an NIHSS score < 6-presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center's experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM).

METHODS

We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM.

RESULTS

Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49-75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0-2.0] versus 3.0 [IQR 1.0-4.0], p = <0.001), a favorable NIHSS shift (-4.0 [IQR -10.0--2.0] versus 0.0 [IQR -2.0-1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024).

CONCLUSIONS

In our center's preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only.

Side matters: differences in functional outcome and quality of life after thrombectomy in left and right hemispheric stroke

BACKGROUND

Patients with a left (LHS) or right hemispheric stroke (RHS) differ in terms of clinical symptoms due to lateralization of specific cortical functions. Studies on functional outcome after stroke and endovascular thrombectomy (EVT) comparing both hemispheres showed conflicting results so far. The impact of stroke laterality on patient-reported health-related quality of life (HRQoL) after EVT has not yet been adequately addressed and still remains unclear.

METHODS

Consecutive stroke thrombectomy patients, derived from a multi-center, prospective registry (German Stroke Registry) between June 2015 and December 2019, were included in this study. At 90 days, outcome after EVT was assessed by the modified Rankin scale (mRS) and HRQoL using the European QoL-five dimensions questionnaire utility-index (EQ-5D-I; higher values indicate better HRQoL) in patients with LHS and RHS. Adjusted regression analysis was applied to evaluate the influence of stroke laterality on outcome after EVT.

RESULTS

In total, 5683 patients were analyzed. Of these, 2953 patients (52.8%) had LHS and 2637 (47.2%) RHS. LHS patients had a higher baseline NIHSS (16 vs. 13, p < 0.001) and a higher ASPECTS (9 vs. 8, p < 0.001) compared to RHS patients. Among survivors, patients with LHS less frequently had a self-reported affected mobility (p = 0.037), suffered less often from pain (p = 0.04) and anxiety/depression (p = 0.032) three months after EVT. After adjusting for confounders (age, sex, baseline NIHSS), LHS was associated with a better HRQoL (ß coefficient 0.04, CI 95% 0.017-0.063; p = 0.001), and better functional outcome assessed by lower values on the mRS (ß coefficient - 0.109, CI 95% - 0.217-0.000; p = 0.049).

CONCLUSIONS

Ninety days after EVT, LHS patients have a better functional outcome and HRQoL. Patients with RHS should be actively assessed and treated for pain, anxiety and depression to improve their HRQoL after EVT.

DNA Methylation and Ischemic Stroke Risk: An Epigenome-Wide Association Study

BACKGROUND

Ischemic stroke (IS) risk heritability is partly explained by genetics. Other heritable factors, such as epigenetics, could explain an unknown proportion of the IS risk. The objective of this study is to evaluate DNA methylation association with IS using epigenome-wide association studies (EWAS).

METHODS

 We performed a two-stage EWAS comprising 1,156 subjects. Differentially methylated positions (DMPs) and differentially methylated regions (DMRs) were assessed using the Infinium 450K and EPIC BeadChip in the discovery cohort (252 IS and 43 controls). Significant DMPs were replicated in an independent cohort (618 IS and 243 controls). Stroke subtype associations were also evaluated. Differentially methylated cell-type (DMCT) was analyzed in the replicated CpG sites using EpiDISH. We additionally performed pathway enrichment analysis and causality analysis with Mendelian randomization for the replicated CpG sites.

RESULTS

 A total of 957 CpG sites were epigenome-wide-significant (p ≤ 10^-7) in the discovery cohort, being CpG sites in the top signals (logFC = 0.058, p = 2.35 × 10^-22; logFC = 0.035, p = 3.22 × 10^-22, respectively). ZFHX3 and MAP3K1 were among the most significant DMRs. In addition, 697 CpG sites were replicated considering Bonferroni-corrected p-values (p < 5.22 × 10^-5). All the replicated DMPs were associated with risk of cardioembolic, atherothrombotic, and undetermined stroke. The DMCT analysis demonstrated that the significant associations were driven by natural killer cells. The pathway enrichment analysis showed overrepresentation of genes belonging to certain pathways including oxidative stress. ZFHX3 and MAP3K1 methylation was causally associated with specific stroke-subtype risk.

CONCLUSION

 Specific DNA methylation pattern is causally associated with IS risk. These results could be useful for specifically predicting stroke occurrence and could potentially be evaluated as therapeutic targets.

Left Hemisphere Bias of NIH Stroke Scale Is Most Severe for Middle Cerebral Artery Strokes

NIHSS score is higher for left vs. right hemisphere strokes of equal volumes. However, differences in each vascular territory have not been evaluated yet. We hypothesized that left vs. right differences are driven by the middle cerebral artery (MCA) territory, and there is no difference between hemispheres for other vascular territories. This study is based on data from 802 patients with evidence of acute ischemic stroke in one major arterial territory (MCA, n = 437; PCA, n = 209; ACA, n = 21; vertebrobasilar, n = 46). We examined differences in patients with left or right strokes regarding to lesion volume, NIHSS, and other covariates (age, sex, race). We used linear models to test the effects of these covariates on NIHSS. We looked at the whole sample as well as in the sample stratified by NIHSS (≤5 or >5) and by lesion location (MCA or PCA). Patients with left MCA strokes had significantly higher NIHSS than those with right strokes. Only patients with MCA strokes showed NIHSS score affected by the hemisphere when controlling for stroke volume and patient's age. This difference was driven by the more severe strokes (NIHSS>5). It is important to consider this systematic bias in the NIHSS when using the score for inclusion criteria for treatment or trials. Patients with right MCA stroke may be under-treated and left with disabling deficits that are not captured by the NIHSS.

Hyperintense vessels on imaging account for neurological function independent of lesion volume in acute ischemic stroke

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Studies have revealed variable significance of FLAIR hyperintense vessels (FHV).

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We found number and location of FHV are associated with functional deficits.

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Functional measures correlated with FHV independently of lesion volume.

In acute ischemic stroke, reported relationships between lesion metrics and behavior have largely focused on lesion volume and location. However, hypoperfusion has been shown to correlate with deficits in the acute stage. Hypoperfusion is typically identified using perfusion imaging in clinical settings, which requires contrast. Unfortunately, contrast is contraindicated for some individuals. An alternative method has been proposed to identify hypoperfusion using hyperintense vessels on fluid-attenuated inversion recovery (FLAIR) imaging. This study aimed to validate the clinical importance of considering hypoperfusion when accounting for behavior in acute stroke and demonstrate the clinical utility of scoring the presence of hyperintense vessels to quantify it.

One hundred and fifty-three participants with acute ischemic stroke completed a battery of commonly-used neurological and behavioral measures. Clinical MRIs were used to determine lesion volume and to score the presence of hyperintense vessels seen on FLAIR images to estimate severity of hypoperfusion in six different vascular regions. National Institutes of Health Stroke Scale (NIHSS) scores, naming accuracy (left hemisphere strokes), and language content produced during picture description were examined in relation to lesion volume, hypoperfusion, and demographic variables using correlational analyses and multivariable linear regression.

Results showed that lesion volume and hypoperfusion, in addition to demographic variables, were independently associated with performance on NIHSS, naming, and content production. Specifically, hypoperfusion in the frontal lobe independently correlated with NIHSS scores, while hypoperfusion in parietal areas independently correlated with naming accuracy and content production.

These results correspond to previous reports associating hypoperfusion with function, confirming that hypoperfusion is an important consideration—beyond lesion volume—when accounting for behavior in acute ischemic stroke. Quantifying hypoperfusion using FLAIR hyperintense vessels can be an essential clinical tool when other methods of identifying hypoperfusion are unavailable or time prohibitive.

National Institutes of Health Stroke Scale as an Outcome in Stroke Research: Value of ANCOVA Over Analyzing Change From Baseline

National Institutes of Health Stroke Scale (NIHSS), measured a few hours to days after stroke onset, is an attractive outcome measure for stroke research. NIHSS at the time of presentation (baseline NIHSS) strongly predicts the follow-up NIHSS. Because of the need to account for the baseline NIHSS in the analysis of follow-up NIHSS as an outcome measure, a common and intuitive approach is to define study outcome as the change in NIHSS from baseline to follow-up (ΔNIHSS). However, this approach has important limitations. Analyzing ΔNIHSS implies a very strong assumption about the relationship between baseline and follow-up NIHSS that is unlikely to be satisfied, drawing into question the validity of the resulting statistical analysis. This reduces the precision of the estimates of treatment effects and the power of clinical trials that use this approach to analysis. ANCOVA allows for the analysis of follow-up NIHSS as the dependent variable while adjusting for baseline NIHSS as a covariate in the model and addresses several challenges of using ΔNIHSS outcome using simple bivariate comparisons (eg, a t test, Wilcoxon rank-sum, linear regression without adjustment for baseline) for stroke research. In this article, we use clinical trial simulations to illustrate that variability in NIHSS outcome is less when follow-up NIHSS is adjusted for baseline compared to ΔNIHSS and how a reduction in this variability improves the power. We outline additional, important clinical and statistical arguments to support the superiority of ANCOVA using the final measurement of the NIHSS adjusted for baseline over, and caution against using, the simple bivariate comparison of absolute NIHSS change (ie, delta).

Primer reporte de inmaduros de Cryptocephalus Geoffroy, 1762 (Coleoptera: Chrysomelidae) de Brasil con notas de su bioecología sobre Wedelia goyazensis Gardner (Asteraceae) y síntesis de los registros de presencia del género en territorio brasileño

Cryptocephalus Geoffroy, 1762 es reconocido por su distribución cosmopolita y gran riqueza, con al menos 1700 especies descritas. Sin embargo, falta información para Brasil: (1) no hay registro de inmaduros; y (2) no se conoce casi nada sobre la biología de este género. En este trabajo se documentan por primera vez las etapas inmaduras de Cryptocephalus de Brasil y se presentan algunas notas sobre su bioecología en la planta huésped. Además, se recopilan sus registros en territorio brasileño a partir de la bibliografía.

Mechanical thrombectomy does not increase the risk of acute symptomatic seizures in patients with an ischaemic stroke: a propensity score matching study

Background

Mechanical thrombectomy and systemic thrombolysis are important therapies for stroke patients. However, there is disagreement about the accompanying risk of acute symptomatic seizures.

Methods

A retrospective analysis of patients with an acute ischaemic stroke caused by large vessel occlusion was performed. The patients were divided into four groups based on whether they received either mechanical thrombectomy (MT) or systemic thrombolysis (ST; group 1: MT+/ST−; group 2: MT+/ST+; group 3: MT−/ST+; group 4: MT−/ST−). Propensity score matching was conducted for each group combination (1:3, 1:4, 2:3, 2:4, 1:2, 3:4) using the covariates “NIHSS at admission”, “mRS prior to event” and “age”. The primary endpoint was defined as the occurrence of acute symptomatic seizures.

Results

A total of 987 patients met the inclusion criteria, of whom 208, 264, 169 and 346 belonged to groups 1, 2, 3 and 4, respectively. Propensity score matched groups consisted of 160:160, 143:143, 156:156, 144:144, 204:204 and 165:165 patients for the comparisons 1:3, 1:4, 2:3, 2:4, 1:2 and 3:4, respectively. Based on chi-squared tests, there was no significant difference in the frequency of acute symptomatic seizures between the groups. Subgroups varied in their frequency of acute symptomatic seizures, ranging from 2.8 to 3.8%, 2.8–4.4%, 3.6–3.8% and 4.9–6.3% in groups 1, 2, 3 and 4, respectively.

Conclusion

There was no association between MT or ST and an increased risk of acute symptomatic seizures in patients with an acute ischaemic stroke caused by large vessel occlusion who were treated at a primary stroke centre.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-10968-5.

Stroke Lateralization in Large Hemisphere Infarctions: Characteristics, Stroke-Related Complications, and Outcomes

Objectives: To assess the hemispheric differences in characteristics, stroke-related complications, and outcomes of patients with large hemisphere infarctions (LHI).

Methods: We enrolled consecutive patients admitted within 24 h after the diagnosis of LHI (defined as an ischemic stroke involving more than 50% of the territory of the middle cerebral artery in computed tomography and/or magnetic resonance imaging). Univariate and multivariate analysis were performed to explore the association between lateralization and stroke-related complications and clinical outcomes.

Results: A total of 314 patients with LHI were enrolled, with 171 (54.5%) having right hemispheric involvement. Right-sided patients with LHI had lower baseline National Institutes of Health Stroke Scale (NIHSS) score (18 vs. 22, p < 0.001), higher frequency of atrial fibrillation (69.0 vs. 52.4%, p = 0.003), and higher proportion of cardio-embolism (73.1 vs. 56.6%, p = 0.013) than the left. Right-sided LHI had higher incidence rates of malignant brain edema (MBE) (48.5 vs. 30.8%, p = 0.001) and a composite of cardiovascular events (29.8 vs. 17.5%, p = 0.011) during hospitalization. The incidence rate of 1-month mortality (34.5 vs. 23.8%, p = 0.036) was higher in right-sided patients with LHI, but there were no hemispheric differences in the incidence rates of 3-month mortality and unfavorable outcome (both p > 0.05). Multivariate analyses suggested right hemisphere involvement was independently associated with increased risk of MBE (adjusted OR 2.37, 95% CI 1.26–4.43, p = 0.007) and composite of cardiovascular events (adjusted OR 2.04, 95% CI 1.12–3.72, p = 0.020). However, it was not independently associated with 1-month death, 3-month mortality, and 3-month unfavorable outcome (all p > 0.05).

Conclusions: Right-sided patients with LHI had higher frequency of atrial fibrillation and cardio-embolism than the left-sided patients. Right hemisphere involvement was independently associated with increased risk of MBE and composite of cardiovascular events during hospitalization, whereas stroke lateralization was not an independent predictor of mortality and unfavorable outcome in patients with LHI.

Spatial Neglect and Anosognosia After Right Brain Stroke

PURPOSE OF REVIEW

Up to 80% of survivors of right brain stroke leave acute care without being diagnosed with a major invisible disability. Studies indicate that a generic cognitive neurologic evaluation does not reliably detect spatial neglect, nor does it identify unawareness of deficit after right brain stroke; this article reviews the symptoms, clinical presentation, and management of these two cognitive disorders occurring after right brain stroke.

RECENT FINDINGS

Stroke and occupational therapy practice guidelines stress a quality standard for spatial neglect assessment and treatment to reduce adverse outcomes for patients, their families, and society. Neurologists may attribute poor outcomes associated with spatial neglect to stroke severity. However, people with spatial neglect are half as likely to return to home and community, have one-third the community mobility, and require 3 times as much caregiver supervision compared with similar stroke survivors. Multiple randomized trials support a feasible first-line rehabilitation approach for spatial neglect: prism adaptation therapy; more than 20 studies reported that this treatment improves daily life independence. Evidence-based treatment of anosognosia is not as developed; however, treatment for this problem is also available.

SUMMARY

This article guides neurologists' assessment of right brain cognitive disorders and describes how to efficiently assemble and direct a treatment team to address spatial neglect and unawareness of deficit.

Psychiatric sequelae of stroke affecting the non-dominant cerebral hemisphere

There are a plethora of cognitive sequelae in addition to neglect and extinction that arise with unilateral right hemispheric stroke (RHS). Cognitive deficits following non-dominant (right) hemisphere stroke are common with unilateral neglect and extinction being the most recognized examples. The severity of RHS is usually underestimated by the National Institutes of Health Stroke Scale (NIHSS), which in terms of lateralized right hemisphere cognitive deficits, tests only for visual inattention/extinction. They account for 2 out of 42 total possible points. Additional neuropsychiatric sequelae include but are not limited to deficiencies in affective prosody comprehension and production (aprosodias), understanding and expressing facial emotions, empathy, recognition of familiar faces, anxiety, mania, apathy, and psychosis. These sequelae have a profound impact on patients' quality of life; affecting communication, interpersonal relationships, and the ability to fulfill social roles. They also pose additional challenges to recovery. There is presently a gap in the literature regarding a cohesive overview of the significant cognitive sequelae following RHS. This paper serves as a narrative survey of the current understanding of the subject, with particular emphasis on neuropsychiatric poststroke syndromes not predominantly associated with left hemisphere lesions (LHL), bilateral lesions, hemiplegia, or paralysis. A more comprehensive understanding of the neuropsychological consequences of RHS extending beyond the typical associations of unilateral neglect and extinction may have important implications for clinical practice, including the ways in which clinicians approach diagnostics, treatment, and rehabilitation.

Impact of Pretreatment Ischemic Location on Functional Outcome after Thrombectomy

Pretreatment ischemic location may be an important determinant for functional outcome prediction in acute ischemic stroke. In total, 143 anterior circulation ischemic stroke patients in the THRACE study were included. Ischemic lesions were semi-automatically segmented on pretreatment diffusion-weighted imaging and registered on brain atlases. The percentage of ischemic tissue in each atlas-segmented region was calculated. Statistical models with logistic regression and support vector machine were built to analyze the predictors of functional outcome. The investigated parameters included: age, baseline National Institutes of Health Stroke Scale score, and lesional volume (three-parameter model), together with the ischemic percentage in each atlas-segmented region (four-parameter model). The support vector machine with radial basis functions outperformed logistic regression in prediction accuracy. The support vector machine three-parameter model demonstrated an area under the curve of 0.77, while the four-parameter model achieved a higher area under the curve (0.82). Regions with marked impacts on outcome prediction were the uncinate fasciculus, postcentral gyrus, putamen, middle occipital gyrus, supramarginal gyrus, and posterior corona radiata in the left hemisphere; and the uncinate fasciculus, paracentral lobule, temporal pole, hippocampus, inferior occipital gyrus, middle temporal gyrus, pallidum, and anterior limb of the internal capsule in the right hemisphere. In conclusion, pretreatment ischemic location provided significant prognostic information for functional outcome in ischemic stroke.

Patent Foramen Ovale Closure Decreases the Incidence but Not the Size of New Brain Infarction on Magnetic Resonance Imaging: An Analysis of the REDUCE Trial

Background and Purpose

Randomized patent foramen ovale closure trials have used open-label end point ascertainment which increases the risk of bias and undermines confidence in the conclusions. The Gore REDUCE trial prospectively performed baseline and follow-up magnetic resonance imaging (MRIs) for all subjects providing an objective measure of the effectiveness of closure.

Methods

We performed blinded evaluations of the presence, location, and volume of new infarct on diffusion-weighted imaging of recurrent clinical stroke or new infarct (>3 mm) on T2/fluid attenuated inversion recovery from baseline to follow-up MRI at 2 years, comparing closure to medical therapy alone. We also examined the effect of shunt size and the development of atrial fibrillation on infarct burden at follow-up.

Results

At follow-up, new clinical stroke or silent MRI infarct occurred in 18/383 (4.7%) patients who underwent closure and 19/177 (10.7%) medication-only patients (relative risk, 0.44 [95% CI, 0.24–0.81], P=0.02). Clinical strokes were less common in closure patients compared with medically treated patients, 5 (1.3%) versus 12 (6.8%), P=0.001, while silent MRI infarcts were similar, 13 (3.4%) versus 7 (4.0%), P=0.81. There were no differences in number, volumes, and distribution of new infarct comparing closure patients to those treated with medication alone. There were also no differences of number, volumes, and distribution comparing silent infarcts to clinical strokes. Infarct burden was also similar for patients who developed atrial fibrillation and for those with large shunts.

Conclusions

The REDUCE trial demonstrates that patent foramen ovale closure prevents recurrent brain infarction based on the objective outcome of new infarcts on MRI. Only clinical strokes were reduced by closure while silent infarctions were similar between study arms, and there were no differences in infarct volume or location comparing silent infarcts to clinical strokes.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00738894.

Similar admission NIHSS may represent larger tissue-at-risk in patients with right-sided versus left-sided large vessel occlusion

BACKGROUND

We investigated the effects of the side of large vessel occlusion (LVO) on post-thrombectomy infarct volume and clinical outcome with regard to admission National Institutes of Health Stroke Scale (NIHSS) score.

METHODS

We retrospectively identified patients with anterior LVO who received endovascular thrombectomy and follow-up MRI. Applying voxel-wise general linear models and multivariate analysis, we assessed the effects of occlusion side, admission NIHSS, and post-thrombectomy reperfusion (modified Thrombolysis in Cerebral Infarction, mTICI) on final infarct distribution and volume as well as discharge modified Rankin Scale (mRS) score.

RESULTS

We included 469 patients, 254 with left-sided and 215 with right-sided LVO. Admission NIHSS was higher in those with left-sided LVO (median (IQR) 16 (10-22)) than in those with right-sided LVO (14 (8-16), p>0.001). In voxel-wise analysis, worse post-thrombectomy reperfusion, lower admission NIHSS score, and poor discharge outcome were associated with right-hemispheric infarct lesions. In multivariate analysis, right-sided LVO was an independent predictor of larger final infarct volume (p=0.003). There was a significant three-way interaction between admission stroke severity (based on NIHSS), LVO side, and mTICI with regard to final infarct volume (p=0.041). Specifically, in patients with moderate stroke (NIHSS 6-15), incomplete reperfusion (mTICI 0-2b) was associated with larger final infarct volume (p<0.001) and worse discharge outcome (p=0.02) in right-sided compared with left-sided LVO.

CONCLUSIONS

When adjusted for admission NIHSS, worse post-thrombectomy reperfusion is associated with larger infarct volume and worse discharge outcome in right-sided versus left-sided LVO. This may represent larger tissue-at-risk in patients with right-sided LVO when applying admission NIHSS as a clinical biomarker for penumbra.

Clinical manifestation of acute cerebral infarcts in multiple arterial territories

OBJECTIVES

We aimed to assess frequencies and radiological aspects of single- and multiterritory clinical manifestation among patients with acute cerebral infarcts in multiple arterial territories (MACI).

MATERIALS & METHODS

We retrospectively reviewed admission records and diffusion-weighted magnetic resonance imaging of patients with MACI admitted to our stroke unit between 2006 and 2017. MACI was defined as acute cerebral ischemic lesions in at least two out of three arterial cerebral territories, that is, the left anterior, right anterior and the bilateral posterior territory. Patients with single- and multiterritory clinical manifestation were then compared for topographical distribution of the ischemic lesions, the number of ischemic lesions, and The Oxfordshire Community Stroke Project classification.

RESULTS

Out of 311 patients with MACI, 222 (71.4%) presented with single-territory clinical manifestation. Involvement of the left hemisphere (OR = 0.37, 95% CI 0.16-0.82), less than five ischemic lesions (OR = 0.58, 95% CI 0.35-0.97), and partial anterior circulation infarct clinical stroke syndrome (OR = 0.57, 95% CI 0.34-0.97) were associated with single-territory clinical manifestation. Involvement of all three territories (OR = 2.58, 95% = 1.48-4.50), more than 10 ischemic lesions (OR = 2.30, 95% CI 1.32-4.01) and total anterior circulation infarct clinical stroke syndrome (OR = 3.31, 95% CI 1.39-7.86) were associated with multiterritory clinical manifestation.

CONCLUSION

Most patients with MACI present with single-territory clinical manifestation on admission. Diffusion-weighted magnetic resonance imaging is therefore necessary for a definite diagnosis.

Anticoagulation After Ischemic Stroke or Transient Ischemic Attack (TIA) in the Time of Direct Oral Anticoagulation (DOAC) and Thrombectomy

Objective To assess anticoagulation (AC) timing and appropriateness in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) due to atrial fibrillation (AF) in a predominantly Hispanic community hospital in the era of direct oral AC (DOAC) and endovascular thrombectomy (EVT). Methods Adult patients presenting with known or new-onset AF and primary diagnosis of AIS/TIA admitted to Baptist Hospital of Miami between January 2018 and January 2019 were included. AC appropriateness was determined on medical history and concordance with American Heart Association AHA/American Stroke Association (ASA) AC guidelines. Median time from AIS/TIA diagnosis to AC initiation was the primary endpoint. AC guideline concordance on admission and at discharge, discordant justification, and AC selection were secondary endpoints. Results The sample included 120 patients. AC initiation was five days (interquartile range (IQR) 2-9) following AIS/TIA. Patients' receiving intravenous (IV) alteplase experienced a 1.4-day delay in AC initiation (x̅=5.44, SE=1.05, p<.05). There was no significant delay for those receiving EVT. A symptomatic hemorrhagic transformation occurred in 3% (n=3) of patients; only one patient was initiated on AC prior to the event. No recurrent AIS/TIAs occurred prior to discharge. Guideline-based AC concordance increased by 14% to 96% from admission to discharge. Apixaban (78%, n=52) was the most prescribed anticoagulant during hospitalization. Discussion This study suggests that early AC initiation for patients with AF and AIS/TIA with or without IV alteplase and/or EVT is a safe and effective stroke prevention intervention. Further, it identified a need for improved concordance with guideline-based AC within the clinic setting.

The association between carotid blood flow and resting-state brain activity in patients with cerebrovascular diseases

Cerebral hypoperfusion impairs brain activity and leads to cognitive impairment. Left and right common carotid arteries (CCA) are the major source of cerebral blood supply. It remains unclear whether blood flow in both CCA contributes equally to brain activity. Here, CCA blood flow was evaluated using ultrasonography in 23 patients with cerebrovascular diseases. Resting-state brain activity and cognitive status were also assessed using magnetoencephalography and a cognitive subscale of the Functional Independence Measure, respectively, to explore the relationships between blood flow, functional brain activity, and cognitive status. Our findings indicated that there was an association between blood flow and resting-state brain activity, and between resting-state brain activity and cognitive status. However, blood flow was not significantly associated with cognitive status directly. Furthermore, blood velocity in the right CCA correlated with resting-state brain activity, but not with the resistance index. In contrast, the resistance index in the left CCA correlated with resting-state brain activity, but not with blood velocity. Our findings suggest that hypoperfusion is important in the right CCA, whereas cerebral microcirculation is important in the left CCA for brain activity. Hence, this asymmetry should be considered when designing appropriate therapeutic strategies.

Study of Symptomatic vs. Silent Brain Infarctions on MRI in Elderly Subjects

Brain infarctions are closely associated with future risk of stroke and dementia. Our goal was to report (i) frequency and characteristics that differentiate symptomatic vs. silent brain infarctions (SBI) on MRI and (ii) frequency and location by vascular distribution (location of stroke by major vascular territories) in a population based sample. From Mayo Clinic Study of Aging, 347 participants (≥50 years) with infarcts detected on their first MRI were included. Infarct information was identified visually on a FLAIR MRI image and a vascular territory atlas was registered to the FLAIR image data in order to identify the arterial territory of infarction. We identified the subset with a clinical history of stroke based on medical chart review and used a logistic regression to evaluate the risk factors associated with greater probability of a symptomatic stroke vs. SBI. We found that 14% of all individuals with infarctions had a history of symptomatic stroke (Silent: n = 300, symptomatic: n = 47). Factors associated with a symptomatic vs. SBI were size which had an odds ratio of 3.07 (p < 0.001), greater frequency of hypertension (odds ratio of 4.12, p = 0.025) and alcohol history (odds ratio of 4.58, p = 0.012). The frequency of infarcts was greater in right hemisphere compared to the left for SBI. This was primarily driven by middle cerebral artery (MCA) infarcts (right = 60%, left = 40%, p = 0.005). While left hemisphere strokes are more common for symptomatic carotid disease and in clinical trials, right hemispheric infarcts may be more frequent in the SBI group.

Integration of ultra-high-pressure liquid chromatography-tandem mass spectrometry with machine learning for identifying fatty acid metabolite biomarkers of ischemic stroke

We report for the first time the integration of ultra-high-pressure liquid chromatography-tandem mass spectrometry with machine learning for identifying fatty acid metabolite biomarkers of ischemic stroke. In particular, we develop an optimal model to discriminate ischemic stroke patients from healthy persons with 100% sensitivity and 93.18% specificity. This research may facilitate understanding the roles of fatty acid metabolites in stroke occurrence, holding great potential in clinical stroke diagnosis.

Cerebrovascular events complicating cardiac catheterization - A tertiary care cardiac centre experience

Background:

Cerebrovascular events (CVEs) are one of the rare complications of cardiac catheterization. This prospective single-center study was conducted to assess the incidence, presentations, and outcomes of CVEs in patients undergoing cardiac catheterization.

Methods:

Patients undergoing cardiac catheterization who developed CVEs within 48 h of procedure were analyzed prospectively with clinical assessment and neuroimaging.

Results:

Out of 55,664 patients, 35 had periprocedural CVEs (0.063%). The incidence of periprocedural CVEs with balloon mitral valvotomy, percutaneous coronary intervention, and coronary angiography was 0.127%, 0.112%, and 0.043%, respectively. A larger proportion of periprocedural CVEs occurred in patients with acute coronary syndrome (ACS, 77.1%) than in patients with stable coronary artery disease (CAD). The majority of CVEs were ischemic type (33 patients, 94.3%). It was most commonly seen in the left middle cerebral artery (MCA) territory. Hemorrhagic CVEs were very rare (2 patients, 5.7%). The majority of the CVEs manifested during or within 24 h of the procedure (31 patients, 88.6%). Neurodeficits persisted during the hospital stay in 20 patients (57.2%), who had longer duration of procedure compared to those with recovered deficits (P = 0.0125). In-hospital mortality occurred in three patients (8.5%) and post-discharge mortality in another 3 (8.5%).

Conclusions:

Periprocedural CVEs are rare and have decreased over time. They occur in a greater proportion in patients with ACS than in patients with stable CAD, more with interventional than diagnostic procedures. Ischemic event in the left MCA territory is the most common manifestation, commonly seen within 24 h of the procedure. Longer duration of procedure was a risk factor for larger infarcts and hence persistent neurodeficit at discharge. Although a substantial number of patients recover the neurodeficits, periprocedural CVEs are associated with adverse outcomes.

Ischemic Lesion Location Based on the ASPECT Score for Risk Assessment of Neurogenic Dysphagia

Dysphagia is common in patients with middle cerebral artery (MCA) infarctions and associated with malnutrition, pneumonia, and mortality. Besides bedside screening tools, brain imaging findings may help to timely identify patients with swallowing disorders. We investigated whether the Alberta stroke program early CT score (ASPECTS) allows for the correlation of distinct ischemic lesion patterns with dysphagia. We prospectively examined 113 consecutive patients with acute MCA infarctions. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed within 24 h after admission for validation of dysphagia. Brain imaging (CT or MRI) was rated for ischemic changes according to the ASPECT score. 62 patients (54.9%) had FEES-proven dysphagia. In left hemispheric strokes, the strongest associations between the ASPECTS sectors and dysphagia were found for the lentiform nucleus (odds ratio 0.113 [CI 0.028–0.433; p = 0.001), the insula (0.275 [0.102–0.742]; p = 0.011), and the frontal operculum (0.280 [CI 0.094–0.834]; p = 0.022). A combination of two or even all three of these sectors together increased relative dysphagia frequency up to 100%. For right hemispheric strokes, only non-significant associations were found which were strongest for the insula region. The distribution of early ischemic changes in the MCA territory according to ASPECTS may be used as risk indicator of neurogenic dysphagia in MCA infarction, particularly when the left hemisphere is affected. However, due to the exploratory nature of this research, external validation studies of these findings are warranted in future.

Discrepancy between post-treatment infarct volume and 90-day outcome in the ESCAPE randomized controlled trial

BACKGROUND

Some patients with ischemic stroke have poor outcomes despite small infarcts after endovascular thrombectomy, while others with large infarcts sometimes fare better.

AIMS

We explored factors associated with such discrepancies between post-treatment infarct volume (PIV) and functional outcome.

METHODS

We identified patients with small PIV (volume ≤ 25th percentile) and large PIV (volume ≥ 75th percentile) on 24-48-h CT/MRI in the ESCAPE randomized-controlled trial. Demographics, comorbidities, baseline, and 24-48-h stroke severity (NIHSS), stroke location, treatment type, post-stroke complications, and other outcome scales like Barthel Index, and EQ-5D were compared between "discrepant cases" - those with 90-day modified Rankin Scale(mRS) ≤ 2 despite large PIV or mRS ≥ 3 despite small PIV - and "non-discrepant cases". Multi-variable logistic regression was used to identify pre-treatment and post-treatment factors associated with small-PIV/mRS ≥ 3 and large-PIV/mRS ≤ 2. Sensitivity analyses used different definitions of small/large PIV and good/poor outcome.

RESULTS

Among 315 patients, median PIV was 21 mL; 27/79 (34.2%) patients with PIV ≤ 7 mL (25th percentile) had mRS ≥ 3; 12/80 (15.0%) with PIV ≥ 72 mL (75th percentile) had mRS ≤ 2. Discrepant cases did not differ by CT versus MRI-based PIV ascertainment, or right versus left-hemisphere involvement (p = 0.39, p = 0.81, respectively, for PIV ≤ 7 mL/mRS ≥ 3). Pre-treatment factors independently associated with small-PIV/mRS ≥ 3 included older age (p = 0.010), cancer, and vascular risk-factors; post-treatment factors included 48-h NIHSS (p = 0.007) and post-stroke complications (p = 0.026). Absence of vascular risk-factors (p = 0.004), CT-based lentiform nucleus sparing (p = 0.002), lower 24-hour NIHSS (p = 0.001), and absence of complications (p = 0.013) were associated with large-PIV/mRS ≤ 2. Sensitivity analyses yielded similar results.

CONCLUSIONS

Discrepancies between functional ability and PIV are likely explained by differences in age, comorbidities, and post-stroke complications, emphasizing the need for high-quality post-thrombectomy stroke care.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT01778335.

Stroke Laterality Did Not Modify Outcomes in the HERMES Meta-Analysis of Individual Patient Data of 7 Trials

Background and Purpose—

There is contradictory evidence on the impact of the stroke side (hemisphere) on outcomes. We investigated any effect modification by laterality on stroke patients’ outcomes in recent endovascular trials.

Methods—

Individual patient-level data were combined in this meta-analysis of all patients included in randomized trials comparing endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischemic patients with stroke (HERMES [Highly Effective Reperfusion Using Multiple Endovascular Devices] Collaboration). We stratified the 90-day functional outcome assessed by ordinal analysis of the modified Rankin Scale according to the stroke side of patients treated with endovascular therapy versus standard care, adjusted for important prognostic variables.

Results—

The meta-analysis included 1737 patients (871 right hemispheric strokes and 866 left hemispheric) from 7 trials. Baseline median National Institutes of Health Stroke Scale scores were significantly higher in left (20) versus right (16) hemispheric strokes ( P <0.001). Other clinical and radiological baseline characteristics were similar. The beneficial response to endovascular therapy assessed by 90-day modified Rankin Scale shift was not modified by the side of the stroke. There were no significant differences between right and left hemispheric stroke in the 90-day functional outcome (modified Rankin Scale score ≤2; 40.7% [95% CI, 37.4%–44.1%] versus 37.6% [95% CI, 37.4%–44.1%]; P =0.19), median final infarct volumes (45 versus 39.5 mL, P =0.51), nor 90-day mortality (15.1% vs 16.8%, P =0.31).

Conclusions—

Stroke side was not a prognostic factor and did not modify the treatment effect among patients treated in the endovascular or control groups in recent endovascular thrombectomy trials.

The role of radiologic, clinical and biochemical parameters in prediction of stroke mortality

Objectives:

To assess National Institutes of Health Stroke Scale (NIHSS), stroke volume, biochemical, and blood parameters for the prediction of one-month mortality in stroke patients

Methods:

The study had retrospective design and 75 patients were involved that presented to a hospital Emergency Department between January 2016 and December 2017 in Adiyaman, Turkey diagnosed with acute ischemic cerebral infarction. The patients were divided into 2 groups according to whether mortality occurred within one month. Values for NIHSS, stroke volume, Glasgow Coma Scale, and blood parameters were compared between the groups.

Results:

Values for Glasgow Coma Scale p=0.002, NIHSS p=0.001, stroke volume p=0.003, monocyte/HDL ratio p=0.047, neutrophils p=0.01, white blood cell p=0.007, calcium p=0.016, and albumin p=0.027 were statistically significant for the prediction of one-month mortality. There were no significant differences between the groups for other parameters.

Conclusion:

The clinical, laboratory, and radiological findings individually provide significant support for the short-term prognosis of stroke. The evaluation of these results together can provide a clearer advance understanding of a prognosis to better manage the course of the disease and prevent death.

Severe Stroke Patients With Left-Sided Occlusion of the Proximal Anterior Circulation Benefit More From Thrombectomy

Background and Purpose: Endovascular thrombectomy improves the functional independence of patients with proximal anterior circulation occlusion. However, a subset of patients fail to benefit from thrombectomy procedures, the reasons for which remain poorly defined. In this study, we investigated whether the effectiveness of thrombectomy was affected by left- or right-sided occlusion among patients with similar stroke severities.

Methods: Patients with proximal anterior circulation occlusion (internal carotid or M1 of middle cerebral artery) treated with the Solitaire stent retriever within 8 h of the onset of acute ischemic stroke were enrolled from the Yijishan Hospital of Wannan Medical College. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS) on admission. The functional outcomes were assessed using the modified Rankin scale (mRS) at 90 days.

Results: We enrolled 174 patients including 90 left-sided occlusion and 84 right-sided occlusion. The NIHSS scores on admission were higher in the left-sided (median, 19; interquartile range, 16 to 20) compared to the right-sided occlusion group (median, 15, interquartile range, 13 to 18) (P < 0.001). Following adjustment for potential risk factors, patients with left-sided occlusion had higher rates of functional independence (mRS ≤ 2) and lower rates of mortality (mRS = 6) compared to the right-sided occlusion patients (39.5 vs. 19.6% and 28.9 vs. 47.8%, respectively) in the severe stroke group (NIHSS ≥ 15).

Conclusions: In severe stroke patients with proximal anterior circulation occlusion, stent retriever thrombectomy within 8 h of the onset of symptoms provides more benefits to left-sided occlusion.

Classification of Mild Stroke: A Mapping Review

Persons with mild stroke experience motor and cognitive impairments that negatively affect their health and quality of life. To address these deficits, it is essential for clinicians and researchers to precisely identify mild stroke survivors. Despite the fact that half of all strokes are categorized as mild, no standards exist on what constitutes a "mild" stroke. The purpose of this study is to summarize the current classification of mild stroke using a mapping review approach. Strategies to categorize "mild stroke" severity were explored in 188 papers indexed in the PubMed database. The results indicate that there was substantial variability in the procedures and scoring criteria used to determine mild stroke. To identify persons with mild stroke, researchers have largely applied assessment instruments developed to inform acute stroke care (eg, National Institutes of Health Stroke Scale, Modified Rankin Scale, Barthel Index). Unfortunately, these approaches demonstrate floor effects and fail to detect the long-term disabling impairments that often limit the outcomes of mild stroke survivors. Additional research is warranted to suggest an evidence-based mild stroke categorization strategy that enhances diagnosis, treatment, and referral decisions to the benefit of mild stroke survivors.

Validation and responsiveness of the Late-Life Function and Disability Instrument Computerized Adaptive Test in community-dwelling stroke survivors

BACKGROUND

Follow-up of stroke survivors is important to objectify activity limitations and/or participations restrictions. Responsive measurement tools are needed with a low burden for professional and patient.

AIM

To examine the concurrent validity, floor and ceiling effects and responsiveness of both domains of the Late-Life Function and Disability Index Computerized Adaptive Test (LLFDI-CAT) in first-ever stroke survivors discharged to their home setting.

DESIGN

Longitudinal study.

SETTING

Community.

POPULATION

First ever stroke survivors.

METHODS

Participants were visited within three weeks after discharge and six months later. Stroke Impact Scale (SIS 3.0) and Five-Meter Walk Test (5MWT) outcomes were used to investigate concurrent validity of both domains, activity limitations, and participation restriction, of the LLFDI-CAT. Scores at three weeks and six months were used to examine floor and ceiling effects and change scores were used for responsiveness. Responsiveness was assessed using predefined hypotheses. Hypotheses regarding the correlations with change scores of related measures, unrelated measures, and differences between groups were formulated.

RESULTS

The study included 105 participants. Concurrent validity (R) of the LLFDI-CAT activity limitations domain compared with the physical function domain of the SIS 3.0 and with the 5MWT was 0.79 and -0.46 respectively. R of the LLFDI-CAT participation restriction domain compared with the participation domain of the SIS 3.0 and with the 5MWT was 0.79 and -0.41 respectively. A ceiling effect (15%) for the participation restriction domain was found at six months. Both domains, activity limitations and participation restrictions, of the LLFDI-CAT, scored well on responsiveness: 100% (12/12) and 91% (12/11) respectively of the predefined hypotheses were confirmed.

CONCLUSIONS

The LLFDI-CAT seems to be a valid instrument and both domains are able to detect change over time. Therefore, the LLFDI-CAT is a promising tool to use both in practice and in research.

CLINICAL REHABILITATION IMPACT

The LLFDI-CAT can be used in research and clinical practice.

Infarct topography and functional outcomes

Acute ischemic stroke represents a major cause of long-term adult disability. Accurate prognostication of post-stroke functional outcomes is invaluable in guiding patient care, targeting early rehabilitation efforts, selecting patients for clinical research, and conveying realistic expectations to families. The involvement of specific brain regions by acute ischemia can alter post-stroke recovery potential. Understanding the influences of infarct topography on neurologic outcomes holds significant promise in prognosis of functional recovery. In this review, we discuss the recent evidence of the contribution of infarct location to patient management decisions and functional outcomes after acute ischemic stroke.

Ischemic Volume and Neurological Deficit: Correlation of Computed Tomography Perfusion with the National Institutes of Health Stroke Scale Score in Acute Ischemic Stroke

BACKGROUND

The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke.

METHODS

This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes.

RESULTS

A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P < .0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r = .76; P < .0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r = .83 and .81; P < .0001), showing a slightly higher slope in the left.

CONCLUSION

This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making.

Early Recovery of Aphasia through Thrombolysis: The Significance of Spontaneous Speech

BACKGROUND

Aphasia is one of the most devastating stroke-related consequences for social interaction and daily activities. Aphasia recovery in acute stroke depends on the degree of reperfusion after thrombolysis or thrombectomy. As aphasia assessment tests are often time-consuming for patients with acute stroke, physicians have been developing rapid and simple tests. The aim of our study is to evaluate the improvement of language functions in the earliest stage in patients treated with thrombolysis and in nontreated patients using our rapid screening test.

MATERIALS AND METHODS

Our study is a single-center prospective observational study conducted at the Stroke Unit of the University Medical Hospital of Trieste (January-December 2016). Patients treated with thrombolysis and nontreated patients underwent 3 aphasia assessments through our rapid screening test (at baseline, 24 hours, and 72 hours). The screening test assesses spontaneous speech, oral comprehension of words, reading aloud and comprehension of written words, oral comprehension of sentences, naming, repetition of words and a sentence, and writing words.

RESULTS

The study included 40 patients: 18 patients treated with thrombolysis and 22 nontreated patients. Both groups improved over time. Among all language parameters, spontaneous speech was statistically significant between 24 and 72 hours (P value = .012), and between baseline and 72 hours (P value = .017).

CONCLUSIONS

Our study demonstrates that patients treated with thrombolysis experience greater improvement in language than the nontreated patients. The difference between the 2 groups is increasingly evident over time. Moreover, spontaneous speech is the parameter marked by the greatest improvement.