Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

Enhanced neuroplasticity and gait recovery in stroke patients: a comparative analysis of active and passive robotic training modes

BACKGROUND

Stroke is a leading cause of long-term disability, with lower limb dysfunction being a common sequela that significantly impacts patients' mobility and quality of life. Robotic-assisted training has emerged as a promising intervention for gait rehabilitation post-stroke. This study aims to compare the effects of active and passive lower limb robotic training on gait recovery in stroke patients.

METHODS

This randomized controlled trial included 45 stroke patients who were divided into three groups: active mode group, passive mode group, and control group. All participants received standard rehabilitation therapy, while the intervention groups additionally received 20 min of robotic training (active or passive mode) daily for 10 sessions over two weeks. Outcome measures included the Fugl-Meyer Assessment (FMA) for motor function, motor evoked potentials (MEP) for neurophysiological assessment, and functional near-infrared spectroscopy (fNIRS) for brain imaging.

RESULTS

Both active and passive groups showed significant improvements in FMA scores and MEP measures compared to pre-treatment baselines (P < 0.01). The active group exhibited significantly greater FMA score improvements (P = 0.02) and MEP amplitudes (P < 0.01) than the passive group. Additionally, fNIRS results indicated significantly enhanced brain activation in the affected motor cortex in the active group post-treatment (F = 5.82, P = 0.026), a change not observed in the passive group. These findings underscore the clinical superiority of active robotic training in enhancing motor recovery post-stroke.

CONCLUSION

Active mode robotic training is more effective than passive mode training in improving motor function and neurophysiological outcomes in stroke patients. These findings support the preferential use of active mode robotic training in clinical rehabilitation settings for enhancing gait recovery post-stroke. Further research with larger sample sizes and longer follow-up periods is warranted to confirm these results and explore long-term benefits.

Prehospital antibiotics and intravenous fluids for patients with sepsis: protocol for a 2×2 factorial randomised controlled trial

INTRODUCTION

Prompt recognition and treatment of patients with sepsis improve survival. Patients transported to hospital with sepsis often do not receive treatment until they are assessed in emergency departments. Initiation of treatments by paramedics at the point of first contact may improve outcomes for these patients.

METHODS AND ANALYSIS

The study design involves two randomised controlled trials (RCTs) conducted using a 2×2 factorial design comparing use of (1) early intramuscular ceftriaxone versus placebo and (2) an early liberal intravenous fluid strategy (up to 2 L normal saline) versus usual care resuscitation guided by paramedic medical directives. Patients who are ≥18 years of age will be eligible for inclusion if they have sepsis, defined as (1) paramedic suspicion of infection, (2) fever (temperature ≥38.0°C measured by paramedic or history of fever during the previous 24 hours), and (3) hypotension: SBP <100 mm Hg. The primary outcome is mortality prior to hospital discharge or within 90 days of admission. Secondary outcomes are all-cause mortality at 90 days after enrolment; organ dysfunction during first 24 hours (mechanical ventilation, vasopressor therapy, dialysis) and hospitalisation (mechanical ventilation; dialysis); rates and duration of hospital admission; rates of ICU admission during index hospitalisation; discharge destination; proportion of patients with positive blood cultures obtained in hospital (first 24 hours); microbiological profile including distribution of microorganism species and resistant organisms; proportion of patients receiving additional antibiotics within 6 hours and within 24 hours of hospital admission; frequency distribution of first antibiotics (if any) delivered within 24 hours of hospital arrival; mean time to antibiotics delivered within 24 hours of hospital arrival (if any); proportion of patients receiving fluid bolus (>250 mL) within 24 hours of hospital arrival; total amount of crystalloid infused during transport and first 24 hours of hospitalisation; and proportion of enrolled patients not suspected to have sepsis or infection by emergency department physicians. Safety outcomes include the proportion of patients with pulmonary oedema during transport to hospital and on initial chest X-ray and the proportion of patients with anaphylaxis or suspected allergic reactions to study medication.

ETHICS AND DISSEMINATION

This study has been approved through Clinical Trials Ontario's streamlined ethics review process (board of record, Sunnybrook Health Sciences Centre). It will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. The final results will be disseminated to participating paramedic services through educational materials, presentations and interactive training. We anticipate our trial will achieve wide dissemination through publication in a peer-reviewed medical journal and presentation at international conferences targeting the fields of prehospital and emergency medicine, resuscitation and critical care.

TRIAL REGISTRATION NUMBER

NCT03068741.

Music Interventions in Hyperacute and Acute Stroke Patients: A Randomized Controlled Pilot Feasibility Study

OBJECTIVE

Music interventions have been shown to have beneficial effects on hemodynamic parameters, pain, and anxiety in various medical settings. However, music interventions in the setting of acute stroke have not been studied. The objective of this trial was to perform a pilot feasibility study of music interventions in the setting of acute stroke to inform a larger efficacy trial.

METHODS

Open label parallel group, randomized controlled trial with objective endpoints.

RESULTS

The percentage of eligible patients approached for consent who were recruited into the trial was 85.7% (95% CI 75.9%-98%; 30/35) and the percentage of eligible patients recruited into the trial was 66.7% (95% CI 52.9%-80.4%; 30/45). Twenty-nine participants completed the first 6 h of the trial 96.7% (95% CI 82.8%-99.9%, 29/30). Participants were highly supportive of music interventions in the target setting (mean value of 8 (SD ± 1.6) on a scale of 1-10). 95% Confidence Intervals for efficacy included clinically important differences. Specifically, the SBPV was non-significantly lower in the intervention arm (mean difference - 1.31 mmHg, [95% CI -4.8 to 2.2 mmHg]). Similarly, the adjusted β was non-significantly lower in the intervention arm for change in pain burden (-3.9 [95% CI -11.4 to 3.7]) and change in anxiety burden (-9.9 [-98.2 to 78.5]).

INTERPRETATION

Our findings support a larger trial of music or sound interventions in hyperacute and acute stroke patients as alternatives to or synergists with pharmacologic management.

Intraarterial Thrombolysis as an Adjunct to Thrombectomy in Acute Ischemic Stroke: Current Status and Future Prospects

BACKGROUND AND PURPOSE

Intraarterial thrombolysis (IAT) has been sporadically used as an adjunct to mechanical thrombectomy (MT) in acute ischemic stroke patients for nearly two decades to improve distal arterial and microvascular perfusion even in patients with near complete or complete recanalization.

METHODS

We provide an overall narrative review that includes a systematic review and meta-analysis of two randomized controlled trials (RCTs), Chemical Optimization of Cerebral Embolectomy and Endovascular Recanalization in Patients with Acute Posterior Circulation Arterial Occlusion, to identify current and future implications. Risk ratios (RRs) were calculated from RCTs using a fixed-effects model. We identified 10 ongoing or planned RCTs after a search on clinicaltrials.gov and other sources, of which eight are in China, one in Europe, and one in Australia.

RESULTS

A previous meta-analysis of 16 (predominantly observational) studies involving 7572 MT-treated patients had identified 14% higher odds of functional independence (modified Rankin scale [mRS] 0-2) at 90 days in patients treated with IAT. In the current analysis of 321 patients who underwent MT in RCTs, 165 were randomized to IAT and 156 were in the control group. The RR of achieving an mRS score of 0-1 at 90 days postrandomization was higher in patients treated with IAT compared with the control group (absolute increase of 12.87%, RR = 1.39, 95% confidence interval [CI] 1.04-1.86). The rate of symptomatic intracerebral hemorrhage (sICH) within 24 h was slightly higher (absolute increase of 1.64%, RR = 0.95, 95% CI 0.07-13.30) in patients treated with IAT. The ongoing RCTs have sample sizes ranging from 80 to 498 that can identify very large minimal clinically important differences (MCIDs) (13%-20% increase) in primary outcomes, but smaller MCIDs (<10%) that can still result in practice changes with interventions associated with low cost and complexity and are easy to implement, such as IAT, will not be identified.

CONCLUSIONS

Observational studies and recent RCTs suggest a potential benefit of IAT in improving functional outcomes among patients post-MT, although the potentially increased risk of sICH, inadequate sample sizes, and lack of data from the United States need to be considered. A large, definitive, and generalizable RCT is required to establish the therapeutic value and safety profile of IAT prior to widespread incorporation into routine practice.

Association between hemoglobin level and clinical outcomes in ischemic stroke patients with high-grade carotid artery stenosis

OBJECTIVE

Abnormal hemoglobin levels may influence stroke outcome, while high-grade carotid artery stenosis (CAS) is linked to distal hemodynamic compromise. The relationship between hemoglobin and ischemic stroke (IS) outcome in patients with high-grade CAS remains unclear. We aimed to investigate this association in acute IS patients with high-grade CAS.

METHODS

To compare the characteristics and outcome in acute IS patients with high-grade CAS across different hemoglobin levels, we conducted an observational cohort study from January 2007 to April 2012 and followed for 5 years.

RESULTS

Among 372 enrolled patients, 75 had hemoglobin < 12 g/dL, 153 had 12-14 g/dL, and 144 had > 14 g/dL. Hemoglobin < 12 g/dL was associated with higher rates of congestive heart failure, gout, and chronic kidney disease, but lower rate of hyperlipidemia. Hemoglobin< 12 g/dL had lower levels of white blood cells, total cholesterol, and estimated glomerular filtration rate, but higher levels of high-sensitivity C-reactive protein and potassium. The Cox proportional hazards model revealed that hemoglobin< 12 g/dL was associated with higher risk of all-cause mortality (hazard ratio (HR) 1.99, 95 % confidence interval (CI) 1.20-3.32, P = 0.008) and lower risk of stroke recurrence over 5 years in IS patients with high-grade CAS (HR 0.50, 95 % CI 0.26-0.95; P = 0.033).

CONCLUSIONS

Hemoglobin< 12 g/dL was associated with higher mortality and lower stroke recurrence risk over 5 years in IS patients with high-grade CAS. Further studies are warranted to determine the optimal hemoglobin level for improving outcomes in these patients.

Novel HOCl-Responsive Theranostic Prodrug for the Early Diagnosis and Therapy of Ischemic Stroke

In this work, a hypochlorous acid (HOCl)-responsive prodrug MB-R for diagnosis and therapy of ischemic stroke (IS) was constructed using the near-infrared fluorophore methylene blue linked to riluzole by the urea bond. MB-R exhibits good biocompatibility, fast response (<1 min), and high selectivity toward HOCl. MB-R was successfully utilized to visualize the HOCl levels, as well as the distribution of HOCl in the brains of IS mice to determine the progression of the disease. Meanwhile, the treatment with MB-R could reduce the cerebral infarction volume and improve the motor function in IS mice. Most importantly, MB-R could be utilized in the treatment of stroke through antioxidant, anti-inflammatory, and neuroprotective effects, further suggesting that riluzole was a potentially therapeutic agent for IS. Thus, this work paves the way for the development of intelligent theranostic agent for the early diagnosis and treatment of IS.

Serum Uric Acid Level and Intraventricular Hemorrhage in Patients with Acute Hemorrhagic Stroke: A Retrospective Observational Study

In contrast to experimental studies indicating the neuroprotective role of uric acid (UA), recent clinical studies have shown that increased UA is associated with a risk of acute hemorrhagic stroke. However, the association of UA with intraventricular hemorrhage (IVH) has not been adequately evaluated. In this study, we determined the relationship between UA and IVH in patients with intracerebral hemorrhage (ICH). We included 721 patients with ICH who were admitted to a tertiary hospital in South Korea. The patients were stratified into quartiles based on their UA levels. IVH decreased continuously across all quartiles of UA. After adjusting for confounding factors, the odds ratio (OR) for IVH was significantly lower in the fourth quartile compared with that in the first quartile (OR: 0.713; 95% CI: 0.546-0.934; P=0.045). In conclusion, UA is independently associated with IVH, suggesting its protective role against IVH in patients with ICH.

From 'strong recommendation' to practice: A pre-test post-test study examining adherence to stroke guidelines for fever, hyperglycaemia, and swallowing (FeSS) management post-stroke

Background

The Quality in Acute Stroke Care (QASC) Trial demonstrated that assistance to implement protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) post-stroke reduced death and disability. In 2017, a 'Strong Recommendation' for use of FeSS Protocols was included in the Australian Clinical Guidelines for Stroke Management. We aimed to: i) compare adherence to FeSS Protocols pre- and post-guideline inclusion; ii) determine if adherence varied with prior participation in a treatment arm of a FeSS Intervention study, or receiving treatment in a stroke unit; and compare findings with our previous studies.

Methods

Pre-test post-test study using Australian acute stroke service audit data comparing 2015/2017 (pre-guideline) versus 2019/2021 (post-guideline) adherence. Primary outcome was adherence to all six FeSS indicators (composite), with mixed-effects logistic regression adjusting for age, sex, stroke type and severity (ability to walk on admission), stroke unit care, hospital prior participation in a FeSS Intervention study, and correlation of outcomes within hospital. Additional analysis examined interaction effects.

Results

Overall, 112 hospitals contributed data to ≥1 one Audit cycle for both periods (pre=7011, post=7195 cases); 42 hospitals had participated in any treatment arm of a FeSS Intervention study. Adherence to FeSS Protocols post-guideline increased (pre: composite measure 35% vs post: composite measure 40 %, aOR:1.2 95 %CI: 1.2, 1.3). Prior participation in a FeSS Intervention study (aOR:1.6, 95 %CI: 1.2, 2.0) and stroke unit care (aOR 2.3, 95 %CI: 2.0, 2.5) were independently associated with greater adherence to FeSS Protocols. There was no change in adherence over time based on prior participation in a FeSS Intervention study (p = 0.93 interaction), or stroke unit care (p = 0.07 interaction).

Conclusions

There is evidence of improved adherence to FeSS Protocols following a 'strong recommendation' for their use in the Australian stroke guidelines. Change in adherence was similar independent of hospital prior participation in a FeSS Intervention study, or stroke unit care. However, maintenance of higher pre-guideline adherence for hospitals prior participation in a FeSS Intervention study suggests that research participation can facilitate greater guideline adherence; and confirms superior care received in stroke units. Nevertheless, less than half of Australian patients are being cared for according to the FeSS Protocols, providing impetus for additional strategies to increase uptake.

Acupuncture for acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials

Objective

Assess the safety and effectiveness of acupuncture for acute ischemic stroke (AIS).

Methods

We conducted a comprehensive search across the PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang, and SinoMed databases from their inception until October 3, 2023. Two reviewers screened eligible randomized controlled trials (RCTs) according to criteria and extracted data using a pre-established form. Cochrane tool was used for risk of bias assessment, and Revman 5.3 was used for subsequent meta-analysis. The GRADE tool will be used to assess the quality of evidence.

Results

Thirty-one RCTs were included, involving 3604 patients. Meta-analysis showed that compared with conventional treatments (CTs), acupuncture combined with CTs could improve in National Institutes of Health Stroke Scale (NIHSS) and Efficiency (MD:1.70, 95 %CI [-2.27, -1.14], P < 0.00001;RR: 1.21, 95 %CI [1.12, 1.31], P < 0.00001,);On the Chinese Stroke Scale (CSS) and effectiveness based on CSS, acupuncture showed positive effects (MD:4.33, 95 %CI [-5.67, -2.98], P < 0.00001; RR: 1.26, 95 %CI [1.13, 1.41], P < 0.0001). Furthermore, ADL, Fugl-Meyer Assessment Scale (FMA), prognosis analyses also showed the effectiveness of acupuncture. (SMD: 0.98, 95 % CI [0.64, 1.31], P < 0.00001; MD: 16.46, 95 %CI [12.56, 20.35], P < 0.00001; RR: 0.38, 95 %CI [0.16, 0.89], P = 0.03). However, the certainty of evidence was low.

Conclusion

According to current evidence, Acupuncture may be effective and safe for AIS. The future still needs high-quality evidence to support this conclusion.

From Gut to Brain: Unraveling the Intricate Link Between Microbiome and Stroke

Stroke, a neurological disorder, is intricately linked to the gut microbiota, influencing microbial composition and elevating the risk of ischemic stroke. The neuroprotective impact of short-chain fatty acids (SCFAs) derived from dietary fiber fermentation contrasts with the neuroinflammatory effects of lipopolysaccharide (LPS) from gut bacteria. The pivotal role of the gut-brain axis, facilitating bidirectional communication between the gut and the brain, is crucial in maintaining gastrointestinal equilibrium and influencing cognitive functions. An in-depth understanding of the interplay among the gut microbiota, immune system, and neurological outcomes in stroke is imperative for devising innovative preventive and therapeutic approaches. Strategies such as dietary adjustments, probiotics, prebiotics, antibiotics, or fecal transplantation offer promise in modulating stroke outcomes. Nevertheless, comprehensive research is essential to unravel the precise mechanisms governing the gut microbiota's involvement in stroke and to establish effective therapeutic interventions. The initiation of large-scale clinical trials is warranted to assess the safety and efficacy of interventions targeting the gut microbiota in stroke management. Tailored strategies that reinstate eubiosis and foster a healthy gut microbiota hold potential for both stroke prevention and treatment. This review underscores the gut microbiota as a promising therapeutic target in stroke and underscores the need for continued research to delineate its precise role and develop microbiome-based interventions effectively.

Hemorrhagic stroke in children

Hemorrhagic stroke (HS) in childhood accounts for almost 50% of childhood strokes, is among the top ten causes of deaths, or determines lifelong disability. These facts form significant socio-economic and demographic problems. The purpose of this review is to analyze current knowledge about HS in children. The data on HS terminology are presented, taking into account the International Classification of Diseases 11 edition. Attention is paid to the epidemiology of HS in children, including the results of individual local studies. The risk factors of HS in children were studied with an analysis of the causal, pathophysiological mechanisms of HS of various etiologies. The ideas about the clinical manifestations of HS in children are described. The analysis of HS treatment in children was carried out with an emphasis on achievements in neurointensive therapy of the acute period of HS. This review also includes information on the outcomes of HS in children.

Prediction of Ischemic Stroke Functional Outcomes from Acute-Phase Noncontrast CT and Clinical Information

Background Clinical outcome prediction based on acute-phase ischemic stroke data is valuable for planning health care resources, designing clinical trials, and setting patient expectations. Existing methods require individualized features and often involve manually engineered, time-consuming postprocessing activities. Purpose To predict the 90-day modified Rankin Scale (mRS) score with a deep learning (DL) model fusing noncontrast-enhanced CT (NCCT) and clinical information from the acute phase of stroke. Materials and Methods This retrospective study included data from six patient datasets from four multicenter trials and two registries. The DL-based imaging and clinical model was trained by using NCCT data obtained 1-7 days after baseline imaging and clinical data (age; sex; baseline and 24-hour National Institutes of Health Stroke Scale scores; and history of hypertension, diabetes, and atrial fibrillation). This model was compared with models based on either NCCT or clinical information alone. Model-specific mRS score prediction accuracy, mRS score accuracy within 1 point of the actual mRS score, mean absolute error (MAE), and performance in identifying unfavorable outcomes (mRS score, >2) were evaluated. Results A total of 1335 patients (median age, 71 years; IQR, 60-80 years; 674 female patients) were included for model development and testing through sixfold cross validation, with distributions of 979, 133, and 223 patients across training, validation, and test sets in each of the six cross-validation folds, respectively. The fused model achieved an MAE of 0.94 (95% CI: 0.89, 0.98) for predicting the specific mRS score, outperforming the imaging-only (MAE, 1.10; 95% CI: 1.05, 1.16; P < .001) and the clinical information-only (MAE, 1.00; 95% CI: 0.94, 1.05; P = .04) models. The fused model achieved an area under the receiver operating characteristic curve (AUC) of 0.91 (95% CI: 0.89, 0.92) for predicting unfavorable outcomes, outperforming the clinical information-only model (AUC, 0.88; 95% CI: 0.87, 0.90; P < .001) and the imaging-only model (AUC, 0.85; 95% CI: 0.84, 0.87; P < .001). Conclusion A fused DL-based NCCT and clinical model outperformed an imaging-only model and a clinical-information-only model in predicting 90-day mRS scores. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Lee in this issue.

Diagnostic Accuracy of Hyperdense Artery Sign in Early Detection of Middle Cerebral Artery Infarction: A Cross-Sectional Validation Study

Background

Hyperdense middle cerebral artery sign (HMCAS) on a non-enhanced multidetector computed tomography (MDCT) scan is considered an important radiological marker in detecting acute arterial thrombotic occlusion, and it is one of the earliest signs of ischemic cerebrovascular accident (CVA). This finding has been observed within 90 min of symptom onset. Modern approaches to patients with cerebral infarction emphasize early diagnosis and management.

Purpose

To determine the diagnostic accuracy of hyperdense artery signs in early detection of middle cerebral artery (MCA) infarction on non-contrast-enhanced MDCT scan using Magnetic Resonance Angiography (MRA) within 24 h as the gold standard for definitive diagnosis.

Method

A total of 140 patients aged 35-70 years, referred to the radiology department of Aga Khan University Hospital with clinical suspicion of acute cerebral infarction, were included. After clinical suspicion of acute infarction, the patient underwent an initial complete MDCT scan of the brain, which was performed using Aquilion ONE 640 slice MDCT (Toshiba Medical Systems, Japan). Consultant radiologists, with a minimum of 5 years of experience in MDCT brain imaging, interpreted the images. Follow-up examination with MRA within 24 h was performed to confirm the diagnosis of MCA infarction.

Results

Overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of HMCAS in the early detection of MCA infarction on non-contrast-enhanced MDCT scan using MRA as the gold standard for definitive diagnosis was 96.20%, 93.44%, 95.0%, 95.0%, and 95.0%, respectively.

Conclusion

This study concluded that the diagnostic accuracy of hyperdense artery signs in the early detection of MCA infarction on non-contrast-enhanced MDCT scans is very high.

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

Association between repeat imaging and readmission in patients with acute ischaemic stroke: a 16-year nationwide population-based study

OBJECTIVES

This study aims to evaluate such usage patterns and identify factors that may contribute to the need for repeat imaging in acute ischaemic stroke patients and determine the association between repeat imaging and readmission in Taiwan.

METHODS

We searched and analysed data from the Taiwan National Health Insurance Research Database for patients admitted for acute ischaemic stroke between 2002 and 2017. Cases where repeat brain imaging during the initial hospital admission occurred and where patients were readmitted within 30 days following discharge were documented.

RESULTS

Of a total of 195 016 patients with new onset ischaemic stroke, 51 798 (26.6%) underwent repeat imaging during their initial admission. Factors associated with repeat brain imaging included younger age, longer hospital stay, use of recombinant tissue plasminogen activator (rt-PA) therapy (odds ratio = 2.10 [95% CI, 1.98-2.22]), more recent year of diagnosis, higher National Institutes of Health Stroke Scale (NIHSS) score, and admission to a hospital offering a higher level of care. Repeat imaging was also associated with an increased risk of ischaemic stroke and all types of stroke readmission.

CONCLUSIONS

Repeat brain imaging of patients with stroke has increased in recent years, and it is associated with certain factors including age, length of stay, use of rt-PA, hospital level of care, and NIHSS score. It is also associated with increased readmission.

ADVANCES IN KNOWLEDGE

Knowledge of the associations of repeat imaging may help clinicians use repeat imaging more carefully and efficaciously.

A Multi-Parametric Approach for Characterising Cerebral Haemodynamics in Acute Ischaemic and Haemorrhagic Stroke

BACKGROUND AND PURPOSE

Early differentiation between acute ischaemic (AIS) and haemorrhagic stroke (ICH), based on cerebral and peripheral hemodynamic parameters, would be advantageous to allow for pre-hospital interventions. In this preliminary study, we explored the potential of multiple parameters, including dynamic cerebral autoregulation, for phenotyping and differentiating each stroke sub-type.

METHODS

Eighty patients were included with clinical stroke syndromes confirmed by computed tomography within 48 h of symptom onset. Continuous recordings of bilateral cerebral blood velocity (transcranial Doppler ultrasound), end-tidal CO2 (capnography), electrocardiogram (ECG), and arterial blood pressure (ABP, Finometer) were used to derive 67 cerebral and peripheral parameters.

RESULTS

A total of 68 patients with AIS (mean age 66.8 ± SD 12.4 years) and 12 patients with ICH (67.8 ± 16.2 years) were included. The median ± SD NIHSS of the cohort was 5 ± 4.6. Statistically significant differences between AIS and ICH were observed for (i) an autoregulation index (ARI) that was higher in the unaffected hemisphere (UH) for ICH compared to AIS (5.9 ± 1.7 vs. 4.9 ± 1.8 p = 0.07); (ii) coherence function for both hemispheres in different frequency bands (AH, p < 0.01; UH p < 0.02); (iii) a baroreceptor sensitivity (BRS) for the low-frequency (LF) bands that was higher for AIS (6.7 ± 4.2 vs. 4.10 ± 2.13 ms/mmHg, p = 0.04) compared to ICH, and that the mean gain of the BRS in the LF range was higher in the AIS than in the ICH (5.8 ± 5.3 vs. 2.7 ± 1.8 ms/mmHg, p = 0.0005); (iv) Systolic and diastolic velocities of the affected hemisphere (AH) that were significantly higher in ICH than in AIS (82.5 ± 28.09 vs. 61.9 ± 18.9 cm/s), systolic velocity (p = 0.002), and diastolic velocity (p = 0.05).

CONCLUSION

Further multivariate modelling might improve the ability of multiple parameters to discriminate between AIS and ICH and warrants future prospective studies of ultra-early classification (<4 h post symptom onset) of stroke sub-types.

Diesel exhaust particles exposure exacerbates pro-thrombogenic plasma features ex-vivo after cerebral ischemia and accelerates tPA-induced clot-lysis in hypertensive subjects

The combustion of fossil fuels, mainly by diesel engines, generates Diesel Exhaust Particles (DEP) which are the main source of Particulate Matter (PM), a major air pollutant in urban areas. These particles are a risk factor for stroke with 5.6% of cases attributed to PM exposure. Our aim was to evaluate the effect of DEP exposure on clot formation and lysis in the context of stroke. An ex-vivo clot formation and lysis turbidimetric assay has been conducted in human and mouse plasma samples from ischemic stroke or control subjects exposed to DEP or control conditions. Experimental DEP exposure was achieved by nasal instillation in mice, or by ex-vivo exposure in human plasma. Results show consistent pro-thrombogenic features in plasma after human ischemic stroke and mouse cerebral ischemia (distal MCAo), boosted by the presence of DEP. Otherwise, thrombolysis times were increased after ischemia in chronically exposed mice but not in the DEP exposed group. Finally, subjects living in areas with high PM levels presented accelerated thrombolysis compared to those living in low polluted areas. Overall, our results point at a disbalance of the thrombogenic/lytic system in presence of DEP which could impact on ischemic stroke onset, clot size and thrombolytic treatment.

Is a minimum duration of 5 days of unfractionated heparin infusion necessary before transition to oral anticoagulation in cerebral venous thrombosis? a retrospective chart review

In managing cerebral venous sinus thrombosis (CVT), the standard approach has been administering parenteral anticoagulation for at least five days, despite limited supporting evidence. This study aimed to determine the optimal duration of parenteral anticoagulation for CVT patients and its potential impact on their functional outcomes upon discharge. This retrospective observational cohort study was conducted across multiple healthcare centers and included adult CVT patients who received varying durations of parenteral anticoagulation: less than 5 days (n = 25) or 5 days or more (n = 16). The primary focus was on the duration of acute anticoagulation treatment, with secondary endpoints including hospital stay length and functional outcomes. The study found that a shorter duration of anticoagulation treatment (< 5 days) was linked to more favorable outcomes, as measured by the modified Rankin Scale (mRS) (68% vs. 25%, RR = 0.37, CI 0.15-0.90, p = 0.007). However, regression analysis showed non statistically significant associations for all variables except gender. Female patients were significantly more likely to receive a shorter duration of anticoagulation (Odds Ratio: 2.6, 95% CI: 2.2-3.1, P-Value: <0.001). These findings suggest a potential connection between shorter anticoagulation duration (< 5 days) and improved CVT patient outcomes, as indicated by their mRS scores at discharge. The observed relationship between female gender and shorter anticoagulation duration warrants further exploration. Nevertheless, caution is necessary when interpreting these findings due to the small sample size and specific patient characteristics. Further research in a larger and more diverse cohort is essential to validate these results and understand their implications fully.

Stroke Thrombolysis in the Context of a Pituitary Macroadenoma

The presence of an intracranial tumour is a relative or absolute contraindication to stroke thrombolysis by most guidelines across the world. This is based on the risk of iatrogenic symptomatic intracranial haemorrhage related to the tumour. We present a patient where the decision to proceed with thrombolysis was complicated by an incidental finding of an intracranial tumour. The decision was made to proceed with thrombolysis. The patient had excellent functional recovery in the hours after administration and didn't suffer any intracranial haemorrhage. The evidence around excluding this patient group from thrombolysis is scant and mostly of low quality. Original randomised controlled trials or stroke thrombolysis excluded this patient group and there have been none since. Published case reports and series are heterogeneous in their conclusions regarding the risk of symptomatic haemorrhage following thrombolysis in patients with intra-axial and extra-axial neoplasms. Further studies may clarify guidelines.

A bibliometric analysis of tenecteplase research utilizing a commonly used citation index

BACKGROUND AND PURPOSE

Tenecteplase is increasingly being used as a first-line treatment for acute ischemic stroke after several randomized studies demonstrated its safety and efficacy, resulting in a massive increase in the number of published studies on this topic. Our aim was to investigate the most impactful authors and relevant journals that have been instrumental in validating this treatment, in hopes of identifying objective research trends that may assist scientists, health organizations, and funding agencies to collaborate and plan future avenues of research.

METHODS

Using the search terms "Tenecteplase" and "Tenecteplase" AND "Stroke," 2683 and 1150 references were queried, respectively, using the abstract and citation database, Scopus. Scopus Citation Analysis was used to categorize the countries and authors who produced the most research. Metadata was retrieved and transferred to bibliographic visualization software, VOSviewer, for co-authorship and co-occurrence analyses to identify trends in tenecteplase research.

RESULTS

Data visualization software identified three tenecteplase research clusters - myocardial infarction, pulmonary embolism, and acute ischemic stroke. Our bibliographic analysis graphically identified that ischemic stroke currently leads both myocardial infarction and pulmonary embolism in annual publications pertaining to tenecteplase therapy, and further pinpointed perfusion imaging and wake-up strokes as the most relevant areas of study. The United States led all countries in tenecteplase publications, including exclusively stroke studies. The European Heart Journal led all journals in overall publications, while Stroke led all journals in stroke-related studies.

CONCLUSIONS

Through the use of bibliographic analysis and data visualization, we identified major articles and journals that reflected and shaped the current landscape of tenecteplase; recognized authors who engaged in tenecteplase research as it progressed from cardiopulmonary disease to stroke; and postulated future avenues of research.

Clinical impact of craniectomy on shunt-dependent hydrocephalus after intracerebral hemorrhage: A propensity score-matched analysis

PURPOSE

A consensus on decompressive craniectomy for intracerebral hemorrhage (ICH) has not yet been established. We aimed to investigate the development of shunt-dependent hydrocephalus based on the method of ICH surgery, with a focus on craniectomy.

METHODS

We retrospectively enrolled 458 patients with supratentorial ICH who underwent surgical hematoma evacuation between April 2005 and December 2021 at two independent stroke centers. Multivariate analyses were performed to characterize risk factors for postoperative shunt-dependent hydrocephalus. Propensity score matching (1:2) was undertaken to compensate for group-wise imbalances based on probable factors that were suspected to affect the development of hydrocephalus, and the clinical impact of craniectomy on shunt-dependent hydrocephalus was evaluated by the matched analysis.

RESULTS

Overall, 43 of the 458 participants (9.4%) underwent shunt procedures as part of the management of hydrocephalus after ICH. Multivariate analysis revealed that intraventricular hemorrhage (IVH) and craniectomy were associated with shunt-dependent hydrocephalus after surgery for ICH. After propensity score matching, there were no statistically significant intergroup differences in participant age, sex, hypertension status, diabetes mellitus status, lesion location, ICH volume, IVH occurrence, or IVH severity. The craniectomy group had a significantly higher incidence of shunt-dependent hydrocephalus than the non-craniectomy group (28.9% vs. 4.3%, p < 0.001; OR 9.1, 95% CI 3.7-22.7), craniotomy group (23.2% vs. 4.3%, p < 0.001; OR 6.6, 95% CI 2.5-17.1), and catheterization group (20.0% vs. 4.0%, p = 0.012; OR 6.0, 95% CI 1.7-21.3).

CONCLUSION

Decompressive craniectomy seems to increase shunt-dependent hydrocephalus among patients undergoing surgical ICH evacuation. The decision to perform a craniectomy for patients with ICH should be carefully individualized while considering the risk of hydrocephalus.

Towards a Systemic Concept of the Brain Ishemia Stroke: Monte Carlo Driven in silico Model

BACKGROUND

The work proposes a new mathematical model of dynamic processes of a typical spatially heterogeneous biological system, and sets and solves a mathematical problem of modeling the dynamics of the system of neurovascular units of the brain in conditions of ischemic stroke. There is a description of only a small number of mathematical models of stroke in the literature. This model is being studied and a numerical and software implementation of the corresponding mathematical problem is proposed.

METHODS

This work is the first attempt ever aiming to employ a Monte Carlo computational approach for In Silico simulation of the most critical parameters in molecular and cellular pathogenesis of the brain ischemic stroke. In this work, a new mathematical model of the development of ischemic stroke is proposed in the form of a discrete model based on neurovascular units (NVU) as elements.

RESULTS

As a result of testing the program with the assignment of empirically selected coefficients, data were obtained on the evolution of the states of the lattice of the cellular automaton of the model for the spread of stroke in a region of the brain tissue. A resulting new theoretical model of the particular pathologically altered biosystem might be taken as a promising tool for further studies in neurology; general pathology and cell biology.

CONCLUSION

For the first time, a mathematical model has been constructed that allows us to represent the spatial dynamics of the development of the affected area in ischemic stroke of the brain, taking into account neurovascular units as single morphofunctional structures.

Predicting stroke outcome: A case for multimodal deep learning methods with tabular and CT Perfusion data

MOTIVATION

Acute ischemic stroke is one of the leading causes of morbidity and disability worldwide, often followed by a long rehabilitation period. To improve and personalize stroke rehabilitation, it is essential to provide a reliable prognosis to caregivers and patients. Deep learning techniques might improve the predictions by incorporating different data modalities. We present a multimodal approach to predict the functional status of acute ischemic stroke patients after their discharge based on tabular data and CT perfusion imaging.

METHODS

We conducted experiments on tabular, imaging, and multimodal deep learning architectures to predict dichotomized mRS scores 3 months after the event. The dataset was collected from a Dutch hospital and includes 98 CVA patients with a visible occlusion on their CT perfusion scan. Tabular data is based on the Dutch Acute Stroke Audit data, and imaging data consists of summed-up CT perfusion maps.

RESULTS

On the tabular data, TabNet outperformed our baselines with an AUC of 0.71, while ResNet-10 on the imaging data performed comparably with an AUC of 0.70. Our implementation of the multimodal DAFT architecture outperforms baselines as well as comparable studies by achieving an 0.75 AUC, and 0.80 F1 score. This was achieved with a final model of less than a hundred thousand optimizable parameters, and a dataset less than half the size of reference papers.

CONCLUSION

Overall, we demonstrate the feasibility of predicting the functional outcome for ischemic stroke patients and the usability of multimodal deep learning architectures for this purpose.

[Treatment of patients with ishemic stroke in the vertebral-basilar system in acute period: experience of using the neuroprotective drug Mexidol]

OBJECTIVE

To assess the clinical efficacy and safety of Mexidol in patients in acute period of ishemic stroke in the vertebral-basilar system (iiVBS).

MATERIAL AND METHODS

An open randomized comparative study involved 52 patients. 32 of them received Mexidol (mail group, MG) and 20 received therapy without neuroprotective drugs. Assessment of the severity of clinical manifestations of iiVBS was performed using the Hoffenberth scale, stroke severity was assessed using the NIHSS, the modified Rankin Scale was used to assess the degree of disability in patients after stroke, neuropsychological examination of patients was performed using the Montreal Cognitive Assessment (MoCA), dynamics were compared on the Hospital Anxiety and Depression Scale (HADS), Subjective assessment scale for asthenia (MFI-20), the patients' quality of life was assessed using the EQ-5D.

RESULTS

The use of Mexidol in the form of long-term sequential therapy in the patients of the MG led to a 53.3% decrease in the severity of clinical manifestations of iiVBS and a 59.5% decrease in neurological deficit according to the NIHSS scale. By the end of Mexidol therapy, 96.9% of patients MG were able to manage their own affairs without assistance (modified Rankin Scale), which was accompanied by regression of emotional disturbances and improved quality of life of patients.

CONCLUSION

Administration of Mexidol in therapy of patients with acute iiVBS can be considered the most justified, since it contributes to an earlier and more significant reduction of neurological deficit and improvement of patients' quality of life.

Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment

BACKGROUND

Emergency medical services (EMS) is an important link in the stroke chain of recovery. Various prehospital quality metrics have been proposed for prehospital stroke care, but their individual impact is uncertain. We sought to measure associations between EMS quality metrics and downstream stroke care.

METHODS

This is a retrospective analysis of a cohort of EMS-transported stroke patients assembled through a linkage between Michigan's EMS and stroke registries. We used multivariable regression to quantify the independent associations between EMS quality metric compliance (dispatch within 90 seconds of 911 call, prehospital stroke screen documentation [Prehospital stroke scale], glucose check, last known well time, maintenance of scene times ≤15 minutes, hospital prenotification, and intravenous line placement) and shorter door-to-CT times (door-to-CT ≤25), accounting for EMS recognition, age, sex, race, stroke subtype, severity, and duration of symptoms. We then developed a simple EMS quality score based on metrics associated with early CT and examined its associations with hospital stroke evaluation times, treatment, and patient outcomes.

RESULTS

Five thousand seven hundred seven EMS-transported stroke cases were linked to prehospital records from January 2018 through June 2019. In multivariable analysis, prehospital stroke scale documentation (adjusted odds ratio, 1.4 [1.2-1.6]), glucose check (1.3 [1.1-1.6]), on-scene time ≤15 minutes (1.6 [1.4-1.9]), hospital prenotification ([2.0 [1.4-2.9]), and intravenous line placement (1.8 [1.5-2.1]) were independently associated with a door-to-CT ≤25 minutes. A 5-point quality score (1 point for each element) was therefore developed. In multivariable analysis, a 1-point higher EMS quality score was associated with a shorter time from EMS contact to CT (-9.2 [-10.6 to -7.8] minutes; P<0.001) and thrombolysis (-4.3 [-6.4 to -2.2] minutes; P<0.001), and higher odds of discharge to home (adjusted odds ratio, 1.1 [1.0-1.2]; P=0.002).

CONCLUSIONS

Five EMS actions recommended by national guidelines were associated with rapid CT imaging. A simple quality score derived from these measures was also associated with faster stroke evaluation, greater odds of reperfusion treatment, and discharge to home.

Neural stem cell-derived exosomes-loaded adhesive hydrogel controlled-release promotes cerebral angiogenesis and neurological function in ischemic stroke

OBJECTIVE

Ischemic stroke has become one of the leading diseases for international death, which brings burden to the economy and society. Exosomes (Exos) derived following neural stem cells (NSCs) stimulation promote neurogenesis and migration of NSCs. However, Exos themselves are easily to be removed in vivo. Our study is to investigate whether adhesive hyaluronic acid (HAD) hydrogel loading NSCs-derived-Exo (HAD-Exo) would promote the recovery of ischemic stroke.

METHODS

A mouse model of middle cerebral artery occlusion (MCAO) was established. PBS, Exo, HAD, and HAD-Exo groups were independently stereotactically injected in mice, respectively. The modified neurological severity score scale and behaviour tests were used to evaluate neurological improvement. Neuroimagings were used to observe the improvement of cerebral infarct volume and vessels. Immunofluorescence staining was used to verify the expression of vascular and cell proliferation-related proteins.

RESULTS

The structural and mechanical property of HAD and HAD-Exo were detected. Behavioral results showed that HAD-Exo significantly improved neurological functions, especially motor function. Neuroimagings showed that HAD-Exo significantly promoted infarct volume and angiogenesis. Immunofluorescence staining showed that HAD-Exo significantly promoted the cerebral angiogenesis and anti-inflammation.

CONCLUSION

NSCs derived exosomes-loaded adhesive HAD hydrogel controlled-release could promote cerebral angiogenesis and neurological function for ischemic stroke.

Artificial intelligence and duplex ultrasound for detection of carotid artery disease

OBJECTIVE

The aim of this study is to evaluate the feasibility, applicability and accuracy of artificial intelligence (AI) in the detection of normal versus carotid artery disease through greyscale static duplex ultrasound (DUS) images.

METHODS

A prospective image acquisition of individuals undergoing duplex sonography for the suspicion of carotid artery disease at a single hospital was conducted. A total of n = 156 images of normal and stenotic carotid arteries (based on NASCET criteria) were evaluated by using geometry group network based on convolutional neural network (CNN) architecture. Outcome was reported based on sensitivity, specificity and accuracy of the network (artificial intelligence) for detecting normal versus stenotic carotid arteries as well as various categories of carotid artery stenosis.

RESULTS

The overall sensitivity, specificity and accuracy of AI in the detection of normal carotid artery was 91%, 86% and 92%, respectively, and for any carotid artery stenosis was 87%, 82% and 90%, respectively. Subgroup analyses demonstrated that the network has the ability to detect stenotic carotid artery images (<50%) versus normal with a sensitivity of 92%, specificity of 87% and an accuracy of 94%. This value (sensitivity, specificity and accuracy) for group of 50-75% stenosis versus normal was 84%, 80% and 88% and for carotid artery disease of more than 75% was 90%, 83% and 92%, respectively.

CONCLUSION

This study demonstrates the feasibility, applicability and accuracy of artificial intelligence in the detection of carotid artery disease in greyscale static DUS images. This network has the potential to be used as a stand-alone software or to be embedded in any DUS machine. This can enhance carotid artery disease recognition with limited or no vascular experience or serve as a stratification tool for tertiary referral, further imaging and overall management.

Thrombolysis in Stroke Mimics: Comprehensive Stroke Centers vs Telestroke Sites

BACKGROUND

Hyperacute treatment of acute stroke may lead to thrombolysis in stroke mimics (SM). Our aim was to determine the frequency of thrombolysis in SM in primary stroke centers (PSC) dependent on telestroke versus comprehensive stroke centers (CSC).

METHOD

Retrospective review of prospectively collected data from the Quality improvement and Clinical Research (QuICR) registry, the Discharge Abstract Database (DAD), and The National Ambulatory Care Reporting System (NACRS) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021.

RESULT

A total of 2471 patients who received thrombolysis were included. Linking the QuICR registry to DAD 169 (6.83%) patients were identified as SM; however, on our review of the records, only 112 (4.53%) were actual SM. SMs were younger with a mean age of 61.66 (±16.15) vs 71.08 (±14.55) in stroke. National Institute of Health Stroke Scale was higher in stroke with a median (IQR) of 10 (5-17) vs 7 (5-10) in SM. Only one patient (0.89 %) in SM groups had a small parenchymal hemorrhage versus 155 (6.57%) stroke patients had a parenchymal hemorrhage. There was no death among patients of thrombolysed SM during hospitalization versus 276 (11.69%) in stroke. There was no significant difference in the rate of SM among thrombolysed patients between PSC 27 (5.36%) versus CSC 85 (4.3%) (P = 0.312). The most responsible diagnosis of SM was migraine/migraine equivalent, functional disorder, seizure, and delirium.

CONCLUSION

The diagnosis of SM may not always be correct when the information is extracted from databases. The rate of thrombolysis in SM via telestroke is similar to treatment in person at CSC.

Site-specific PEGylation of recombinant tissue-type plasminogen activator

Tissue-type plasminogen activator (tPA) is the gold standard for emergency treatment of ischemic stroke, which is the third leading cause of death worldwide. Major challenges of tPA therapy are its rapid elimination by plasminogen activator inhibitor-1 (PAI-1) and hepatic clearance, leading to the use of high doses and consequent serious side effects, including internal bleeding, swelling and low blood pressure. In this regard, we developed three polyethylene glycol (PEG)ylated tPA bioconjugates based on the recombinant human tPA drug Alteplase using site-specific conjugation strategies. The first bioconjugate with PEGylation at the N-terminus of tPA performed by reductive alkylation showed a reduced proteolytic activity of 68 % compared to wild type tPA. PEGylation at the single-free cysteine of tPA with linear and branched PEG revealed similar proteolytic activities as the wild-type protein. Moreover, both bioconjugates with PEG-cysteine-modification showed 2-fold slower inhibition kinetics by PAI-1. All bioconjugates increased in hydrodynamic size as a critical requirement for half-life extension.

Perioperative stroke in parapharyngeal space schwannoma: an unusual, dreaded complication

BACKGROUND

Post-styloid parapharyngeal space tumours (PPS) have a notorious course owing to their anatomy and proximity to neurovascular bundles. Nerve injuries are usual outcomes in schwannomas. Our case is the first documented complication of contralateral hemiplegia occurring in the postoperative period in a benign PPS tumour.

CASE REPORT

A 24-year-old presented with a swelling on the left lateral aspect of the neck, diagnosed as a PPS schwannoma. He underwent transcervical excision with mandibulotomy with extracapsular dissection of the tumour. Contralateral hemiplegia, as a dreaded complication, was encountered. He was managed conservatively according to ASPECTS stroke guidelines by the critical care team. On a regular follow-up, he noticed an improvement in the lower limb with subsequent upper limb power.

CONCLUSION

Perioperative stroke is a dreaded complication involving PPS in large benign tumours. To prevent unforeseen circumstances, necessary preoperative patient counselling and immense intraoperative care should be taken while dissecting the major vessels.

Super-resolution Ultrasound Microvascular Angiography for Spinal Cord Penumbra Imaging

OBJECTIVE

After spinal cord injury (SCI) or ischemia, timely intervention in the penumbra, such as recanalization and tissue reperfusion, is essential for preservation of its function. However, limited by imaging resolution and micro-blood flow sensitivity, golden standard angiography modalities, including magnetic resonance angiography (MRA) and digital subtraction angiography (DSA), are still not applicable for spinal cord microvascular imaging. Regarding spinal cord penumbra, to the best of authors' knowledge, currently, there is no efficient in vivo imaging modality for its evaluation. With tens-of-micrometer resolution and deep penetration, advanced ultrasound localization microscopy (ULM) could potentially meet the needs of emergent diagnosis and long-term monitoring of spinal cord penumbra.

METHODS

ULM microvasculature imaging was performed on rats with all laminae removed to obtain the blood supply in major spinal cord segments (C5-L5). For adult rats with spinal cord penumbra induced by compression injury (1 s, 10 s and 15 s), ULM imaging was conducted. The corresponding angiography results are investigated in terms of microvessel saturation, morphology, and flow velocity. The Basso/Beattie/Bresnahan (BBB) locomotor rating scale and hematoxylin and eosin staining were utilized for model validation and comparison.

RESULTS

The feasibility of ULM enabling spinal cord penumbra imaging and development monitoring was demonstrated. The focal injury core and penumbra can be clearly identified using the proposed method. Significant difference of perfusion can be observed after 1 s, 10 s and 15 s compression. Quantitative results show a high correlation between in vivo ultrasonic angiography, BBB functional evaluation and ex vivo histology assessment under different compression duration.

CONCLUSION

It is demonstrated that the super-resolution ULM micro-vasculature imaging can be used to evaluate the penumbra in spinal cord at acute and early stage of chronic phase, providing an efficient modality for micro-hemodynamics monitoring of the spinal cord.

Systolic blood pressure in acute ischemic stroke and impact on clinical outcomes

CONTEXT

Stroke is one of the largest healthcare burdens in the United States and globally. It continues to be one of the leading causes of morbidity and mortality. Patients with acute ischemic stroke (AIS) often present with elevated blood pressure (BP).

OBJECTIVES

The objective of our study was to evaluate the association of systolic blood pressure (SBP) in the emergency department (ED) with stroke severity in patients with AIS.

METHODS

This observational study was conducted at an ED with an annual census of 80,000 visits, approximately half (400) of which are for AIS. The cohort consisted of adult patients who presented to the ED within 24 h of stroke symptom onset. BP was measured at triage by a nurse blinded to the study. Stroke severity was measured utilizing the National Institutes of Health Stroke Scale (NIHSS). Statistical analyses were performed utilizing JMP 14.0. This study was approved by our medical school's institutional review board.

RESULTS

Patients with higher SBP had significantly lower NIHSS scores (p=0.0038). This association was significant even after adjusting for age and gender. By contrast, diastolic blood pressure (DBP) did not appear to impact stroke severity. There was no difference in the DBP values between men and women. Higher SBP was also significantly associated with being discharged home as well as being less likely to die in the hospital or discharged to hospice. The DBP did not demonstrate this association. Neither the SDP nor the DBP were significantly associated with the hospital length of stay (LOS). In multivariate models that included age, gender, basal metabolic index (BMI), comorbidities, and ED presentation, elevated SBP was associated with better prognosis.

CONCLUSIONS

In this cohort of patients presenting with stroke-like symptoms to the ED, higher SBP was associated with lower stroke severity and higher rates of being discharged to home rather than hospice or death.

Predicting patient decompensation from continuous physiologic monitoring in the emergency department

Anticipation of clinical decompensation is essential for effective emergency and critical care. In this study, we develop a multimodal machine learning approach to predict the onset of new vital sign abnormalities (tachycardia, hypotension, hypoxia) in ED patients with normal initial vital signs. Our method combines standard triage data (vital signs, demographics, chief complaint) with features derived from a brief period of continuous physiologic monitoring, extracted via both conventional signal processing and transformer-based deep learning on ECG and PPG waveforms. We study 19,847 adult ED visits, divided into training (75%), validation (12.5%), and a chronologically sequential held-out test set (12.5%). The best-performing models use a combination of engineered and transformer-derived features, predicting in a 90-minute window new tachycardia with AUROC of 0.836 (95% CI, 0.800-0.870), new hypotension with AUROC 0.802 (95% CI, 0.747-0.856), and new hypoxia with AUROC 0.713 (95% CI, 0.680-0.745), in all cases significantly outperforming models using only standard triage data. Salient features include vital sign trends, PPG perfusion index, and ECG waveforms. This approach could improve the triage of apparently stable patients and be applied continuously for the prediction of near-term clinical deterioration.

Impact of a series of measures for optimisation hospital code stroke care on door-to-needle times

INTRODUCTION

Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital.

METHODS

Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol.

RESULTS

The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001).

CONCLUSIONS

The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.

Patterns and predictors of dental hospitalizations in patients with acquired brain injury from pre-injury to acute and post-acute injury

BACKGROUND

Acquired brain injury (ABI) can cause long-term disability and functional impairment.

OBJECTIVE

This study aims to determine the prevalence of dental hospitalizations in an ABI cohort across different phases of injury and identify factors associated with such hospitalizations.

METHODS

The cohort comprises patients with ABI (n = 683), traumatic (n = 282) and non-traumatic (n = 401) who were admitted to a neurorehabilitation service in Western Australia between 1991 and 2016. De-identified patient data were linked to the Hospital Morbidity Data Collection. The incidence of dental hospitalizations was calculated per 1,000 person-years (PY), and associated factors were investigated using multilevel mixed-effects logistic regression.

RESULTS

Dental hospitalizations significantly increased from pre-injury (3.35/1,000PY) to acute injury (302.65, Δ+299.3) and remained elevated in the post-acute phase (23.98, Δ+20.63). Dental caries had the highest incidence rate among all diagnoses in the pre-injury and post-acute phases (0.68 and 8.93, respectively), followed by gingivitis and periodontal diseases (3.60) in the post-acute phase. Tooth extractions were performed more often than restorative and preventive treatment in the pre-and post-injury phase, p < 0.001. Dental hospitalizations were associated with the type of ABI, age at injury, remoteness, and history of pre-injury hospitalization.

CONCLUSION

Implementing comprehensive preventive dental care can reduce potentially preventable dental hospitalization among ABI patients.

A step-by-step guide for the diagnosis and management of hyponatraemia in patients with stroke

Hyponatraemia is common in patients with stroke and associated with adverse outcomes and increased mortality risk. The present review presents the underlying causes and provides a thorough algorithm for the diagnosis and management of hyponatraemia in stroke patients. Concomitant diseases and therapies, such as diabetes, chronic kidney disease and heart failure, along with diuretics, antidepressants and proton pump inhibitors are the most common causes of hyponatraemia in community. In the setting of acute stroke, the emergence of hyponatraemia might be attributed to the administration of hypotonic solutions and drugs (ie. mannitol and antiepileptics), poor solute intake, infections, as well as stroke-related conditions or complications, such as the syndrome of inappropriate secretion of antidiuretic hormone, cerebral salt wasting syndrome and secondary adrenal insufficiency. Diagnostically, the initial step is to differentiate hypotonic from non-hypotonic hyponatraemia, usually caused by hyperglycaemia or recent mannitol administration in patients with stroke. Determining urine osmolality, urine sodium level and volume status are the following steps in the differentiation of hypotonic hyponatraemia. Of note, specific parameters, such as fractional uric acid and urea excretion, along with plasma copeptin concentration, may further improve the diagnostic yield. Therapeutic options are based on the duration and symptoms of hyponatremia. In the case of acute or symptomatic hyponatraemia, hypertonic saline administration is recommended. Hypovolaemic chronic hyponatremia is treated with isotonic solution administration. Although fluid restriction remains the first-line treatment for the rest forms of chronic hyponatraemia, therapies increasing renal free water excretion may be necessary. Loop diuretics and urea serve this purpose in patients with stroke, whereas sodium-glucose transport protein-2 inhibitors appear to be a promising therapy. Nevertheless, it is yet unclear whether the appropriate restoration of sodium level improves outcomes in such patients. Randomized trials designed to compare therapeutic strategies in managing hyponatraemia in patients with stroke are required.

Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains

Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.

Usefulness of carotid duplex ultrasonography in predicting residual large-vessel occlusions after intravenous recombinant tissue plasminogen activator therapy in patients with acute ischemic stroke

PURPOSE

Endovascular therapy (EVT) preceded by intravenous thrombolysis with recombinant tissue plasminogen activator (iv-rtPA) has been established as a standard treatment in patients with stroke caused by large-vessel occlusion (LVO). Primary stroke centers without EVT competence need to identify patients with residual LVO after iv-rtPA therapy and transport them to an EVT-capable facility. Carotid ultrasonography (CUS) is easily applicable at bed side and useful for detecting extra- and intracranial LVO. This study aimed to determine whether CUS findings at admission are useful to predict patients with residual LVO after iv-rtPA.

METHODS

Patients scheduled to undergo iv-rtPA for acute cerebral infarction were registered. Before iv-rtPA, they underwent CUS, followed by CTA or MRA evaluation within 6 h after iv-rtPA. A model that can achieve 100% sensitivity for detecting residual LVO after iv-rtPA was studied.

RESULTS

This study included 68 of 116 patients treated with iv-rtPA during the study period. National Institutes of Health Stroke Scale (NIHSS) score (cutoff value = 10) on arrival, hyperdense MCA sign on non-contrast CT, end-diastolic (ED) ratio on CUS, and eye deviation were significantly different between patients with residual LVO after iv-rtPA and those without. If any of these clinical features are positive in the screening test, residual LVO could be predicted with 100% sensitivity, 50% specificity, 64% positive predictive value, and 100% negative predictive value.

CONCLUSION

Prediction of residual LVO with 100% sensitivity may be feasible by adding CUS to NIHSS score > 10, the presence of eye deviation, and hyperdense MCA sign.

Updates in mechanical thrombectomy

Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.

Neutrophil to High-Density Lipoprotein Ratio is Associated with Hemorrhagic Transformation in Patients with Acute Ischemic Stroke

BACKGROUND

Hemorrhagic transformation (HT) is one of the most common and severe complications in patients with acute ischemic stroke (AIS). It indicates a poor prognosis in AIS patients. However, the association of neutrophil to high-density lipoprotein ratio (NHR) with HT remains unclear.

PURPOSE

This study examined whether the NHR has a predictive effect on HT in AIS patients and explored the predictive cutoff value of the NHR.

METHODS

This is a retrospective study and consecutively included AIS patients admitted to the Department of Neurology of the First Affiliated Hospital of Wannan Medical College between December 2019 and January 2022. All subjects had blood samples collected within 24 h of admission, and neutrophil counts and high-density lipoprotein counts were detected. HT was diagnosed with hemorrhage on subsequent magnetic resonance imaging (MRI) or computed tomography (CT) of the brain. Univariate logistic regression analysis was performed to identify confounding factors, and multivariate logistic regression analysis determined the correlation between NHR and HT. Receiver operating characteristic (ROC) curves were used to evaluate the clinical predictive value of NHR.

RESULTS

A total of 725 patients were finally included in this study, of which 87 (12%) developed HT. The median NHR value in the HT group was 4.31, which was significantly higher than that in the non-HT group, and the difference was statistically significant [4.31 (3.54-6.24) vs 3.63 (2.68-4.64), p < 0.001]. The binary logistic regression analysis showed that NHR was independently associated with HT in AIS patients (OR: 1.180, 95% CI: 1.036-1.344, p = 0.013). The area under ROC curve (AUC) of NHR for predicting HT in AIS patients was 0.633 (95% CI: 0.567-0.699, p < 0.001), and its optimal cutoff were 3.52.

CONCLUSION

The NHR was a reliable and simple independent predictor of HT in AIS patients.

Naoxintong Capsule for Secondary Prevention of Ischemic Stroke: A Multicenter, Randomized, and Placebo-Controlled Trial

OBJECTIVE

To examine whether the combination of Naoxintong Capsule with standard care could further reduce the recurrence of ischemic stroke without increasing the risk of severe bleeding.

METHODS

A total of 23 Chinese medical centers participated in this trial. Adult patients with a history of ischemic stroke were randomly assigned in a 1:1 ratio using a block design to receive either Naoxintong Capsule (1.2 g orally, twice a day) or placebo in addition to standard care. The primary endpoint was recurrence of ischemic stroke within 2 years. Secondary outcomes included myocardial infarction, death due to recurrent ischemic stroke, and all-cause mortality. The safety of drugs was monitored. Results were analyzed using the intention-to-treat principle.

RESULTS

A total of 2,200 patients were enrolled from March 2015 to March 2016, of whom 143 and 158 in the Naoxintong and placebo groups were lost to follow-up, respectively. Compared with the placebo group, the recurrence rate of ischemic stroke within 2 years was significantly lower in the Naoxintong group [6.5% vs. 9.5%, hazard ratio (HR): 0.665, 95% confidence interval (CI): 0.492-0.899, P=0.008]. The two groups showed no significant differences in the secondary outcomes and safety, including rates of severe hemorrhage, cerebral hemorrhage and subarachnoid hemorrhage (P>0.05).

CONCLUSION

The combination of Naoxintong Capsule with standard care reduced the 2-year stroke recurrence rate in patients with ischemic stroke without increasing the risk of severe hemorrhage in high-risk patients. (Trial registration No. NCT02334969).

Potential application of traditional Chinese medicine in cerebral ischemia—Focusing on ferroptosis

Traditional Chinese medicine (TCM) has attracted a great deal of attention in the treatment of cerebral ischemia is credited with the remarkable neuroprotective effects. However, the imperfect functional mechanism of TCM is a major obstacle to their application. Many studies have been conducted to illustrate the pathophysiology of post-ischemic cerebral ischemia by elucidating the neuronal cell death pathway. Meanwhile, a new type of cell death, ferroptosis, is gradually being recognized in various diseases and is becoming a new pathway of therapeutic intervention strategy to solve many health problems. Especially since ferroptosis has been found to be closely involved into the pathogenesis of cerebral ischemia, it has been considered as a key target in the treatment of cerebral ischemia. Therefore, this paper reviews the latest research findings about the treatment of cerebral ischemia with TCM focused on ferroptosis as a target. Also, in order to explores the possibility of a new approach to treat cerebral ischemia with TCM, we discusses the correlation between ferroptosis and other cell death pathways such as apoptosis and autophagy, which would provide references for the following researches.

Favorable neurological outcomes in thoracic endovascular aortic repair with RELAY™ branched-An international perspective

BACKGROUND

While open surgical repair continues to be the mainstay option for aortic arch reconstruction, the associated mortality, morbidity, and high turn-down rates have led to a need for the development of minimally invasive options for aortic arch repair. Though RELAY™ Branched (Terumo Aortic, Inchinnan, UK) represents a promising option for complex endovascular aortic arch repair, neurological complications remain a pertinent risk. Herein we seek to present multicenter data from Europe documenting the neurological outcomes associated with RELAY™ Branched.

METHODS

Prospective data collected between January 2019 and January 2022 associated with patients treated with RELAY™ single-, double-, and triple-branched endoprostheses from centers across Europe was retrospectively analyzed with descriptive and distributive analysis. Follow-up data from 30 days and 6, 12, and 24 months postoperatively were included. Patient follow-up was evaluated for the onset of disabling stroke (DS) and non-disabling stroke (NDS).

RESULTS

Technical success was achieved in 147 (99.3%) cases. Over 24 months period, in total, six (4.1%) patients suffered DS, and eight (5.4%) patients suffered NDS after undergoing aortic arch repair with RELAY™. All patients that developed postoperative DS had been treated with the double-branched RELAY™ endoprosthesis.

DISCUSSION

The data presented herein demonstrates that RELAY™ Branched is associated with favorable neurological outcomes and excellent technical success rates. Key design features of the endoprosthesis and good perioperative management can contribute greatly to mitigating neurological complications following endovascular aortic arch repair.

Incidence of Acute Myocardial Infarction in Patients Presenting With Cerebrovascular Accident in a Tertiary Care Centre in Eastern India

Acute myocardial infarction in individuals who have had a cerebrovascular accident or transient ischemic attack (CVA-TIA) is a medical emergency, which must be examined and treated as soon as possible. Physicians face a significant problem in managing this scenario because early treatment of one ailment would surely postpone treatment of the other. Early detection and treatment will have an impact on the patient's morbidity and mortality in the future, as well as aid in the patient's rehabilitation. On the basis of ECG alterations and cardiac biomarkers, a prospective observational study was conducted in 103 diagnosed CVA patients to investigate the incidence of myocardial infarction. Infarct and hemorrhagic CVA cases were evenly distributed. According to the age-based distribution, the highest rate of myocardial infarction (8%, 8) was observed in those aged 51-60 years. The male-to-female ratio is 1.86:1. Thirty-two patients had diabetes, among them 75% had only elevated creatine kinase MB (CKMB) with no myocardial infarction (MI), whereas 59 patients had hypertension of which 70% had only elevated CK-MB with no MI. ST-elevation myocardial infarction (STEMI) with high CKMB accounted for 14.78% (15) of the cases, but the majority (71%, 73) of the cases had elevated CKMB with no MI, and the rest presented with normal CKMB. Elevated CKMB with or without STEMI serves as a poor prognosticating factor. Therefore, these patients should be managed on a priority basis for a better outcome.

A Review on Preclinical Models of Ischemic Stroke: Insights Into the Pathomechanisms and New Treatment Strategies

BACKGROUND

Stroke is a serious neurovascular problem and the leading cause of disability and death worldwide. The disrupted demand to supply ratio of blood and glucose during cerebral ischemia develops hypoxic shock, and subsequently necrotic neuronal death in the affected regions. Multiple causal factors like age, sex, race, genetics, diet, and lifestyle play an important role in the occurrence as well as progression of post-stroke deleterious events. These biological and environmental factors may be contributed to vasculature variable architecture and abnormal neuronal activity. Since recombinant tissue plasminogen activator is the only clinically effective clot bursting drug, there is a huge unmet medical need for newer therapies for the treatment of stroke. Innumerous therapeutic interventions have shown promise in the experimental models of stroke but failed to translate it into clinical counterparts.

METHODS

Original publications regarding pathophysiology, preclinical experimental models, new targets and therapies targeting ischemic stroke have been reviewed since the 1970s.

RESULTS

We highlighted the critical underlying pathophysiological mechanisms of cerebral stroke and preclinical stroke models. We discuss the strengths and caveats of widely used ischemic stroke models, and commented on the potential translational problems. We also describe the new emerging treatment strategies, including stem cell therapy, neurotrophic factors and gut microbiome-based therapy for the management of post-stroke consequences.

CONCLUSION

There are still many inter-linked pathophysiological alterations with regards to stroke, animal models need not necessarily mimic the same conditions of stroke pathology and newer targets and therapies are the need of the hour in stroke research.

A Meta-Transfer Learning Approach to ECG Arrhythmia Detection

Automatic classification of cardiac abnormalities is becoming increasingly popular with the prevalence of ECG recordings. Many signal processing and machine learning algorithms have shown the potential to identify cardiac ab-normalities accurately. However, most of these methods heavily rely on a large amount of relatively homogeneous datasets. In real life, chances are that there is not enough data for a specific category, and regular deep learning may fail in this scenario. A straightforward intuition is to use the knowledge learned from previous data to solve the problem. This idea leads to learning-to-learn: extrapolating the knowledge accumulated from the old dataset and using it in a different but somewhat related dataset. In this way, we do not need to have considerable data to learn the new task because the underlying features of the old and new datasets resemble one another. In this paper, a novel machine learning method is introduced to solve the ECG arrhythmia detection problem with a limited amount of data. The proposed method combines the popular techniques of meta-learning and transfer learning. It is shown that our method achieves much higher accuracy in ECG arrhythmia classification with a few data and learns the new task faster than regular deep learning.

Stroke severity modified the effect of chronic atrial fibrillation on the outcome of thrombolytic therapy

There is conflicting information regarding the impact of chronic atrial fibrillation (AF) on the outcomes of thrombolyzed patients with stroke. This study was designed to identify high-risk patients with chronic AF who had undergone thrombolysis treatment and to explore whether the baseline National Institutes of Health Stroke Scale (NIHSS) could be used to distinguish poor clinical outcomes in thrombolyzed patients. A total of 164 acute ischemic stroke patients with chronic AF were enrolled in this study. The patients were categorized as having poor or favorable outcomes. A favorable 90-day outcome was defined as a modified Rankin Scale (mRS) score ≤2. Our study showed that the baseline NIHSS score of patients with poor functional recovery (mRS >2) was significantly higher than that of patients with favorable outcomes (median 16 vs 12). Receiver operating characteristic (ROC) curve analysis of mRS score showed that a baseline NIHSS score of 14 was the optimal threshold for predicting unfavorable outcomes in patients with chronic AF. Multivariate logistic regression analysis showed that baseline NIHSS score >14 was independently associated with poor outcomes (odds ratio = 4.182, 95% confidence interval 2.092-8.361). Our study showed that stroke severity modified the effect of chronic AF on the outcome of thrombolytic therapy. The approach of stratifying stroke severity may be used to evaluate treatment strategies for decision making in intravenous thrombolytic therapy for acute stroke with chronic AF.

Patent foramen ovale and risks of recurrence in stroke of determined etiology

OBJECTIVE

Patent foramen ovale (PFO) is often found in stroke patients with determined etiologies. PFO may be the actual cause of stroke in some of them. We determined whether the risk of recurrent ischemic stroke differs with PFO status in stroke patients with determined etiologies.

METHODS

This study included consecutive patients with stroke of determined etiology who underwent transesophageal echocardiography. We compared the rates of recurrent cerebral infarction in patients with versus without PFO, and according to PFO-Associated Stroke Causal Likelihood (PASCAL) classification.

RESULTS

Of 2314 included patients, 827 (35.7%) had PFO. During a median follow-up of 4.4 years, cerebral infarction recurred in 202 (8.7%). In multivariate modified Cox regression analyses, recurrence of infarction did not significantly differ between patients with PFO and those without PFO (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.64-1.17; P = 0.339). Interaction analysis showed a significant effect of PFO in patients < 65 years (adjusted P for interaction = 0.090). PFO was independently associated with a decreased risk of recurrent infarction in patients younger than 65 years (HR, 0.41; 95% CI, 0.20-0.85; adjusted P = 0.016). Patients with probable PFO-associated stroke on the PASCAL classification had a significantly lower risk of recurrent infarction than those without PFO (HR 0.31; 95% CI 0.10-0.97; P=0.044).

INTERPRETATION

Considering the generally low risk of recurrence in PFO-associated stroke, PFO may be the actual cause of stroke in some patients with determined etiologies, especially younger patients or those with PFO features of probable PFO-associated stroke. This article is protected by copyright. All rights reserved.

The PI3K/AKT Pathway-The Potential Key Mechanisms of Traditional Chinese Medicine for Stroke

Stroke is associated with a high disability and fatality rate, and adversely affects the quality of life of patients and their families. Traditional Chinese Medicine (TCM) has been used effectively in the treatment of stroke for more than 2000 years in China and surrounding countries and regions, and over the years, this field has gleaned extensive clinical treatment experience. The Phosphatidylinositol 3 kinase (PI3K)/protein kinase B (AKT) pathway is important for regulation of cell migration, proliferation, differentiation, and apoptosis, and plays a vital role in vascularization and oxidative stress in stroke. Current Western medicine treatment protocols for stroke include mainly pharmacologic or mechanical thrombectomy to restore blood flow. This review collates recent advances in the past 5 years in the TCM treatment of stroke involving the PI3K/AKT pathway. TCM treatment significantly reduces neuronal damage, inhibits cell apoptosis, and delays progression of stroke via various PI3K/AKT-mediated downstream pathways. In the future, TCM can provide new perspectives and directions for exploring the key factors, and effective activators or inhibitors that affect occurrence and progression of stroke, thereby facilitating treatment.