D-Dimer as Predictor of Large Vessel Occlusion in Acute Ischemic Stroke

Could emergency admission plasma D-dimer level predict first pass effect of stent retriever thrombectomy in acute ischemic stroke?

BACKGROUND

Evidence on plasma biomarkers to identify first pass effect (FPE) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) treated with thrombectomy is limited.

PURPOSE

To evaluate whether plasma D-dimer could predict FPE.

MATERIAL AND METHODS

Consecutive patients with LVO who underwent first-line stent retriever thrombectomy at our center between January 2018 and August 2021 were enrolled. Patients were classified into the FPE (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2c) group or non-FPE (mTICI 0-2b) group based on angiographic outcomes. Logistic regression analysis was performed to determine the predictors of FPE. The overall ability of D-dimer levels in predicting FPE was evaluated using receiver operating characteristic (ROC) curves.

RESULTS

In total, 313 patients were included; 88 (28.1%) patients achieved FPE. Compared to those with non-FPE, patients with FPE had more diabetes mellitus history, lower D-dimer levels, higher clot burden score, a higher proportion of M1 middle cerebral artery, and a higher proportion of main stem occlusion pattern (P <0.05). After adjusting for potential variables, D-dimer levels (OR=0.81, 95% CI=0.52-0.96), clot burden score (OR=1.76, 95% CI=1.38-2.87), and main stem occlusion pattern (OR=1.85, 95% CI=1.19-2.62) remained independently associated with FPE. Based on the ROC analysis, the D-dimer as a predictor for predicting FPE presented with a specificity of 79%, a negative predictive value of 87%, and an area under the curve of 0.761.

CONCLUSION

Low emergency admission plasma D-dimer level is an independent predictor of FPE in patients with AIS treated with stent retriever thrombectomy.

Clinical characteristics of stroke in SARS-CoV-2 infected patients in Japan: A prospective nationwide study

INTRODUCTION

We investigated the clinical characteristics and outcomes of stroke in SARS-CoV-2 infected patients in Japan.

METHODS

This prospective, multicenter observational study of stroke in patients with SARS-CoV-2 infection involving 563 primary stroke centers across Japan was conducted between July 2020, and May 2022. We included 159 stroke cases (131 ischemic stroke, 2 transient ischemic attack (TIA), 21 intracranial hemorrhage, and 5 subarachnoid hemorrhage) and collected their clinical characteristics. Ischemic stroke and TIA (n = 133) were analyzed separately.

RESULTS

The mean age of the 159 patients was 70.6 years, with 66% being men. Poor outcomes (modified Rankin Scale score 5-6) occurred in 40% (63/159) at discharge. Among patients with ischemic stroke and TIA, 30%, 18%, 10%, and 42% had cardioembolism, large-artery atherosclerosis, small-vessel occlusion, and cryptogenic stroke or embolic stroke of undetermined source, respectively. One-third (34%) presented with large vessel occlusion (LVO) of the internal carotid, middle cerebral M1, or basilar arteries. Poor outcomes included age (adjusted odds ratio (aOR): 1.06, 95%CI: 1.01-1.12), ischemic heart disease (IHD) history (aOR: 13.00, 95%CI: 1.51-111.70), moderate to severe pneumonia (aOR: 7.78, 95%CI: 1.18-51.42), an National Institutes of Health Stroke Scale score at baseline (aOR: 1.10, 95%CI: 1.03-1.17), LVO (aOR: 14.88, 95%CI: 2.33-94.97), and log10 D-dimer (aOR: 3.38, 95%CI: 1.01-11.26).

CONCLUSION

Upon discharge, 40% of SARS-CoV-2 infected patients with ischemic stroke and TIA had poor outcomes. Poor outcomes were associated with older age, IHD history, moderate to severe pneumonia, higher NIHSS scores, LVO, and higher log10 D-dimer.

REGISTRATION

UMIN Clinical Trials Registry: https://www.umin.ac.jp/ctr/. Unique identifier: UMIN000041226.

Optimization of sensitivity and specificity of a biomarker-based blood test (LVOCheck-Opti): A protocol for a multicenter prospective observational study of patients suspected of having a stroke

Introduction

Acute ischemic stroke (AIS) is a time-critical medical emergency. For patients with large-vessel occlusions (LVO), mechanical thrombectomy (MT) is the gold-standard treatment. Mobile Stroke Units (MSUs) provide on-site diagnostic capabilities via computed tomography (CT) and have been shown to improve functional outcomes in stroke patients, but are cost-efficient only in urban areas. Blood biomarkers have recently emerged as possible alternative to cerebral imaging for LVO diagnosis. Prehospital LVO diagnosis offers the potential to transport patients directly to centers that have MT treatment available. In this study, we assess the accuracy of combining two biomarkers, HFABP and NT-proBNP, with clinical indicators to detect LVO using ultra-early prehospital blood samples. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00030399).

Methods and analysis

We plan a multicenter prospective observational study with 800 patients with suspected stroke enrolled within 24 h of symptom onset. Study participants will be recruited at three sites (MSUs) in Berlin, Germany. Blood-samples will be taken pre-hospitally at the scene and tested for HFABP and NT-proBNP levels. Additional clinical data and information on final diagnosis will be collected and documented in an electronic case report form (eCRF). Sensitivity and specificity of the combination will be calculated through iterative permutation-response calculations.

Discussion

This study aims to evaluate the diagnostic capabilities of a combination of the biomarkers HFABP and NT-proBNP in LVO prediction. In contrast to most other biomarker studies to date, by employing MSUs as study centers, ultra-early levels of biomarkers can be analyzed. Point-of-care LVO detection in suspected stroke could lead to faster treatment in both urban and rural settings and thus improve functional outcomes on a broader scale.

Clinical trial registration

Deutsches Register klinischer Studien https://drks.de/search/de/trial/DRKS00030399, DRKS00030399.

Construction and comparison of short-term prognosis prediction model based on machine learning in acute ischemic stroke

Objective

To construct and compared the short-term prognosis prediction models of acute ischemic stroke (AIS) by machine learning (ML).

Methods

Retrospectively study. The group W (mRS≤3) was clustered, and combined with group P (mRS>3) to form the post-clustering dataset for modeling. The "glmnet", "rpart", "xgboost", "randomForest", "neuralnet" packages were used to construct ML models. The accuracy, sensitivity, specificity, positive predict value (PPV), negative predict value (NPV) among the models were compared. Four external clinical datasets were used for external clinical validation. The optimal prediction model was determined by variable screening ability, model visualization, and external clinical validation performance.

Results

The post-clustering dataset contains 139 patients (group W) and 122 patients (group P). The neutrophil multiplied by D-dimer (NDM) has predictive value in all ML prediction models in this study. In the decision tree model, NDMQ occupies the first tree node, When NDM≤5.62 and the age<74.5, the probability of poor prognosis of AIS is less than 20 %. When NDM>5.62 and accompanied by pneumonia, the incidence of poor prognosis of AIS is about 90 %. In the Random Forest (RF) model, NDMQ had the highest Gini index. The variable combination screened by the RF model had the best performance in the neural network, and the accuracy, sensitivity, specificity, PPV, and NPV of the external validation were 0.800, 0.774, 0.833, 0.857, and 0.741, respectively. The RF model had the best performance in the external clinical validation datasets, with accuracies of 0.646, 0.697, 0.695, and 0.713, respectively.

Conclusions

NDM shows predictive value for AIS short-term prognosis in all ML models in this study. The optimal model in screening characteristic variables and the performance of in external clinical datasets was RF model. In the analysis of medical data with small sample size and outcome as categorical variables, RF could be used as the main algorithm to build a model.

Emergency admission plasma D-dimer: a novel predictor for symptomatic intracranial hemorrhage after thrombectomy in acute ischemic stroke

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) is a common and severe complication in patients with acute ischemic stroke (AIS) after treatment with thrombectomy.

OBJECTIVE

To explore the ability of admission plasma D-dimer levels to predict sICH after thrombectomy.

METHODS

Between February 2018 and August 2021, consecutive patients with AIS who underwent thrombectomy at our single comprehensive stroke center were retrospectively enrolled. sICH was defined according to the criterion of the Heidelberg Bleeding Classification. Logistic regression analysis was performed to determine the risk factors of sICH. The overall discriminative ability of D-dimer levels in predicting sICH was evaluated by adopting a receiver operating characteristic (ROC) curve.

RESULTS

Of the 395 enrolled patients, 48 (12.2%) had sICH. Patients with sICH were older (72.9 vs 69.3 years, P=0.037), more often female (62.5% vs 45.5%, P=0.027), had higher D-dimer levels (2.70 vs 0.74 mg/L, P<0.001), higher National Institutes of Health Stroke Scale score (20 vs 15, P<0.001), lower Alberta Stroke Program Early CT Score (8 vs 9, P<0.001), a higher proportion of internal carotid artery occlusions (56.2% vs 30.3%, P<0.001), and less commonly had large-artery atherosclerosis stroke etiology (12.5% vs 32.3%, P=0.010) than patients without sICH. After adjustment for potential confounders, D-dimer levels (adjusted OR=2.45, 95% CI 1.75 to 3.43, P<0.001) remained significantly associated with sICH. Based on the ROC, the D-dimer as a predictor for predicting sICH, presented with a specificity of 86.2%, a negative predictive value of 94.6%, and an area under the curve of 0.774.

CONCLUSION

Elevated admission D-dimer levels are an independent predictor of sICH in patients with AIS after thrombectomy.

Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial

Importance

Prehospital transfer protocols are based on rapid access to reperfusion therapies for patients with ischemic stroke. The effect of different protocols among patients receiving a final diagnosis of intracerebral hemorrhage (ICH) is unknown.

Objective

To determine the effect of direct transport to an endovascular treatment (EVT)-capable stroke center vs transport to the nearest local stroke center.

Design, Setting, and Participants

This was a prespecified secondary analysis of RACECAT, a multicenter, population-based, cluster-randomized clinical trial conducted from March 2017 to June 2020 in Catalonia, Spain. Patients were evaluated by a blinded end point assessment. All consecutive patients suspected of experiencing a large vessel occlusion stroke (Rapid Arterial Occlusion Evaluation Scale [RACE] score in the field >4 on a scale of 0 to 9, with lower to higher stroke severity) with final diagnosis of ICH were included. A total of 1401 patients were enrolled in RACECAT with suspicion of large vessel occlusion stroke. The current analysis was conducted in October 2022.

Intervention

Direct transport to an EVT-capable stroke center (n = 137) or to the closest local stroke center (n = 165).

Main Outcomes and Measures

The primary outcome was tested using cumulative ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI of the shift analysis of disability at 90 days as assessed by the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) in the intention-to-treat population. Secondary outcomes, included 90-day mortality, death or severe functional dependency, early neurological deterioration, early mortality, ICH volume and enlargement, rate of neurosurgical treatment, rate of clinical complications during initial transport, and rate of adverse events until day 5.

Results

Of 1401 patients enrolled, 1099 were excluded from this analysis (32 rejected informed consent, 920 had ischemic stroke, 29 had transient ischemic attack, 12 had subarachnoid hemorrhage, and 106 had stroke mimic). Thus, 302 patients were included (204 [67.5%] men; mean [SD] age 71.7 [12.8] years; and median [IQR] RACE score, 7 [6-8]). For the primary outcome, direct transfer to an EVT-capable stroke center (mean [SD] mRS score, 4.93 [1.38]) resulted in worse functional outcome at 90 days compared with transfer to the nearest local stroke center (mean [SD] mRS score, 4.66 [1.39]; adjusted common OR, 0.63; 95% CI, 0.41-0.96). Direct transfer to an EVT-capable stroke center also suggested potentially higher 90-day mortality compared with transfer to the nearest local stroke center (67 of 137 [48.9%] vs 62 of 165 [37.6%]; adjusted hazard ratio, 1.40; 95% CI, 0.99-1.99). The rates of medical complications during the initial transfer (30 of 137 [22.6%] vs 9 of 165 patients [5.6%]; adjusted OR, 5.29; 95% CI, 2.38-11.73) and in-hospital pneumonia (49 of 137 patients [35.8%] vs 29 of 165 patients [17.6%]; OR, 2.61; 95% CI, 1.53-4.44) were higher in the EVT-capable stroke center group.

Conclusions and Relevance

In this secondary analysis of the RACECAT randomized clinical trial, bypassing the closest stroke center resulted in reduced chances of functional independence at 90 days for patients who received a final diagnosis of ICH.

Trial Registration

ClinicalTrials.gov Identifier: NCT02795962.

Emergency medical service utilization and timely treatment among acute ischemic stroke patients in Beijing from 2018 to 2021

BACKGROUND AND IMPORTANCE

Activation of emergency medical services (EMS) is recommended for timely reperfusion therapy for acute ischemic stroke (AIS). The association of EMS utilization and time intervals from hospital arrival to a series of necessary procedures before reperfusion therapy was rarely investigated.

OBJECTIVE

The objective of this study is to investigate the association of EMS utilization with the time intervals from hospital arrival to therapy in patients with AIS.

DESIGN

Observational study.

SETTINGS AND PARTICIPANTS

Medical records for AIS in all emergency departments in Beijing were obtained from January 2018 to December 2021.

INTERVENTION OR EXPOSURE

Patients transported by ambulance were defined as the EMS group, whereas others as the non-EMS group.

OUTCOME MEASURES AND ANALYSIS

Door-to-imaging time (DIT), door-to-needle time (DTN) and door-to-puncture time (DTP) were compared between the two groups.

MAIN RESULTS

There were 11 190 (46%) and 13 106 (54%) AIS patients in the EMS and non-EMS groups. Compared with the non-EMS group, patients in the EMS group were more likely to receive intravenous thrombolysis or endovascular therapy (OR, 1.81; 95% CI, 1.68-1.94). For intravenous thrombolysis therapy, the DIT, ITN (time in minutes from obtaining the first brain imaging to tPA delivery) and DTN times in the EMS group were significantly shorter with time differences between the two groups of -1.1 (95% CI, -1.1 to -1.1) min, -2.6 (-2.6 to -2.6) min, and -3.7 (-3.8, -3.7) min, respectively. The proportion of DIT ≤25 min, DTN ≤45 min or DTN ≤60 min was significantly higher in the EMS group (OR, 1.03, 95% CI, 1.02-1.05; 1.11, 1.07-1.14; 1.05, 1.03-1.07). For endovascular therapy, the differences in DIT, ITP (time in minutes from obtaining the first brain imaging to groin puncture) and DTP times between the EMS and non-EMS groups were +1.1 (1.0-1.2) min, -3.8 (-4.2 to -3.5) min, -2.7 (-3.1 to -2.4) min, respectively, but no significant association was observed between EMS usage and the proportion of DIT ≤25 min or DTP ≤90 min.

CONCLUSION

In this observational study, the use of EMS for patient with AIS was associated with a shorter time from hospital arrival to intravenous thrombolysis and endovascular therapy.

Early plasma D-dimer as a predictor of acute intracranial atherosclerosis-related large vessel occlusion in acute ischemic stroke

BACKGROUND

Intracranial atherosclerosis-related large vessel occlusion (ICAS+LVO) poses an important technical challenge for endovascular thrombectomy (EVT).

PURPOSE

To evaluate the value of D-dimer in predicting ICAS+LVO alone and in combination with other clinical and imaging predictors.

MATERIAL AND METHODS

Consecutive patients who underwent EVT at our center between January 2018 and June 2021 were retrospectively reviewed. Patients were classified to the ICAS+LVO or ICAS-LVO group according to angiographic findings. Collateral gradings were evaluated based on computed tomography angiography and categorized as follows: score 0-1 unfavorable collaterals and score 2-3 favorable collaterals. Receiver operating characteristic curve was analyzed to evaluate the predictive value of D-dimer and the combination of other predictors for ICAS+LVO.

RESULTS

A total of 374 patients were enrolled, among them, 107 (28.6%) had an ICAS+LVO, while ICAS-LVO was determined in 267 (71.4%) patients. Median D-dimer levels were lower (0.36 vs. 1.18 mg/L; P < 0.001) while the proportion of favorable collaterals was higher (85.0% vs. 22.5%; P < 0.001) in the ICAS+LVO group than the ICAS-LVO group. After multivariable analysis, D-dimer (adjusted odds ratio [OR]=0.32, 95% confidence interval [CI]=0.21-0.50; P < 0.001) and collaterals (adjusted OR=16.25, 95% CI=7.58-34.84; P < 0.001) remained independent predictors of ICAS+LVO. The area under the curve of D-dimer, collaterals, and combination for identification of ICAS+LVO was 0.82, 0.85, and 0.92, respectively.

CONCLUSION

Low early plasma D-dimer levels are a significant and independent predictor of ICAS+LVO, and predictive value strengthens when in a combined model using D-dimer and collateral grading.

C1QC, VSIG4, and CFD as Potential Peripheral Blood Biomarkers in Atrial Fibrillation-Related Cardioembolic Stroke

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. We aimed to identify novel potential biomarkers with diagnostic value in patients with atrial fibrillation-related cardioembolic stroke (AF-CE).Publicly available gene expression profiles related to AF, cardioembolic stroke (CE), and large artery atherosclerosis (LAA) were downloaded from the Gene Expression Omnibus (GEO). Differentially expressed genes (DEGs) were identified and then functionally annotated. The support vector machine recursive feature elimination (SVM-RFE) and least absolute shrinkage and selection operator (LASSO) regression analysis were conducted to identify potential diagnostic AF-CE biomarkers. Furthermore, the results were validated by using external data sets, and discriminability was measured by the area under the ROC curve (AUC). In order to verify the predictive results, the blood samples of 13 healthy controls, 20 patients with CE, and 20 patients with LAA stroke were acquired for RT-qPCR, and the correlation between biomarkers and clinical features was further explored. Lastly, a nomogram and the companion website were developed to predict the CE-risk rate. Three feature genes (C1QC, VSIG4, and CFD) were selected and validated in the training and the external datasets. The qRT-PCR evaluation showed that the levels of blood biomarkers (C1QC, VSIG4, and CFD) in patients with AF-CE can be used to differentiate patients with AF-CE from normal controls (P < 0.05) and can effectively discriminate AF-CE from LAA stroke (P < 0.05). Immune cell infiltration analysis revealed that three feature genes were correlated with immune system such as neutrophils. Clinical impact curve, calibration curves, ROC, and DCAs of the nomogram indicate that the nomogram had good performance. Our findings showed that C1QC, VSIG4, and CFD can potentially serve as diagnostic blood biomarkers of AF-CE; novel nomogram and the companion website can help clinicians to identify high-risk individuals, thus helping to guide treatment decisions for stroke patients.

Neutrophil count multiplied by D-dimer combined with pneumonia may better predict short-term outcomes in patients with acute ischemic stroke

Objective

To investigate the predictive value of neutrophil, D-dimer and diseases associated with stroke for short-term outcomes of acute ischemic stroke (AIS).

Methods

By collecting the subitems of laboratory data especially routine blood and coagulation test in AIS patients, and recording their clinical status, the correlation, regression and predictive value of each subitem with the short-term outcomes of AIS were analyzed. The predict model was constructed.

Results

The neutrophil count multiplied by D-dimer (NDM) had the best predictive value among the subitems, and the area under the receiver operating characteristic (ROC) curve reached 0.804. When clinical information was not considered, the Youden index of NDM was calculated to be 0.48, corresponding to an NDM value of 7.78, a diagnostic sensitivity of 0.79, specificity of 0.69, negative predictive value of 96%. NDM were divided into 5 quintiles, the five grade of NDM (quintile) were < = 1.82, 1.83–2.41, 2.42–3.27, 3.28–4.49, 4.95+, respectively. The multivariate regression analysis was conducted between NDM (quintile), Babinski+, pneumonia, cardiac disease and poor outcomes of AIS. Compared with the first grade of NDM (quintile), the second grade of NDM (quintile) was not significant, but the third grade of NDM (quintile) showed 7.061 times, the fourth grade of NDM (quintile) showed 11.776 times, the fifth grade of NDM (quintile) showed 23.394 times in short-term poor outcomes occurrence. Babinski sign + showed 1.512 times, pneumonia showed 2.995 times, cardiac disease showed 1.936 times in short-term poor outcomes occurrence compared with those negative patients.

Conclusions

NDM combined with pneumonia may better predict short-term outcomes in patients with AIS. Early prevention, regular examination and timely intervention should be emphasized for patients, which may reduce the risk of short-term poor outcomes.

Neurovascular Unit-Derived Extracellular Vesicles: From Their Physiopathological Roles to Their Clinical Applications in Acute Brain Injuries

Extracellular vesicles (EVs) form a heterogeneous group of membrane-enclosed structures secreted by all cell types. EVs export encapsulated materials composed of proteins, lipids, and nucleic acids, making them a key mediator in cell–cell communication. In the context of the neurovascular unit (NVU), a tightly interacting multicellular brain complex, EVs play a role in intercellular communication and in maintaining NVU functionality. In addition, NVU-derived EVs can also impact peripheral tissues by crossing the blood–brain barrier (BBB) to reach the blood stream. As such, EVs have been shown to be involved in the physiopathology of numerous neurological diseases. The presence of NVU-released EVs in the systemic circulation offers an opportunity to discover new diagnostic and prognostic markers for those diseases. This review outlines the most recent studies reporting the role of NVU-derived EVs in physiological and pathological mechanisms of the NVU, focusing on neuroinflammation and neurodegenerative diseases. Then, the clinical application of EVs-containing molecules as biomarkers in acute brain injuries, such as stroke and traumatic brain injuries (TBI), is discussed.

Acute Middle Cerebral Artery Occlusion Detection Using Mobile Non-Imaging Brain Perfusion Ultrasound-First Case

Mobile brain perfusion ultrasound (BPU) is a novel non-imaging technique creating only hemispheric perfusion curves following ultrasound contrast injection and has been specifically designed for early prehospital large vessel occlusion (LVO) stroke identification. We report on the first patient investigated with the SONAS^® system, a portable point-of-care ultrasound system for BPU. This patient was admitted into our stroke unit about 12 h following onset of a fluctuating motor aphasia, dysarthria and facial weakness resulting in an NIHSS of 3 to 8. Occlusion of the left middle cerebral artery occlusion was diagnosed by computed tomography angiography. BPU was performed in conjunction with injection of echo-contrast agent to generate hemispheric perfusion curves and in parallel, conventional color-coded sonography (TCCS) assessing MCAO. Both assessments confirmed the results of angiography. Emergency mechanical thrombectomy (MT) achieved complete recanalization (TICI 3) and post-interventional NIHSS of 2 the next day. Telephone follow-up after 2 years found the patient fully active in professional life. Point-of-care BPU is a non-invasive technique especially suitable for prehospital stroke diagnosis for LVO. BPU in conjunction with prehospital stroke scales may enable goal-directed stroke patient placement, i.e., directly to comprehensive stroke centers aiming for MT. Further results of the ongoing phase II study are needed to confirm this finding.

Increased Neutrophil elastase and proteinase 3 are closely associated with occurrence and severity of stroke and acute myocardial infarction in patients with type 2 diabetes mellitus

AIMS

The role of Neutrophil elastase (NE) and proteinase 3 (PR3) in the occurrence and severity of stroke and acute myocardial infarction (AMI) have not been explored in type 2 diabetes mellitus (T2DM). This study aimed to investigate the relationship and predictive ability of NE and PR3 in the development of stroke and AMI in patients with T2DM, and to explore the pattern of NE and PR3 in atherosclerotic plaques.

METHODS

465 patients with T2DM (stroke or AMI, n = 234; non stroke or AMI, n = 231) were recruited. Clinical characteristics, and NE and PR3 concentration were measured in all subjects. Semi-quantitative analysis of immunohistochemistry staining for NE and PR3 was performed in detached emboli and stable plaques.

RESULTS

Patients with stroke or AMI had a higher level of NE and PR3, with a more pronounced increase in more severe cases (higher mRS score in stroke and Gensini score in AMI) and associated with clinical markers. An increase in NE and PR3 was an independent risk factor for stroke (OR = 4.318, P = 0.017; OR = 2.979, P = 0.048, respectively) and AMI (OR = 8.385, P = 0.015; OR = 5.540, P = 0.047). Finally, immunohistochemistry staining revealed that the NE and PR3 positive area increased significantly in detached emboli compared with stable plaques.

CONCLUSION

Increased NE and PR3 was associated with occurrence and severity of stroke and AMI in patients with T2DM. Enriched NE and PR3 in detached emboli may be associated with plaque vulnerability.

Streamlining Acute Stroke Care by Introducing National Institutes of Health Stroke Scale in the Emergency Medical Services: A Prospective Cohort Study

National Institutes of Health Stroke Scale (NIHSS) is the most validated clinical scale for stroke recognition, severity grading, and symptom monitoring in acute care and hospital settings. Numerous modified prehospital stroke scales exist, but these scales contain less clinical information and lack compatibility with in-hospital stroke scales. In this real-life study, we aimed to investigate if NIHSS conducted by paramedics in the field is a feasible and accurate prehospital diagnostic tool.

Optimization of Large Vessel Occlusion Detection in Acute Ischemic Stroke Using Machine Learning Methods

The early detection of large-vessel occlusion (LVO) strokes is increasingly important as these patients are potential candidates for endovascular therapy, the availability of which is limited. Prehospital LVO detection scales mainly contain symptom variables only; however, recent studies revealed that other types of variables could be useful as well. Our aim was to comprehensively assess the predictive ability of several clinical variables for LVO prediction and to develop an optimal combination of them using machine learning tools. We have retrospectively analysed data from a prospectively collected multi-centre stroke registry. Data on 41 variables were collected and divided into four groups (baseline vital parameters/demographic data, medical history, laboratory values, and symptoms). Following the univariate analysis, the LASSO method was used for feature selection to select an optimal combination of variables, and various machine learning methods (random forest (RF), logistic regression (LR), elastic net method (ENM), and simple neural network (SNN)) were applied to optimize the performance of the model. A total of 526 patients were included. Several neurological symptoms were more common and more severe in the group of LVO patients. Atrial fibrillation (AF) was more common, and serum white blood cell (WBC) counts were higher in the LVO group, while systolic blood pressure (SBP) was lower among LVO patients. Using the LASSO method, nine variables were selected for modelling (six symptom variables, AF, chronic heart failure, and WBC count). When applying machine learning methods and 10-fold cross validation using the selected variables, all models proved to have an AUC between 0.736 (RF) and 0.775 (LR), similar to the performance of National Institutes of Health Stroke Scale (AUC: 0.790). Our study highlights that, although certain neurological symptoms have the best ability to predict an LVO, other variables (such as AF and CHF in medical history and white blood cell counts) should also be included in multivariate models to optimize their efficiency.

High D-dimer concentration is a significant independent prognostic factor in patients with acute large vessel occlusion undergoing endovascular thrombectomy

OBJECTIVE

This study aimed to investigate prognostic factors that affect modified Rankin Scale (mRS) score at 3 months after onset in acute stroke patients with large vessel occlusion (LVO) undergoing endovascular thrombectomy.

METHODS

We retrospectively examined 87 consecutive patients who underwent endovascular cerebral thrombectomy for acute anterior circulation LVO at Oita University Hospital and Nagatomi Neurosurgery Hospital from January 2014 to December 2020.

RESULTS

Age, National Institutes of Health Stroke Scale (NIHSS) score, and D-dimer concentration on admission were significant univariate prognostic factors related to mRS score 3 months after stroke onset. Multivariate logistic regression analysis showed that D-dimer concentration was the only significant independent prognostic factor. The area under the receiver operating characteristic curve for D-dimer concentration and mRS score at 3 months was 0.715 (95% confidence interval, 0.599 - 0.831); sensitivity and specificity were 60.6% and 80.0%, respectively, using a 1.9 μg/mL cutoff value.

CONCLUSIONS

Prognosis may be worse in patients undergoing acute endovascular cerebral thrombectomy with high D-dimer concentration on admission. Other treatment options should be considered for these patients.

Potential Biomarkers to Predict Acute Ischemic Stroke in Type 2 Diabetes

Background and Purpose: Patients with type 2 diabetes (T2D) have increased risk of cardiovascular disease (CVD), encompassing myocardial infarction, stroke, and peripheral vascular disease. We hypothesized that those biomarkers indicative of acute ischemic stroke (AIS) seen in large vessel occlusion (LVO) may also be elevated in T2D and further enhanced by stress conditions; therefore, these proteins represent potentially predictive biomarkers for those T2D patients at high risk of AIS.

Methods: We performed an exploratory proteomic analysis in control subjects (n = 23) versus those with type 2 diabetes (T2D) (n = 23) who underwent a hyperinsulinemic clamp study to transient severe hypoglycemia [blood glucose <2.0 mmol/L (36 mg/dl)] in a prospective case-control study. We compared these proteins described as diagnostic and prognostic biomarkers for AIS due to LVO: lymphatic vessel endothelial hyaluronic acid receptor-1 (LYVE1), thrombospondin-1 (THBS1), pro-platelet basic protein (PPBP), and cadherin 1 (CDH1).

Results: At baseline (BL), PPBP (p < 0.05), THBS1 (p < 0.05), and CDH1 (p < 0.01) were elevated in T2D; LYVE1 was not different between controls and T2D subjects at BL or at subsequent timepoints. PPBP and THBS1 tended to increase at hypoglycemia in both cohorts, though reached significance only in controls (p < 0.05), returning to BL levels post-hypoglycemia. CDH1 levels were higher in T2D at BL, at hypoglycemia and up to 2-h posthypoglycemia, thereafter reverting to BL levels.

Conclusion: Elevated levels of PPBP, THBS1, and CDH1, circulatory proteins suggested as biomarkers of AIS due to LVO, may, in T2D patients, be prognostically indicative of a cohort of T2D patients at increased risk of ischaemic stroke. Prospective studies are needed to determine if this reflects future clinical risk.

Clinical trial reg. no: NCT03102801.

A Novel Combination of Blood Biomarkers and Clinical Stroke Scales Facilitates Detection of Large Vessel Occlusion Ischemic Strokes

Acute ischemic stroke caused by large vessel occlusions (LVOs) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging. We recruited two separate cohorts of suspected stroke patients and screened a panel of blood-derived protein biomarkers for LVO detection. Diagnostic performance was estimated by using blood biomarkers in combination with NIHSS-derived stroke severity scales. Multivariable analysis demonstrated that D-dimer (OR 16, 95% CI 5–60; p-value < 0.001) and GFAP (OR 0.002, 95% CI 0–0.68; p-value < 0.05) comprised the optimal panel for LVO detection. Combinations of D-dimer and GFAP with a number of stroke severity scales increased the number of true positives, while reducing false positives due to hemorrhage, as compared to stroke scales alone (p-value < 0.001). A combination of the biomarkers with FAST-ED resulted in the highest accuracy at 95% (95% CI: 87–99%), with sensitivity of 91% (95% CI: 72–99%), and specificity of 96% (95% CI: 90–99%). Diagnostic accuracy was confirmed in an independent cohort, in which accuracy was again shown to be 95% (95% CI: 87–99%), with a sensitivity of 82% (95% CI: 57–96%), and specificity of 98% (95% CI: 92–100%). Accordingly, the combination of D-dimer and GFAP with stroke scales may provide a simple and highly accurate tool for identifying LVO patients, with a potential impact on time to treatment.