Disabling stroke in persons already with a disability: Ethical dimensions and directives

Endovascular thrombectomy for large vessel occlusion stroke in patients with pre-existing disability

BACKGROUND

Approximately one in three patients with acute ischemic stroke (AIS) suffer from a premorbid disability prior to their incident AIS. These patients have largely been excluded from clinical trials of endovascular thrombectomy (EVT) for the treatment of AIS and current literature remains unclear regarding the safety and efficacy of EVT in these patients.

METHODS

We queried our prospectively maintained registry of patients with AIS from December 1, 2014 to October 31, 2023 to identify all patients who underwent EVT. Patients were stratified by their baseline modified Rankin Scale (mRS) score into those with (mRS 2-5) and without (mRS 0-1) baseline disability. Univariate analyses using the χ2 test for categorical variables and the Wilcoxon rank-sum test for continuous variables were performed to compare demographics between the two groups. Generalized logistic and linear regression models for multivariable analysis were used to compare outcomes between the groups.

RESULTS

Of a total of 1489 patients, 367 (24.6%) had a pre-existing disability. Patients with baseline disability were older (79.6 years vs 67.7 years, P<0.001), more likely to be female (65.7% vs 45.9%, P<0.001), and had higher rates of stroke risk factors. There were higher odds of return to baseline (90-day ΔmRS =<0: OR 2.83, P<0.001) and 90-day ΔmRS =<1 (OR 2.94, P<0.001) for patients with baseline disability post-EVT compared with their healthier counterparts. There was no relative adjusted increase in symptomatic intracerebral hemorrhage or 90-day mortality.

CONCLUSIONS

EVT appears to be safe and effective in patients with baseline disability, often associated with a return to their premorbid functional status at 90 days.

Bioinspired Smart Triboelectric Soft Pneumatic Actuator-Enabled Hand Rehabilitation Robot

Quantitative assessment for post-stroke spasticity remains a significant challenge due to the encountered variable resistance during passive stretching, which can lead to the widely used modified Ashworth scale (MAS) for spasticity assessment depending heavily on rehabilitation physicians. To address these challenges, a high-force-output triboelectric soft pneumatic actuator (TENG-SPA) inspired by a lobster tail is developed. The bioinspired TENG-SPA can generate approximately 20 N at 0.1 MPa, providing sufficient stretching force for spastic fingers. The anti-interference, durability, and electrical output characteristics of the TENG-SPA under varying conditions-such as different air pressures, bending frequencies, and simulated spastic finger stretching-are explored, demonstrating TENG-SPA's ability to sense resistance during the stretching process. Furthermore, a TENG-SPA-enabled hand rehabilitation robot system integrated with the convolutional neural network (CNN) is further developed, which is tested in a clinical trial involving 15 stroke patients. The results have demonstrated that a classification accuracy for the levels of finger spasticity reaches 93.3% and the MAS scores predicted by the CNN regression model exhibit a strong linear relationship with the actual MAS (R2 = 0.8451, p < 0.01). This study presents promising potential applications in digital rehabilitation medicine, human-machine interaction, biomedicine, and related fields.

Sensorineural hearing loss in stroke: an age-matched retrospective study

OBJECTIVE

To compare characteristics between stroke populations with and without sensorineural hearing loss (SNHL) and assess the impact of SNHL on stroke outcome.

METHODS

A retrospective study of patients admitted with stroke was carried out. Patients were divided into two groups, where group A were diagnosed with SNHL and group B were without SNHL. Baseline age, gender, vascular risk factors and disability were compared. Logistic regression analyses were performed with three-month mortality and SNHL as dependent variables.

RESULTS

A total of 631 admissions were reviewed, with mean age 79.2 years, including 305 patients with SNHL and 326 without. More severe disability was more prevalent in patients with SNHL. Sensorineural hearing loss was not associated with increased mortality (odds ratio = 1.1, 95 per cent confidence interval = 0.7-2.0, p = 0.668). Hypertension was present in 210 (68.9 per cent) with SNHL versus 189 (58 per cent) without SNHL (p = 0.005). Small-vessel disease aetiology was more prevalent in SNHL 51 (16.7 per cent) versus 30 (9.2 per cent) without SNHL (p = 0.005).

CONCLUSION

Sensorineural hearing loss appears to have an association with stroke of small-vessel disease aetiology and hypertension. Sensorineural hearing loss does not affect three-month mortality but is associated with increased disability.

Utilization, Workflow, and Outcomes of Endovascular Thrombectomy in Patients With vs Without Premorbid Disability in a National Registry

Background and Objectives

Given the paucity of high-quality safety/efficacy data on acute stroke therapies in patients with premorbid disability, they risk being routinely excluded from such therapies. We examined utilization of endovascular thrombectomy (EVT), associated workflow, and poststroke outcomes among patients with vs without premorbid disability.

Methods

We used national registry data on thrombolysis/EVT for the Czech Republic from 1 January 2016 to 31 December 2020. Premorbid disability was defined as prestroke modified Rankin Scale score (mRS) ≥3. We compared proportions of patients with vs without premorbid disability who received EVT and examined workflow times. We compared ΔmRS-change in mRS from prestroke to 3 months-in patients with vs without premorbid disability, in addition to intracerebral hemorrhage (ICH), mortality, and discharge NIHSS (National Institutes of Health Stroke Scale score), adjusting for age, sex, baseline NIHSS, and comorbidities, and verified using propensity score weighting (PSW) and matching for differences in treatment assignment. We stratified by age group (<65, 65-74, 75-84, ≥85 years) to explore outcome heterogeneity with vs without premorbid disability.

Results

Among 22,405 patients with ischemic stroke who received thrombolysis/EVT/both, 1,712 (7.6%) had prestroke mRS ≥ 3. Patients with prestroke disability were less likely to receive EVT vs those without (10.1% vs 20.7%, aOR: 0.30, 95% CI 0.24-0.36). When treated, they had longer door-to-arterial puncture times (median: 75 minutes, IQR: 58-100 vs 54, IQR: 27-77, adjusted difference: 12.5, 95% CI 2.68-22.3). Patients with prestroke disability receiving thrombolysis/EVT/both had worse ΔmRS (adjusted rate ratio, aIRR on PSW: 1.57, 95% CI 1.43-1.72), rates of 3-month mRS 5-6, discharge NIHSS, and mortality (aOR-PSW [mortality]: 2.54, 95% CI 1.92-3.34), while ICH did not significantly differ. 32.1% of patients with prestroke disability receiving thrombolysis/EVT/both successfully returned to prestroke state, but this proportion ranged from 19.6% for those older than 85 years to 66.0% for those younger than 65 years. Regardless of premorbid disability, EVT was associated with better outcomes including lower ΔmRS (aIRR-PSW: 0.87, 95% CI 0.83-0.91) and mortality, with no interaction of treatment effect by premorbid disability status (e.g., mortality pinteraction = 0.73). EVT recipients with premorbid disability did not differ significantly for several outcomes including ΔmRS (aIRR: 0.99, 95% CI 0.84-1.17) but were more likely to have 3-month mRS 5-6 (70.1% vs 39.5% without premorbid disability, aOR: 1.85, 95% CI 1.12-3.04).

Discussion

Patients with premorbid disability were less likely to receive EVT, had slower treatment times, and had worse outcomes compared with patients without premorbid disability. However, regardless of premorbid disability, patients fared better with EVT vs medical management and one-third with prestroke disability returned to their prestroke status.

Association of phenotypic age and accelerated aging with severity and disability in patients with acute ischemic stroke

OBJECTIVE

Biological age may be more accurate than chronological age in determining chronic health outcomes. However, few studies have shown the association between biological age and acute ischemic stroke (AIS). In this study we showed the association between phenotypic age (PhenoAge) or accelerated aging and severity and disability in patients with AIS.

DESIGN

Retrospective study.

SETTING AND SUBJECTS

936 patients with AIS during January 2019 to July 2021 and 512 patients during June 2022 to July 2023 for a validation.

METHODS

Stroke severity was evaluated based on the National Institute of Health stroke scale (NIHSS) questionnaire scale. Disability was evaluated by modified Rankin Scale. PhenoAge was calculated based on chronological age and 9 clinical chemistry biomarkers. Logistic regression analyses were applied to estimate the relationship between PhenoAge and the severity and disability.

RESULTS

PhenoAge (odds ratio [OR] = 1.03, 95% confidence interval [CI]: 1.0-1.04, for NIHSS ≥ 5; OR = 1.05, 95%CI: 1.03-1.07, for NIHSS ≥ 10) was independently associated with stroke severity. The probability of NIHSS ≥ 5 or NIHSS ≥ 10 was significantly increased in individuals with accelerated ageing versus individuals with no accelerated aging (age gap: OR = 1.79, 95%CI: 1.18-2.72; OR = 3.53, 95%CI: 1.60-7.77; phenotypically older vs. phenotypically younger: OR = 2.01, 95%CI: 1.21-3.35; OR = 3.69, 95%CI: 1.36-10.0). Similar trends was observed when accelerated aging was defined by residual discrepancies between PhenoAge and chronological age (OR = 1.02, 95%CI: 1.01-1.04, for NIHSS ≥ 5; OR = 1.05, 95%CI: 1.02-1.08, for NIHSS ≥ 10). The area under the curve of PhenoAge was higher than that of chronological age in identifying patients with NIHSS ≥ 5 (0.66, 95%CI:0.62-0.70 vs. 0.61, 95%CI: 0.58-0.65, p < 0.01) and NIHSS ≥ 10 (0.69, 95%CI:0.60-0.77 vs. 0.63, 95%CI: 0.55-0.72, p = 0.05). The probability of severe disability was significantly increased in individuals with accelerated aging versus individuals with no accelerated aging (age gap: OR = 2.87, 95%CI: 1.09-7.53; phenotypically older vs. phenotypically younger: 4.88 (1.20-19.88). Similar results were observed in the validation population.

CONCLUSION

PhenoAge or accelerated aging is associated with stroke severity and disability even after adjusting for chronological age.

Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness

People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.

Limitation of life sustaining therapy in disorders of consciousness: ethics and practice

Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.

Sex differences in acute stroke metrics and outcome dependent on COVID status

BACKGROUND AND PURPOSE

Biological sex is known to have an impact on quality metrics of acute stroke. We aimed to determine whether COVID positivity accentuates this effect and constitutes worse outcome.

METHODS

The present analysis was based on the Global COVID-19 Stroke Registry, a retrospective, international, cohort study of consecutive ischemic stroke patients receiving intravenous thrombolysis and/or endovascular thrombectomy between 1 March 2020 and 30 June 2021. We investigated differences between the sexes in patient characteristics, acute stroke metrics as well as post-stroke outcome in COVID-positive and COVID-negative stroke patients undergoing acute revascularization procedures.

RESULTS

A total of 15,128 patients from 106 centers were recorded in the Global COVID-19 Stroke Registry, 853 (5.6%) of whom were COVID-positive. Overall, COVID-positive individuals were treated significantly slower according to every acute stroke metric compared to COVID-negative patients. We were able to show that key quality indicators in acute stroke treatment were unfavorable for COVID-negative women compared to men (last-seen-well-to-door time + 11 min in women). Furthermore, COVID-negative women had worse 3-month outcomes (3-month modified Rankin Scale score [interquartile range] 3.0 [4.0] vs. 2.0 [3.0]; p < 0.01), even after adjusting for confounders. In COVID-positive individuals no such difference between the sexes, either in acute management metrics or in 3-month outcome, was seen.

CONCLUSION

Known sex-related differences in acute stroke management exist and extend to times of crisis. Nevertheless, if patients were COVID-19-positive at stroke onset, women and men were treated the same, which could be attributed to structured treatment pathways.

Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

BACKGROUND AND PURPOSE

We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability.

METHODS

In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0-4 and LVO who underwent EVT 6-24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0-2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2-4) and those without (mRS score 0-1).

RESULTS

A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43-1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995).

CONCLUSION

A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.

Role of age and sex in the association between BMI and functional limitations in stroke patients: Cross-sectional analysis in three European and US cohorts

BACKGROUND

A U- or J-shaped association between BMI and different post-stroke outcomes is suggested. Thus, the aim is to evaluate the association between BMI with ADL, IADL and mobility limitations in the ageing post-stroke population at different ages, as well as the differences in this association by sex.

METHODS

A total of 5,468 participants with stroke and 21,872 without stroke over 50 years of age were assessed for the number of limitations in basic or instrumental activities of daily living (ADL/IADL) as well as mobility tasks. The association between BMI at the interview (continuous time-dependent variable) and the level of limitations was assessed using a linear mixed model stratified by sex and stroke status.

RESULTS

The association between BMI and ADL/IADL and mobility limitations were found to be significant in both men and women regardless of stroke status (p<0.001 for all). The association differs between those who have suffered a stroke and those who have not (p<0.001 for all). In ADL/IADL limitations, men with stroke showed a transition from an inverted J-shape to a U-shape association with age. In women, the BMI showed a less pronounced association between BMI and ADL/IADL limitations compared to men but with similar trends. A effect of sex was observed in the association between BMI and mobility, with women with and without stroke showing a linear association that differed from the inverted J-shaped or U-shaped association of men.

CONCLUSION

Our results suggest that BMI is associated with limitations in ADL, IADL and mobility in stroke patients. In addition, this association differs between men and women and is also influenced by age.

Predictors of favorable outcome and mortality after endovascular thrombectomy in young Chinese patients with large vascular occlusions

Background

Endovascular thrombectomy (EVT) has evolved into the standard treatment for patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO). However, little information is available on the management of EVT in young patients with AIS-LVO in China. The purpose of this study was to assess the favorable outcomes and mortality rates after 90 days of EVT in young Chinese patients with AIS-LVO and their predictors.

Methods

This retrospective study included young Chinese patients aged 18-50 years with AIS-LVO. The primary efficacy endpoint was the modified Rankin scale (mRS) score at day 90, and the primary safety endpoint was mortality within 90 days. Using univariate and multivariate logistic regression analyses, the associations between clinical, imaging, and procedure variables and favorable (mRS 0-2) outcomes or mortality at 90 days were analyzed.

Results

A total of 113 patients were included in the study with a mean age of 43.1 ± 6.3 years. Symptomatic intracranial hemorrhage (sICH) occurred in 8 (7.1%) patients. Favorable functional outcomes (mRS 0-2) were recovered in 42.5% of patients at 3 months. After 90 days, the mortality rate was 32.3%. Multivariate analysis revealed that the increase in admission NIHSS score was associated with a lower probability of functional independence (aOR 1.08, 95% CI 1.02-1.15, p = 0.01 and aOR 1.01, 95% CI 1-1.01, p = 0.008, respectively) and a higher probability of death at 90 days (aOR 1.1, 95% CI 1.03-1.18, p = 0.007 and aOR 1.00, 95% CI 1-1.01, p = 0.021, respectively).

Conclusion

This study demonstrate that EVT provides higher rates of arterial recanalization, rather than better favorable outcomes and lower risk of death at 3 months in young Chinese patients with AIS-LVO. Increased NIHSS scores on admission may be associated with poor patient prognosis.

Percent Insular Ribbon Infarction for Predicting Infarct Growth Rate and 90-Day Outcomes in Large-Vessel Occlusive Stroke: Secondary Analysis of Prospective Clinical Trial Data

BACKGROUND. Insight into the natural history of infarct growth could help identify patients with slowly progressing stroke who may benefit from delayed endovascular thrombectomy (EVT). OBJECTIVE. The purpose of this article is to evaluate associations of percent insular ribbon infarction (PIRI) with infarct growth rate (IGR) and 90-day outcomes in patients with large-vessel occlusive stroke. METHODS. This retrospective study was a secondary analysis of a prior clinical trial that enrolled patients with acute stroke not treated with reperfusion therapies from January 2007 to June 2009. The present analysis evaluated 31 trial patients (median age, 71 years; 12 women, 19 men) with anterior-circulation large-vessel occlusion who underwent serial MRI examinations. Two neuroradiologists independently scored PIRI on presentation MRI examinations on the basis of the ratio of the length of the portion of the insula showing restricted diffusion to the insula's total length using a previously described 0-4 scale; scores were categorized (mild [0-1], moderate [2], or severe [3-4]), and discrepancies were resolved by consensus. The 90-day modified Rankin Scale (mRS) was obtained. As part of earlier clinical trial analyses, collateral pattern on CTA was classified as symmetric, malignant, or other, and infarct volumes were measured on DWI during the initial 48 hours after presentation and on FLAIR at 90 days. RESULTS. Interrater agreement for PIRI category was strong (κ = 0.89). PIRI was mild in 10, moderate in four, and severe in 17 patients. For mild, moderate, and severe PIRI, median IGR from onset to presentation was 1.6 cm3/h, 8.5 cm3/h, and 17.5 cm3/h (p < .001); median IGR from presentation to 48 hours was 0.3 cm3/h, 0.2 cm3/h, and 1.2 cm3/h (p = .005); median 90-day infarct volume was 9.4 cm3, 39.8 cm3, and 108.6 cm3 (p = .01); and 90-day mRS of 2 or less occurred in 78%, 67%, and 6% of patients (p = .001). In multivariable models controlling for age, internal carotid artery occlusion, and collateral pattern, PIRI category independently predicted onset-to-presentation IGR (β = 1.5), presentation-to-48-hour IGR (β = 1.3), and 90-day mRS of 2 or less (OR = 0.2). For predicting 90-day mRS of 2 or less, mild-to-moderate PIRI had sensitivity of 90.0% and specificity of 84.2%; symmetric collateral pattern had sensitivity of 70.0% and specificity of 73.7%. CONCLUSION. PIRI was independently associated with IGR and 90-day outcome. CLINICAL IMPACT. PIRI may help identify patients who could benefit from late-window EVT when requiring transfer to EVT-capable centers.

Functional outcomes of ischemic stroke patients aged over 80 years treated with acute revascularization therapy according to pre-morbid disability: a PARADISE study

Introduction

Aging population leads to changes in the profile of patients with acute ischemic stroke (IS), and older adults were largely excluded from randomized clinical trials of acute revascularization therapy. This study aimed to assess functional outcomes of treated IS patients > 80 years old according to prior disability and identify associated factors.

Methods

Consecutively older patients with acute IS treated with either IV thrombolysis and/or mechanical thrombectomy were enrolled between 2016 and 2019. Pre-morbid disability was assessed using the modified Rankin Scale (mRS) score, and patients were classified as being independent (mRS score, 0-2) or having pre-existing disability (mRS score, 3-5). A multivariable logistic regression analysis was performed to assess factors associated with a poor functional outcome (mRS score > 3) at 3 and 12 months in each group of patients.

Results

Among 300 included patients (mean age: 86.3 ± 4.6 years, 63% women, median NIHSS score: 14, IQR: 8-19), 100 had a pre-existing disability. In patients with a pre-morbid mRS score of 0-2, 51% had mRS >3 including 33% of deaths at 3 months. At 12 months, 50% had a poor outcome including 39% of deaths. In patients with a pre-morbid mRS score of 3-5, 71% had a poor outcome at 3 months including 43% of deaths, and at 12 months, 76% had mRS >3 including 52% of deaths. In multivariable models, the NIHSS score at 24 h was independently associated with poor outcomes at 3 and 12 months in both patients with (OR = 1.32; 95% CI: 1.16-1.51, p < 0.001 for 12 months outcome) or without (OR = 1.31; 95% CI: 1.19-1.44, p < 0.001 for 12 months outcome) pre-morbid disability.

Conclusion

Although a large proportion of older patients with a pre-existing disability had a poor functional outcome, they did not differ from their non-impaired counterparts regarding prognostic factors. This means that there were no factors in our study that would help clinicians identify patients at risk of poor functional outcomes after revascularization therapy among those with prior disability. Further studies are needed to better understand the post-stroke trajectory of older IS patients with a pre-morbid disability.

The Key Role of Initiation Timing on Stroke Rehabilitation by Remote Ischemic Conditioning with Exercise (RICE)

OBJECTIVE

Physical therapy is an integral part of post-stroke rehabilitation. Remote ischemic conditioning (RIC) induces neuroprotection within 24 hours after stroke, during which exercise is unsafe and ineffective. We combined RIC with exercise to establish a novel rehabilitation strategy, RICE (RIC+Exercise). The aim of this study was to optimize the RICE protocol in neurorehabilitation.

METHODS

Thirty-two adult male Sprague-Dawley rats were placed in one of four groups: stroke with no rehabilitation or stroke with various RICE protocols. To further understand the mechanisms underlying neurorehabilitation, sixteen adult male Sprague-Dawley were added, each placed in one of two groups: stroke with exerciseor RIC  . Long-term functional outcomes were determined by beam balance, rota-rod, grid walk, forelimb placing, and Morris water maze tests up to 28 days after stroke (p < 0.05). Changes in neuroplasticity including synaptogenesis (assessed by measuring synaptophysin, post-synaptic density protein-95, and brain-derived neutrophic factor), angiogenesis (via vascular endothelial growth factor, Angiopoietin-1, and Angiopoietin-2), and regulatory molecules (including hypoxia inducible factor-1α, phospholipase D2 and the mechanistic target of rapamycin pathway), were all measured at both mRNA and protein levels (p < 0.05).

RESULTS

All rehabilitation groups showed significant improvement in functional outcomes and levels of synaptogenesis and angiogenesis. 5 day RICE groups, in which RIC was started five days prior to exercise, demonstrated the greatest improvement among these parameters. The results also suggested that the HIF-1α/PLD2/mTOR signaling pathway may be implicated in post-stroke neuroplasticity.

CONCLUSIONS

RICE, particularly RIC initiation at hour 6 post-reperfusion followed by exercise on day 5, enhanced post-stroke rehabilitation in rats.

Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy

BACKGROUND

Analyses of the effect of pre-stroke functional levels on the outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial pre-stroke disability. The effect of complete freedom from pre-existing disability (modified Rankin Scale (mRS) 0) versus predominantly mild pre-existing disability/symptoms (mRS 1-2) has not been well delineated.

METHODS

The HERMES meta-analysis pooled data from seven randomized trials that tested the efficacy of EVT. We tested for a multiplicative interaction effect of pre-stroke mRS on the relationship between treatment and outcomes. Ordinal regression was used to assess the association between EVT and 90-day mRS (primary outcome) in the subgroup of patients with pre-stroke mRS 1-2. Multivariable regression modeling was then used to test the effect of mild pre-stroke disability/symptoms on the primary and secondary outcomes (delta-mRS, mRS 0-2/5-6) compared with patients with pre-stroke mRS 0.

RESULTS

We included 1764 patients, of whom 199 (11.3%) had pre-stroke mRS 1-2. No interaction effect of pre-stroke mRS on the relationship between treatment and outcome was observed. Patients with pre-stroke mRS 1-2 had worse outcomes than those with pre-stroke mRS 0 (adjusted common OR (acOR) 0.53, 95% CI 0.40 to 0.70). Nonetheless, a significant benefit of EVT was observed within the mRS 1-2 subgroup (cOR 2.08, 95% CI 1.22 to 3.55).

CONCLUSIONS

Patients asymptomatic/without disability prior to onset have better outcomes following EVT than patients with mild disability/symptoms. Patients with pre-stroke mRS 1-2, however, more often achieve good outcomes with EVT compared with conservative management. These findings indicate that mild pre-existing disability/symptoms influence patient prognosis after EVT but do not diminish the EVT treatment effect.

Successful thrombectomy is beneficial in patients with pre-stroke disability: Results from an international multicenter cohort study

BACKGROUND

Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion.

METHODS

Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes.

RESULTS

Among 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11-11.5]; p 0.048).

CONCLUSION

In patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.

Cost-Effectiveness of Endovascular Treatment in Large Vessel Occlusion Stroke With Mild Prestroke Disability: Results From the HERMES Collaboration

BACKGROUND

The clinical and economic benefit of endovascular treatment (EVT) in addition to best medical management in patients with stroke with mild preexisting symptoms/disability is not well studied. We aimed to investigate cost-effectiveness of EVT in patients with large vessel occlusion and mild prestroke symptoms/disability, defined as a modified Rankin Scale score of 1 or 2.

METHODS

Data are from the HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials), which pooled patient-level data from 7 large, randomized EVT trials. We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes from a health care and a societal perspective. Incremental cost-effectiveness ratio and net monetary benefits were calculated, and a probabilistic sensitivity analysis was performed.

RESULTS

EVT in addition to best medical management resulted in lifetime cost savings of $2821 (health care perspective) or $5378 (societal perspective) and an increment of 1.27 quality-adjusted life years compared with best medical management alone, indicating dominance of additional EVT as a treatment strategy. The net monetary benefits were higher for EVT in addition to best medical management compared with best medical management alone both at the higher (100 000$/quality-adjusted life years) and lower (50 000$/quality-adjusted life years) willingness to pay thresholds. Probabilistic sensitivity analysis showed decreased costs and an increase in quality-adjusted life years for additional EVT compared with best medical management only.

CONCLUSIONS

From a health-economic standpoint, EVT in addition to best medical management should be the preferred strategy in patients with acute ischemic stroke with large vessel occlusion and mild prestroke symptoms/disability.

Symmetric collateral pattern on CTA predicts favorable outcomes after endovascular thrombectomy for large vessel occlusion stroke

Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion (LVO) stroke management, but often requires advanced imaging. The collateral pattern on CT angiograms may be an alternative because a symmetric collateral pattern correlates with a slowly growing, small ischemic core. We tested the hypothesis that such patients will have favorable outcomes after EVT. Consecutive patients (n = 74) with anterior LVOs who underwent EVT were retrospectively analyzed. Inclusion criteria were available CTA and 90-day modified Rankin Scale (mRS). CTA collateral patterns were symmetric in 36%, malignant in 24%, or other in 39%. Median NIHSS was 11 for symmetric, 18 for malignant, and 19 for other (p = 0.02). Ninety-day mRS ≤2, indicating independent living, was achieved in 67% of symmetric, 17% of malignant, and 38% of other patterns (p = 0.003). A symmetric collateral pattern was a significant determinant of 90-day mRS ≤2 (aOR = 6.62, 95%CI = 2.24,19.53; p = 0.001) in a multivariable model that included age, NIHSS, baseline mRS, thrombolysis, LVO location, and successful reperfusion. We conclude that a symmetric collateral pattern predicts favorable outcomes after EVT for LVO stroke. Because the pattern also marks slow ischemic core growth, patients with symmetric collaterals may be suitable for transfer for thrombectomy. A malignant collateral pattern is associated with poor clinical outcomes.

Brain activation of the PFC during dual-task walking in stroke patients: A systematic review and meta-analysis of functional near-infrared spectroscopy studies

Background

Dual-task walking is a good paradigm to measure the walking ability of stroke patients in daily life. It allows for a better observation of brain activation under dual-task walking to assess the impact of the different tasks on the patient when combining with functional near-infrared spectroscopy (fNIRS). This review aims to summarize the cortical change of the prefrontal cortex (PFC) detected in single-task and dual-task walking in stroke patients.

Methods

Six databases (Medline, Embase, PubMed, Web of Science, CINAHL, and Cochrane Library) were systematically searched for relevant studies, from inception to August 2022. Studies that measured the brain activation of single-task and dual-task walking in stroke patients were included. The main outcome of the study was PFC activity measured using fNIRS. In addition, a subgroup analysis was also performed for study characteristics based on HbO to analyze the different effects of disease duration and the type of dual task.

Results

Ten articles were included in the final review, and nine articles were included in the quantitative meta-analysis. The primary analysis showed more significant PFC activation in stroke patients performing dual-task walking than single-task walking (SMD = 0.340, P = 0.02, I ² = 7.853%, 95% CI = 0.054-0.626). The secondary analysis showed a significant difference in PFC activation when performing dual-task walking and single-task walking in chronic patients (SMD = 0.369, P = 0.038, I ² = 13.692%, 95% CI = 0.020-0.717), but not in subacute patients (SMD = 0.203, P = 0.419, I ² = 0%, 95% CI = -0.289-0.696). In addition, performing walking combining serial subtraction (SMD = 0.516, P < 0.001, I ² = 0%, 95% CI = 0.239-0.794), obstacle crossing (SMD = 0.564, P = 0.002, I ² = 0%, 95% CI = 0.205-0.903), or a verbal task (SMD = 0.654, P = 0.009, I ² = 0%, 95% CI = 0.164-1.137) had more PFC activation than single-task walking, while performing the n-back task did not show significant differentiation (SMD = 0.203, P = 0.419, I ² = 0%, 95% CI = -0.289-0.696).

Conclusions

Different dual-task paradigms produce different levels of dual-task interference in stroke patients with different disease durations, and it is important to choose the matching dual-task type in relation to the walking ability and cognitive ability of the patient, in order to better improve the assessment and training effects.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022356699.

Understanding Delays in MRI-based Selection of Large Vessel Occlusion Stroke Patients for Endovascular Thrombectomy

PURPOSE

Given the efficacy of endovascular thrombectomy (EVT), optimizing systems of delivery is crucial. Magnetic resonance imaging (MRI) is the gold standard for evaluating tissue viability but may require more time to obtain and interpret. We sought to identify determinants of arrival-to-puncture time for patients who underwent MRI-based EVT selection in a real-world setting.

METHODS

Patients were identified from a prospectively maintained database from 2011-2019 that included demographics, presentations, treatments, and outcomes. Process times were obtained from the medical charts. MRI times were obtained from time stamps on the first sequence. Linear and logistic regressions were used to infer explanatory variables of arrival-to-puncture times and effects of arrival-to-puncture time on functional outcomes.

RESULTS

In this study 192 patients (median age 70 years, 57% women, 12% non-white) underwent MRI-based EVT selection. 66% also underwent computed tomography (CT) at the hub before EVT. General anesthesia was used for 33%. Among the entire cohort, the median arrival-to-puncture was 102 min; however, among those without CT it was 77 min. Longer arrival-to-puncture times independently reduced the odds of 90-day good outcome (∆mRS ≤ 2 from pre-stroke, aOR = 0.990, 95%CI = 0.981-0.999, p = 0.040) when controlling for age, NIHSS, and good reperfusion (TICI 2b-3). Independent determinants of longer arrival-to-puncture were CT plus MRI (β = 0.205, p = 0.003), non-white race/ethnicity (β = 0.162, p = 0.012), coronary disease (β = 0.205, p = 0.001), and general anesthesia (β = 0.364, p < 0.0001).

CONCLUSION

Minimizing arrival-to-puncture time is important for outcomes. Real-world challenges exist in an MRI-based EVT selection protocol; avoiding double imaging is key to saving time. Racial/ethnic disparities require further study. Understanding variables associated with delay will inform protocol changes.

Measurement properties of the Brazilian version of the Stroke Upper Limb Capacity Scale (SULCS-Brazil)

BACKGROUND

The Stroke Upper Limb Capacity Scale (SULCS) is a clinically useful measure of upper-limb (UL) capacity, which assesses both basic and advanced capacities.

OBJECTIVES

To examine the reliability, construct validity, and interpretability of the SULCS-Brazil with community-dwelling individuals with stroke.

METHODS

The SULCS-Brazil and measures of impairment (handgrip strength and motor function of the paretic UL), capacity (manual and digital dexterities), and performance were applied during the first session, to establish construct validity (80 patients). The SULCS-Brazil was applied again during a second session (a sub-set of 30 patients), to investigate test-retest reliability. Test-retest reliability was evaluated using kappa statistics (k) for the individual items, intraclass correlation coefficient (ICC) for the total scores, standard error of measurement (SEM), minimal detectable change (MDC), and Bland-Altman plot. For the evaluation of construct validity, pre-defined hypotheses were created to estimate the strength of the correlations between the SULCS-Brazil scores and established measures of UL function, using Spearman correlation coefficients. Interpretability was investigated by evaluating both ceiling/ floor effects.

RESULTS

High level of agreement was found between the SUCLS-Brazil total scores obtained on both applications (ICC = 0.98; 95%CI:0.96-0.99) and 80% of the individual items had almost perfect agreement (k= 0.81-1.0). The SEM (0.46) and the MDC (1.27) showed clinically acceptable values. All pre-defined hypotheses were confirmed, indicating adequate construct validity of the SULCS-Brazil. No significant ceiling/floor effects were observed.

CONCLUSIONS

The SULCS-Brazil showed to be reliable and valid for the evaluation of upper-limb capacity of individuals with stroke.

Longitudinal Impact of Community-Based Rehabilitation Programs on Functional Recovery After Stroke: A Scoping Review

The purpose of this scoping review is to guide the effects of long-term application of CBRP in stroke patients and to help make recommendations for developing treatment protocols for therapeutic application. The study examined relevant literature published between 2009 and 2020 using searches of 4 scientific databases. CBRP may have long-term effects on the functional effectiveness of stroke patients. In particular, long-term effects on walking ability and level of daily living activities have been identified. However, disease-related health conditions and quality of life were less effective in the long run. The effect decreased over time, but the long-term effect was maintained. Long-term intervention after discharge has proven to make a significant difference in the outcome of the goal. Given the potential therapeutic benefits of this process, the results of this review highlight the lack of further research to establish the effectiveness of this form of community-based long-term rehabilitation therapy for stroke patients.

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Introduction

Endovascular thrombectomy (EVT) is a well-established and effective therapeutic option for patients that meet certain criteria. However, this modality is not well studied in patients with pre-existing disability. The aim of the present study was to investigate the impact of mechanical thrombectomy in patients with acute onset ischemic stroke and pre-stroke dependency (PSD) in regard to their clinical outcome and mortality.

Materials and Methods

The MEDLINE, Scopus, and Cochrane Library databases were comprehensively searched with a cut-off date of December 11th, 2021. We performed meta-analysis to investigate the 90-day clinical outcome, the 90-day mortality, and the rate of symptomatic intracerebral hemorrhage (sICH) between the PSD (modified Rankin Scale score ≥ 3) and non-PSD (modified Rankin Scale score = 0-2) groups who underwent EVT for acute onset ischemic stroke.

Results

Six studies were included in the meta-analysis involving 4,543 cases with no PSD and 591 cases with PSD. The non-PSD group showed a statistically significant better clinical outcome at 90 days compared to the PSD group [RR (95% CI) = 1.44 (1.06, 1.85); p z = 0.02]. The non-PSD group demonstrated a statistically significant lower risk of death at 90 days in comparison to the PSD group [RR (95% CI) = 0.45 (0.41, 0.50); p z < 0.01]. Lastly, the rate of sICH was comparable between the two groups [RR (95% CI) = 0.89 (0.64, 1.24); p z = 0.48].

Discussion

We report a higher rate of unfavorable clinical outcome and a higher mortality rate in patients with PSD undergoing EVT compared to those with no previous disability. However, there was a significant proportion of PSD cases who fared well post-procedurally, indicating that PSD patients should not be routinely excluded from mechanical thrombectomy.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021284181, identifier: CRD42021284181.

Association of Infarct Topography and Outcome After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

BACKGROUND AND OBJECTIVES

The care of patients with large vessel occlusion (LVO) stroke has been revolutionized by endovascular thrombectomy (EVT). While EVT has a large effect size, most patients treated with EVT remain disabled or die within 90 days. A better understanding of outcomes may influence EVT selection criteria, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions.

METHODS

For this cohort study, consecutive patients with LVO who were treated with EVT and underwent post-EVT MRI were identified from a tertiary referral center (2011-2019). Acute ischemic lesions were manually segmented from diffusion-weighted imaging and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to 10 essential lesion patterns with the use of unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS) score (>2) was modeled via bayesian regression, taking the 10 lesion patterns as inputs and controlling for lesion size, age, sex, acute NIH Stroke Scale (NIHSS) score, alteplase, prior stroke, intracerebral hemorrhage, and good reperfusion (Thrombolysis in Cerebral Infarction 2b-3). In comparative analyses, 90-day mRS score was modeled considering covariates only, and compartment-wise relevances for acute stroke severity and 90-day mRS score were evaluated.

RESULTS

There were 151 patients with LVO identified (age 68 ± 15 years, 52% female). The median NIHSS score was 16 (interquartile range 13-20); 56% had mRS score >2. Lesion locations predictive of 90-day mRS score involved bilateral but left hemispherically more pronounced precentral and postcentral gyri, insular and opercular cortex, and left putamen and caudate (area under the curve 0.91, highest probability density interval [HPDI] covering 90% certainty 0.90-0.92). The lesion location model outperformed the simpler model relying on covariates only (bayesian model comparison of 97% weight to the model with vs 3% weight to the model without lesion location). While lesions affecting subcortical nuclei had the highest relevance for stroke severity (posterior distribution mean 0.75, 90% HPDI 0.256-1.31), lesions affecting white matter tracts had the highest relevance for 90-day mRS score (0.656, 90% HPDI 0.0864-1.12).

DISCUSSION

These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.

Ethical Considerations in Clinical Trials for Disorders of Consciousness

As the clinical trial landscape for patients with disorders of consciousness (DoC) expands, consideration of associated ethical challenges and opportunities is of ever-increasing importance. Responsible conduct of research in the vulnerable population of persons with DoC, including those with coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS), covert cortical processing (CCP), and cognitive motor dissociation (CMD), demands proactive deliberation of unique ethical issues that may arise and the adoption of robust protections to safeguard patients, surrogates, and other key stakeholders. Here we identify and critically evaluate four central categories of ethical considerations in clinical trials involving participants with DoC: (1) autonomy, respect for persons and informed consent of individuals with liminal consciousness; (2) balancing unknown benefits and risks, especially considering the epistemological gap between behavior and consciousness that complicates ordinary ascription of subjective states; (3) disclosure to surrogates and clinical teams of investigational results pertaining to consciousness; and (4) justice considerations, including equitable access to clinical trial enrollment across communities and geographies. We outline guiding principles and research opportunities for clinicians, neuroethicists, and researchers engaged in DoC clinical trials to advance ethical study design and deployment in this complex yet crucial area of investigation.

Pre-stroke Disability and Long-Term Functional Limitations in Stroke Survivors: Findings From More of 12 Years of Follow-Up Across Three International Surveys of Aging

Background

Almost 50% of the post-stroke disabled population already have a premorbid disability before stroke. These patients may be offered a different care pathway in the acute and subacute phase than those without pre-morbid disability. Therefore, the aim of this study was to assess the association of the severity of premorbid disability with change of limitations in basic and instrumental activities of daily living (ADL/IADL) 1 year after stroke and over the following decade.

Methods

Among 3,432 participants from HRS, SHARE and ELSA cohorts with a first stroke, ADL/IADL limitations were measured at 1-2 years prior to stroke, at 1 year post-stroke, and during the chronic phase. Modified Ranking Scale (P-mRS) was used to categorize the participants by level of premorbid disability (1-2 years pre-stroke). Change in ADL/IADL limitations by P-mRS level (0-1, 2-3, and 4-5) was assessed using a piecewise linear mixed model with a breakpoint set at 1 year post-stroke, stratified by median age groups.

Results

Increase in ADL limitations at 1 year post-stroke was less pronounced in P-mRS ≥2 (p < 0.005). After years of relative stability, limitations of ADL increased for all P-mRS levels (p = 0.003). In those aged ≥75 years at stroke event, the increase was similar irrespective of P-mRS (p = 0.090). There were no significant differences in IADL trajectories between P-mRS levels (p ≥ 0.127).

Conclusion

These results suggest similar trajectories of functional limitations between P-mRS levels up to 9 years post-stroke, highlighting the possible benefit of including patients with pre-morbid disability to certain treatments during the acute phase.

Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke

INTRODUCTION

Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after endovascular thrombectomy (EVT) for emergent large vessel occlusion ischemic stroke (ELVO).

METHODS

Patients presenting to a single referral center with an anterior circulation ELVO that underwent EVT from 2011 to 2019 were included in this retrospective analysis. Sex differences in history, presentation, adequate reperfusion (TICI 2b-3), and 90-day good outcome [delta modified Rankin Scale (mRS) ≤ 2 from pre-stroke] were examined. Multivariable logistic regression analyses were performed to assess sex-specific associations with outcomes.

RESULTS

Three hundred and eighty-one consecutive ELVO patients were identified. Women (N = 193) were older (75 vs 64 years, p < 0.0001), had more pre-stroke disability (17% vs 9%, p = 0.032), more atrial fibrillation (41% vs 30%, p = 0.033), but less carotid atherosclerosis (8% vs 16%, p = 0.027). Rates of TICI 2b-3 and good outcome were similar between sexes. Carotid atherosclerosis (OR 0.315, 95% CI 0.130, 0.762) and dissection (OR 0.124, 95% CI 0.027, 0.569) independently decreased the odds of TICI 2b-3 among men but not women. Older age, more severe stroke, and not achieving TICI 2b-3 independently decreased the odds of good outcome among both sexes, while prior stroke (OR 0.258, 95% CI 0.083, 0.797) and hemorrhagic transformation (OR 0.111, 0.021, 0.592) were determinants exclusive to men.

CONCLUSION

In a real-world analysis of ELVO stroke patients treated with EVT, we found that despite advanced age and more pre-stroke disability, women have comparable reperfusion rates and functional outcomes compared to men. Sex-specific determinants of reperfusion and functional outcome were identified that require further study.

The neuroethics of disorders of consciousness: a brief history of evolving ideas

Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.

Neuroprotective effect of herniarin following transient focal cerebral ischemia in rats

Ischemic stroke is a devastating central nervous disease. Despite extensive research in to this area, few innovative neuroprotective treatments have been presented. 7-methoxycoumarin, also known as herniarin, is a common natural coumarin in several plant species. This project examined the effects of the herniarin in rats subjected to the middle cerebral artery occlusion (MCAO). Herniarin at doses of 10 and 20 mg/kg was administered through intraperitoneal injection for 7 days before MCAO induction. Rats were subjected to a 30 min MCAO and a subsequent 24 h' reperfusion. 24 h after the termination of MCAO, neurologic outcome, volume of brain infarction, level of interleukin-1β (IL-1β) and tumor necrosis factor alpha (TNF-α), as inflammatory markers, and oxidative stress markers including levels of total thiol, malondialdehyde (MDA), and superoxide dismutase (SOD) activity were estimated. Herniarin administration decreased the MCAO-induced infarct volume and neurological deficits. Moreover, pretreatment with herniarin significantly decreased the levels of MDA while simultaneously increasing the level of total thiol and SOD activity in the brain tissues of MCAO rats. Moreover, herniarin pretreatment decreased the levels of IL-1β and TNF-α in the brain tissues of MCAO rats. These results suggest that herniarin presents beneficial effects against ischemic stroke, partly through the inhibition of oxidative stress and inflammation.

Previous Disability and Benefit of Acute Phase Therapy in Functional Prognosis of Selected Patients with Ischemic Stroke

OBJECTIVES

Patients' previous disability (PD) is a key factor when considering acute stroke therapy. PD's exact impact on functional prognosis of patients with acute ischemic stroke remains not entirely clarified. We aimed to analyze PD's influence on functional outcome three months after ischemic stroke.

MATERIALS AND METHODS

Retrospective analysis of prospectively collected data concerning patients with acute ischemic stroke admitted to Stroke Unit of a tertiary center who underwent acute phase therapy between 2017 and 2019. Modified Rankin Scale (mRS) was used to define PD (with previous mRS≥3). Patients with PD were selected for treatment based on similar baseline characteristics to patients without PD. Patients were classified into two groups according to previous mRS: mRS<3 and mRS≥3. We defined bad outcome at three months after stroke as mRS≥3 for patients with previous mRS<3, and as a higher score than baseline mRS for patients with previous mRS≥3.

RESULTS

We identified 1169 eligible patients - 1016 patients with previous mRS<3 and 153 patients with previous mRS≥3. Most baseline characteristics did not differ significantly between them. For patients ≤75 years old, PD was associated with worse outcome (odds ratio estimate [OR] 4.50, p < 0.001). For patients >75 years old, PD was protective against worse outcome (OR 0.42, p < 0.001). In patients with previous mRS≥3 and >75 years old, there was a higher proportion of women (p = 0.005).

CONCLUSIONS

PD might not be a relevant factor when considering acute stroke therapy in selected patients >75 years old, especially women. Further studies are needed to clarify these findings.

When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative?

Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.

'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model

BACKGROUND

Randomized trials have not demonstrated benefit from intravenous thrombolysis among patients undergoing endovascular thrombectomy (EVT). However, these trials included primarily patients presenting directly to an EVT capable hub center. We sought to study outcomes for EVT candidates who presented to spoke hospitals and were subsequently transferred for EVT consideration, comparing those administered alteplase at spokes (i.e., 'drip-and-ship' model) versus those not.

METHODS

Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CT angiography defined emergent large vessel occlusion and Alberta Stroke Program CT score ≥6 were identified from a prospectively maintained Telestroke database. Outcomes of interest included adequate reperfusion (Thrombolysis in Cerebral Infarction (TICI) 2b-3), intracerebral hemorrhage (ICH), discharge functional independence (modified Rankin Scale (mRS) ≤2), and 90 day functional independence.

RESULTS

Among 258 patients, median age was 70 years (IQR 60-81), median National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-19), and 50% were women. Ninety-eight (38%) were treated with alteplase at spokes and 113 (44%) underwent EVT at the hub. Spoke alteplase use independently increased the odds of discharge mRS ≤2 (adjusted OR 2.43, 95% CI 1.08 to 5.46, p=0.03) and 90 day mRS ≤2 (adjusted OR 3.45, 95% CI 1.65 to 7.22, p=0.001), even when controlling for last known well, NIHSS, and EVT; it was not associated with an increased risk of ICH (OR 1.04, 95% CI 0.39 to 2.78, p=0.94), and there was a trend toward association with greater TICI 2b-3 (OR 3.59, 95% CI 0.94 to 13.70, p=0.06).

CONCLUSIONS

Intravenous alteplase at spoke hospitals may improve discharge and 90 day mRS and should not be withheld from EVT eligible patients who first present at alteplase capable spoke hospitals that do not perform EVT. Additional studies are warranted to confirm and further explore these benefits.

Stroke Disparities Among Nonracial Minorities in the All of Us Research Program

[Figure: see text].

Relevant Biophysical Parameters Discrimination along Corticospinal Tract in Patients with Stroke Using Convolutional Neural Networks

Stroke remains the leading source of long-term disability. As the only direct descending motor pathway, the corticospinal tract (CST) is the primary pathway to innervate spinal motor neurons and one of the most well studied tracts in human neuroanatomy. Its clinical significance can be demonstrated in many distinguished traumatic situations and diseases such as stroke. Along‐tract statistics analysis enables the extraction of quantitative diffusion metrics along specific white matter fiber tracts. Besides quantitative metrics derived from classical diffusion tensor imaging (DTI), such as fractional anisotropy and diffusivities. In this study, we extracted DTI derived quantitative microstructural diffusion metrics along the CST tract in patients with moderate to severe subacute stroke. Respectively DTI metric of individual patient's fiber tract was then plotted. This approach may be useful for future studies that may compare in two different time (acute and chronic). The contribution of this work presents a totally computerized method of DTI image recognition based on conventional neural network (CNN) in order to supply quantitative appraisal of clinical characteristics. The obtained results have achieved an important classification (Accuracy=94.12%) when applying the CNN. The proposed methodology enables us to assess the classification of the used DTI images database within a reduced processing time. Experimental results prove the success of the proposed rating system for a suitable analysis of microstructural diffusion when compared to previous work.

Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions

OBJECTIVES

Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs.

MATERIALS AND METHODS

Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed.

RESULTS

From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency.

CONCLUSIONS

Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.

Infarct Growth despite Endovascular Thrombectomy Recanalization in Large Vessel Occlusive Stroke

BACKGROUND AND PURPOSE

Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion stroke care. However, not all patients with good endovascular results achieve good outcomes. We sought to understand the clinical significance of magnetic resonance imaging defined infarct growth despite adequate reperfusion and identify associated clinical and radiographic variables.

METHODS

History, presentation, treatments, and outcomes for consecutive EVT patients at a referral center were collected. Adequate reperfusion was defined as thrombolysis in cerebral infarction (TICI) score 2b-3. Region-specific infarct volumes in white matter, cortex, and basal ganglia were determined on diffusion-weighted imaging. Infarct growth was defined as post-EVT minus pre-EVT volume. Good outcome was defined as 90-day modified Rankin Scale ≤2.

RESULTS

Forty-four patients with adequate reperfusion were identified with median age 72 years; 64% were women. Each region showed infarct growth: white matter (median pre-EVT 7 cubic centimeters [cc], post-EVT 16 cc), cortex (4 cc, 15 cc), basal ganglia (2 cc, 4 cc), total (20 cc, 39 cc). In multivariable regression, total infarct growth independently decreased the odds of good outcome (odds ratio = .946, 95% CI = .897, .998). Further multivariable analyses for determinants of infarct growth identified female sex was associated with less total growth (β = -.294, P = .042), TICI 3 was associated with less white matter growth (β = -.277, P = .048) and cortical growth (β = -.335, P = .017), and both female sex (β = -.332, P = .015) and coronary disease (β = -.337, P = .015) were associated with less cortical growth.

CONCLUSIONS

Infarct growth occurred despite adequate reperfusion, disproportionately in the cortex, and independently decreased the odds of good outcome. Infarct growth occurred while patients were hospitalized and may represent a therapeutic target. Potential determinants of region-specific infarct growth were identified that require confirmation in larger studies.

Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities

BACKGROUND

Persons with pre-existing disabilities represent over one-third of acute stroke presentations, but account for a far smaller proportion of those receiving endovascular thrombectomy (EVT) and thrombolysis. This is despite existing ethical, economic, legal, and social directives to maximize equity for this vulnerable population. We sought to determine associations between baseline modified Rankin Scale (mRS) and outcomes after EVT.

METHODS

Individuals who underwent EVT were identified from a prospectively maintained database. Demographics, medical history, presentations, treatments, and outcomes were recorded. Baseline disability was defined as baseline mRS≥2. Accumulated disability was defined as the delta between baseline mRS and absolute 90-day mRS.

RESULTS

Of 381 individuals, 49 had baseline disability (five with mRS=4, 23 mRS=3, 21 mRS=2). Those with baseline disability were older (81 vs 68 years, P<0.0001), more likely female (65% vs 49%, P=0.032), had more coronary disease (39% vs 20%, P=0.006), stroke/TIA history (35% vs 15%, P=0.002), and higher NIH Stroke Scale (19 vs 16, P=0.001). Baseline mRS was associated with absolute 90-day mRS ≤2 (OR=0.509, 95%CI=0.370-0.700). However, baseline mRS bore no association with accumulated disability by delta mRS ≤0 (ie, return to baseline, OR=1.247, 95%CI=0.943-1.648), delta mRS ≤1 (OR=1.149, 95%CI=0.906-1.458), delta mRS ≤2 (OR 1.097, 95% CI 0.869-1.386), TICI 2b-3 reperfusion (OR=0.914, 95%CI=0.712-1.173), final infarct size (P=0.853, β=-0.014), or intracerebral hemorrhage (OR=0.521, 95%CI=0.244-1.112).

CONCLUSIONS

While baseline mRS was associated with absolute 90-day disability, there was no association with accumulated disability or other outcomes. Patients with baseline disability should not be routinely excluded from EVT based on baseline mRS alone.

Goal-Concordant Care in the Era of Advanced Stroke Therapies

Stroke is a leading cause of disability and mortality worldwide. Recent advances in stroke care now enable patients with severe ischemic stroke owing to large vessel occlusion to safely undergo endovascular thrombectomy (EVT) up to 24 hours since their time of last known well, with the goal of improving functional outcomes by recanalization of the occluded vessel and reperfusion of downstream ischemic brain tissue. The objective of this analysis is to highlight clinical and ethical challenges related to ensuring goal-concordant care in this era of unprecedented advances in acute stroke care. Specifically, there is a salient challenge of whether advanced therapies such as EVT may be justifiably considered comfort focused, given their potential to preempt accumulated neurologic disability and suffering at the end of life. Through the lens of a patient case, we discuss key challenges, lessons learned, and suggestions for future care and research endeavors at the intersection of acute stroke care and palliative care principles. Although therapies such as thrombolysis and EVT may be considered aggressive prima facie, their potential to ameliorate additional disability and potential suffering at the end of life prompt close consideration of the proper role of these therapies on a case-by-case basis in the context of comfort-focused care. Modification to the workflow for EVT evaluations may facilitate goal-concordant care and timely resource allocation, especially for cases that involve hospital-to-hospital transfers for advanced stroke care.

Physician, know thyself: implicit and explicit decision-making for mechanical thrombectomy in stroke

Few clinical situations in medical practice are as time-sensitive and and have such profound ramifications as selection of patients with acute stroke for mechanical thrombectomy (MT). Emergent large vessel occlusion has become a treatable disease with minimal numbers needed to treat to achieve a functional, long-term neurologic outcome. However, MT carries risk and many patients who are appropriately reperfused continue to have significant neurologic deficits and disability despite a successful procedure. The decision to offer or withhold MT can be complex. Frequently decisions must be made based on incomplete information or emergently while the physician is awoken from sleep or distracted while performing other procedures. A growing number of studies have examined cognitive errors and biases as they pertain to patient diagnosis and treatment in medicine. Dual process theory identifies two decision-making processes as system 1 ('implicit') and system 2 ('explicit') and describes the patterns through which decisions are formulated. The implicit system is the default pathway as it requires little effort or focus, uses mental short cuts, and is rapid; however, this pathway is subject to considerable bias and error. This manuscript reviews the mechanisms underlying the way in which physician decisions about MT are made, specifically highlighting prominent biases that may affect judgment, and reviews other important principles, such as confidence in decisions, aggressiveness to pursue MT, and strategies to improve decisions.