Abstract WP168: Socioeconomic Status and Stroke Severity

Background and Purpose: Once a stroke occurs in a patient with atrial fibrillation (AF), it is likely to be severe. Patients with newly diagnosed AF after stroke and those with known AF before stroke have different background characteristics, yet the difference in stroke severity has not been sufficiently evaluated. In the current study, we compared the stroke severity and in-hospital outcomes between these patient groups.Methods: We retrospectively analyzed a database of 196 patients with acute ischemic stroke and AF between January 2010 and October 2019. We divided the patients into two groups: patients with “newly diagnosed AF” and those with “known AF.” We assessed the stroke severity using the National Institutes of Health Stroke Scale (NIHSS) score on admission and in-hospital outcomes using the modified Rankin Scale (mRS) score at discharge.Results: The proportion of newly diagnosed AF was 33% (64/196). There were no differences in age, hypertension, diabetes mellitus, and past history of heart failure between patients with newly diagnosed AF and those with known AF. Patients with newly diagnosed AF were associated with a lower proportion of male sex (male; 50 vs. 67%, p < 0.05), a lower proportion of past history of stroke (12 vs. 35%, p < 0.01), a lower CHA2DS2-VASc score (median [interquartile range]; 3 [2–4] vs. 3.5 [3–5], p < 0.01), and a lower proportion of pre-stroke oral anticoagulation (5 vs. 59%, p < 0.01). There were no differences in the NIHSS score on admission (12 [4–19] vs. 9 [3–19]) or the mRS score at discharge (3 [1–5] vs. 3 [1–5]). After adjustment for relevant covariates, newly diagnosed AF was not associated with the NIHSS score on admission [adjusted common odds ratio (OR), 0.85; 95% confidence interval (CI), 0.45–1.60] or the mRS score at discharge (adjusted common OR, 1.67; 95% CI, 0.88–3.18). After propensity score matching, newly diagnosed AF was not associated with the NIHSS score on admission (adjusted common OR, 0.91; 95% CI, 0.48–1.73) and the mRS score at discharge (adjusted common OR, 1.77; 95% CI, 0.92–3.43).Conclusion: Stroke severity and in-hospital outcomes in patients with newly diagnosed AF did not differ from those in patients with known AF after adjustment for clinically relevant factors. The importance of detection of latent AF and subsequent anticoagulation in preventing severe stroke should be further emphasized.

Objective To explore associations of serum neurofilament light chain (sNfL) at admission with clinical deficits and the long-term prognosis of acute ischaemic stroke (AIS). Methods We recruited 110 AIS patients with serum sampled at hospital arrival. The concentrations of sNfL were detected by a Simoa HD-1 analyser. We first investigated the determinants of sNfL levels at admission within the study population. Associations of sNfL levels with National Institutes of Health Stroke Scale (NIHSS) scores and modified Rankin Scale (mRS) scores were then tested. We further divided the patients into revascularized and nonrevascularized groups, and the associations of sNfL levels with NIHSS and mRS scores were assessed in these subgroups. Results Age, sex, stroke history, and the time between the onset of illness and arrival at the hospital were independent influencing factors of sNfL levels within the study population. The sNfL levels at admission were correlated with the NIHSS scores 7 days after stroke (p = 0.004) across all subjects but showed no correlation with the NIHSS scores at admission (p = 0.293) or the mRS scores 6 months after stroke (p = 0.065). Further analysis revealed that in the nonrevascularized group of AIS patients, the sNfL levels at admission were positively correlated with NIHSS scores (NIHSS at admission, p = 0.005; NIHSS 7 days after stroke, p = 0.003) and negatively correlated with mRS scores (p = 0.011). Conclusion sNfL levels at admission could be a potential biomarker for predicting clinical deficits and prognosis in the natural course of AIS.

Patients with moderate to severe strokes (NIHSS score >10) undergoing urgent carotid interventions within 48 hours have worse functional outcomes

Introduction: Functional prognosis after an Acute Ischaemic Stroke (AIS) has been linked to two blood enzymes: Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT). The metabolic effects of AST and ALT in decreasing blood glutamate levels may account for this association. Aim: To establish a correlation between AIS, its severity and mortality with their De Ritis ratio (AST/ALT). Materials and Methods: In this hospital-based prospective cohort study conducted at the Department of Medicine at Acharya Vinoba Bhave Rural Teaching Hospital, Wardha, Maharashtra, India, 100 AIS patients were enrolled from December 2020 to December 2022. The parameters used in this study included the Aspartate Aminotransferase/Alanine Transaminase Ratio (AAR), AST, ALT, age, Body Mass Index (BMI) and hypertension. The patients were categorised into four subgroups according to AAR quartiles. The National Institutes of Health Stroke Scale (NIHSS) score was calculated at admission and the modified Rankin Scale (mRS) score was assessed at a 3-month follow-up period. Univariate and multivariate non conditional logistic regression models were employed to assess the relationship between AAR quartiles and outcomes among AIS patients. An association of the De Ritis ratio with these scores was evaluated. Microsoft Office Excel was used for data entry and Statistical Package for the Social Sciences (SPSS) version 28.0 was used for analysis. Results: In the patients’ demographic information, including their past medical history and co-morbidities, 94.0% of the patients were aged ≥40 years, with a mean age of 58.16±13.44 years. The anthropometric measurements (BMI=23.89±2.42 kg/m2 ) and blood indices of all patients were compared and highlighted in the baseline characteristics. There was a significant association between disease severity, as per the NIHSS score and the De Ritis ratio (p=0.038). Disease severity increased significantly with the De Ritis ratio. Additionally, there was a significant association between the outcome 3 months after discharge (mRS score) and the ratio of AST to ALT (p=0.043). Notably, 42.9% of deaths occurred in patients with a De Ritis ratio &gt;1.45. Patients with higher NIHSS and mRS scores were significantly associated with an elevated De Ritis ratio. Conclusion: The De Ritis ratio (AST/ALT) relates to the severity of stroke (NIHSS score), poor outcomes (mRS score) and mortality. The value of the De Ritis ratio can be used as a reliable assessment tool for the prognosis of patients with AIS. The De Ritis ratio can serve as a non invasive and cost-effective tool for assessing AIS, differentiating stroke severity and predicting mortality.

The present study aims to examine the relationship between post-stroke fibrinogen levels and long-term (three-month) prognosis in patients who had their first ischemic stroke and to determine the effect of fibrinogen levels on morbidity and mortality. A prospective study was carried out on 100 patients presenting with their first ischemic stroke at the Neurology Clinic of Gaziantep City Hospital. Stroke severity was examined utilizing the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) at initial admission and at third month post-stroke. Serum fibrinogen levels were recorded from routine blood tests, and the relationship between fibrinogen levels and clinical outcomes was analyzed statistically. Significant positive correlations were observed between fibrinogen levels and stroke severity and outcomes. Fibrinogen levels were associated with NIHSS admission scores (r = 0.371, p < 0.001) and mRS admission scores (r = 0.439, p < 0.001). At third month, fibrinogen levels were significantly related with NIHSS (r = 0.544, p < 0.001) and mRS (r = 0.538, p < 0.001) scores. Regression analysis revealed that a one-unit increase in fibrinogen levels resulted in a 0.018-unit increase in NIHSS scores and a 0.008-unit increase in mRS scores (p < 0.001). Elevated fibrinogen levels during the acute phase are related with poorer neurological outcomes and increased morbidity and mortality within the three-month follow-up period in patients with first-time ischemic stroke. These resultsindicate that fibrinogen could be considered a prognostic biomarker for stroke management and rehabilitation planning.

Clinical Features of a First-Ever Lacunar Infarction in Japanese Patients: Poor Outcome in Females

There is uncertainty about whether patients with an anterior circulation large vessel occlusion (LVO) and a low NIH Stroke Scale (NIHSS) score (≤5) benefit from endovascular therapy (EVT) in the late time window (6-24 hours). We compared the clinical outcomes of these patients receiving EVT with those receiving medical management (MM). The CT for Late Endovascular Reperfusion multinational cohort study was conducted at 66 sites across 10 countries from January 2014 to May 2022. This subanalysis included consecutive patients with late-window stroke due to an anterior circulation LVO, defined as occlusion of the internal carotid artery or proximal middle cerebral artery (M1/M2 segments), and a baseline NIHSS score ≤5 who received EVT or MM alone. The primary end point was a 90-day ordinal shift in the modified Rankin Scale (mRS) score. Secondary outcomes were 90-day excellent outcome (defined as mRS scores 0-1 or return to baseline mRS score in patients with a prestroke mRS score >1) and favorable outcome (defined as mRS scores 0-2 or return to baseline mRS score in patients with prestroke mRS score >2). Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality. We used ordinal and binary logistic regression models to test for outcome differences. Among 5,098 patients, 318 patients were included (median [interquartile range] age 67 [56-76] years; 149 [46.9%] were female; baseline NIHSS score was 4 [2-5]). A total of 202 patients (63.5%) received EVT and 116 MM (36.5%). There was no difference in favorable 90-day ordinal mRS score shift (adjusted common odds ratio [OR] 0.77, 95% CI 0.45-1.32), excellent outcome (adjusted OR 0.86, 95% CI 0.49-1.50), or favorable outcome (adjusted OR 0.72, 95% CI 0.35-1.50) in the EVT group compared with MM. Symptomatic intracranial hemorrhage risk (adjusted OR 3.40, 95% CI 0.84-13.73) and mortality at 90 days (adjusted OR 2.44, 95% CI 0.60-10.02) were not statistically different between treatment groups. In patients with an anterior LVO and low NIHSS score in the 6-24-hour time window, there was no statistical difference in disability outcomes or intracranial bleeding risk between patients treated with EVT compared with MM. The retrospective and observational design limits our findings. Ongoing randomized controlled trials will provide further insight. This study provides Class III evidence that in adult patients with anterior circulation LVO and low NIHSS score (≤5) presenting in the late time window (6-24 hours), EVT does not improve clinical outcome vs MM. This study was registered at clinicaltrials.gov under NCT04096248.

Background: Since stroke patients with nonvalvular atrial fibrillation (NVAF) have poor outcomes in general, the prediction of outcomes following discharge is of utmost concern for these patients. We previously reported that brain natriuretic peptide (BNP) levels were significantly higher in NVAF patients with larger infarcts, higher modified Rankin Scale (mRS) score, and higher CHADS₂ score. In the present study, we evaluated an array of variables, including BNP, in order to determine significant predictors for functional outcome in patients with NVAF after acute ischemic stroke (AIS). Methods: A total of 615 consecutive patients with AIS within 48 h of symptom onset, admitted to our hospital between April 2010 and October 2015, were retrospectively searched. Among these patients, we enrolled consecutive patients with NVAF. We evaluated the mRS score 3 months after onset of stroke and investigated associations between mRS score and the following clinical and echocardiographic variables. Categorical variables included male sex, current smoking, alcohol intake, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, peripheral artery disease, use of antiplatelet drugs, anticoagulants, or tissue plasminogen activator (tPA), and infarct size. Continuous variables included age, systolic blood pressure (SBP), diastolic blood pressure, hemoglobin, creatinine, D-dimer, brain natriuretic peptide (BNP), left atrial diameter, left ventricular ejection fraction (EF), and early mitral inflow velocity/diastolic mitral annular velocity (E/e’). We also analyzed the association of prestroke CHADS₂, CHA₂DS₂-VASc, and R₂CHADS₂ scores, and National Institutes of Health Stroke Scale (NIHSS) score on admission with mRS score 3 months after the onset of stroke. Patients were classified into 2 groups according to mRS score: an mRS score ≤2 was defined as good outcome, an mRS score ≥3 was defined as poor outcome. To clarify the correlations between categorical or continuous variables and mRS score, uni- and multivariate logistic regression models using the stepwise variable selection method were applied. Results: Among 157 patients with NVAF after AIS, 63.7% were male and the mean age was 75.9 years. In univariate regression analysis, poor outcome (mRS score ≥3) was associated with use of tPA, infarct size, age, SBP, BNP, EF, and NIHSS score. In multivariate regression analysis, BNP levels (odds ratio [OR] 6.40; 95% confidence interval [CI] 1.26–32.43; p = 0.0235) and NIHSS score (OR 2.87; 95% CI 1.84–4.47; p < 0.001) were significantly associated with poor outcome (mRS score ≥3) after adjusting for use of tPA, infarct size, age, BNP, EF, and NIHSS score. Conclusions: Apart from NIHSS score, BNP was a very useful predictor for long-term outcomes of patients with NVAF after AIS.

Texture analysis based on ADC maps and T2-FLAIR images for the assessment of the severity and prognosis of ischaemic stroke

Does Mild Deficit for Patients with Stroke Justify the Use of Intravenous Tissue Plasminogen Activator?

To characterize the effect of white matter microstructural integrity on cerebral tissue and long-term functional outcomes after acute ischemic stroke (AIS). Consecutive AIS patients with brain MRI acquired within 48 hours of symptom onset and 90-day modified Rankin Scale (mRS) score were included. Acute infarct volume on diffusion-weighted imaging (DWIv) and white matter hyperintensity volume (WMHv) on T2 fluid-attenuated inversion recovery MRI were measured. Median fractional anisotropy (FA), mean diffusivity, radial diffusivity, and axial diffusivity values were calculated within normal-appearing white matter (NAWM) in the hemisphere contralateral to the acute lesion. Regression models were used to assess the association between diffusivity metrics and acute cerebral tissue and long-term functional outcomes in AIS. Level of significance was set at p < 0.05 for all analyses. Among 305 AIS patients with DWIv and mRS score, mean age was 64.4 ± 15.9 years, and 183 participants (60%) were male. Median NIH Stroke Scale (NIHSS) score was 3 (interquartile range [IQR] 1-8), and median normalized WMHv was 6.19 cm3 (IQR 3.0-12.6 cm3). Admission stroke severity (β = 0.16, p < 0.0001) and small vessel stroke subtype (β = -1.53, p < 0.0001), but not diffusivity metrics, were independently associated with DWIv. However, median FA in contralesional NAWM was independently associated with mRS score (β = -9.74, p = 0.02), along with age, female sex, NIHSS score, and DWIv. FA decrease in NAWM contralateral to the acute infarct is associated with worse mRS category at 90 days after stroke. These data suggest that white matter integrity may contribute to functional recovery after stroke.

Background: Hyperglycemia is a frequent finding in acute intracerebral hemorrhage (ICH), but there is debate concerning its prognostic significance. Objective: To investigate the impact of blood glucose (BG) measured during admission on short-term mortality and functional outcome in hospital-admitted patients with acute ICH. Methods: This prospective cohort study included 224 ICH patients [age 60 (50-70) years, median (IQR); female 99 (44.2%)] in the stroke unit of the National Institute of Neurosciences and Hospital Dhaka, Bangladesh from July 2019 to December 2019. All patients underwent routine clinical examination, neuroimaging, and biochemical tests. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS). Capillary BG was measured using a standardized glucometer. BG level ≥10 mmol/L was used as the cut-off for elevated BG. Mortality was noted and functional assessment was done by modified Rankin Scale (mRS) score at 30 days from ictus. Result: The NIHSS score, ICH volume, and frequency of aspiration pneumonia were significantly higher whereas the GCS score was significantly lower in the elevated BG group (p=0.002, 0.036, 0.022, and 0.022 respectively). In-hospital mortality, mortality after 30 days, and mRS score after 30 days were also higher in the elevated BG group (p=0.003 in all). Cumulative survival of ICH patients was significantly lower in the elevated BG group after 30-days of acute stroke event (p&lt;0.001). When adjusted for age, creatinine, presence of aspiration, midline shift in CT scan, volume, site, and ventricular extension of ICH, multivariate Cox regression revealed that admission BG could independently predict the mortality 30 days after ICH [HR 1.11 (95%CI 1.06-1.16; p&lt;0.001). Conclusions: In patients with acute ICH, admission BG is linked to an increase in 30-day and in-hospital mortality rates. J Assoc Clin Endocrinol Diabetol Bangladesh, January 2022; 1 (1): 15-21

The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for patients with M2 occlusion. This study aims to compare the efficacy and safety of endovascular treatment (EVT) with best medical management (BMM) in patients with M2 occlusion, and to investigate whether the optimal treatment varies according to stroke severity. Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT and BMM. According to stroke severity, the study population were classified into those with moderate-severe stroke and those with mild stroke. National Institute of Health Stroke Scale (NIHSS) scores ≥ 6 was defined as moderate-severe stroke, and NIHSS scores 0-5 as mild stroke. Random-effects meta-analyses were performed to measure the symptomatic intracranial hemorrhage (sICH) within 72h, and the modified Rankin Scale (mRS) scores 0-2 and the mortality at 90 days. Totally, 20 studies were identified, including 4358 patients. In the moderate-severe stroke population, the EVT had 82% higher odds for mRS scores 0-2 (OR 1.82, 95% CI 1.34-2.49) and a 43% lower odds for mortality (OR 0.57, 95% CI 0.39-0.82) compared with the BMM. However, no difference was found in the sICH rate (OR 0.88, 95% CI 0.44-1.77). In the mild stroke population, no differences were observed in the mRS scores 0-2 (OR 0.81, 95% CI 0.59-1.10) or mortality (OR 1.23, 95% CI 0.72-2.10) between EVT and BMM, whereas EVT was associated with higher sICH rate (OR 4.21, 95% CI 1.86-9.49). EVT may be only beneficial for patients with M2 occlusion and high stroke severity, but not for those with NIHSS scores 0-5.

IntroductionEndovascular recanalization therapy has demonstrated considerable efficacy in the treatment of acute ischemic stroke (AIS). However, not all patients appear to benefit on the long term from this therapy. No studies have assessed the role of Cerebrolysin following mechanical thrombectomy (MT). The present study was conducted to evaluate the safety and efficacy of Cerebrolysin as add-on treatment to MT in patients with cardioembolic AIS.MethodsThis study evaluated 150 patients admitted to the stroke unit. Data were prospectively collected from 75 patients with cardioembolic AIS and National Institutes of Health Stroke Scale (NIHSS) ≥10, who underwent successful MT ± recombinant tissue plasminogen activator (rt-PA). Patients fulfilling inclusion criteria were consecutively enrolled and treated with Cerebrolysin at a daily dose of 30 ml for 14 days, with treatment initiated within 8 h following MT. Patients were compared with a historical control group of 75 well-matched patients who underwent MT ± rt-PA but did not receive Cerebrolysin. The primary outcome measure was a favorable modified Rankin Scale (mRS = 0–2) at day 90. Secondary parameters included the NIHSS, the Montreal Cognitive Assessment (MoCA), the rate of hemorrhagic transformation, mortality, and adverse events. Propensity score matching was performed to match the variables between the compared groups.Results and discussionThe overall results demonstrated that patients treated with Cerebrolysin exhibited a significantly higher proportion of mRS scores of 0–2 at day 90 (64% vs. 34.7%) in comparison to the control group. This finding was consistent with lower NIHSS and mRS scores at all study visits, and a lower any hemorrhagic transformation rate (20% vs. 57.3%). Furthermore, the logistic regression analysis revealed that patients with favorable mRS scores were less likely to undergo hemorrhagic transformation (odds ratio = 2.75, 95% confidence interval = 1.17, 6.45; p = 0.002). The administration of Cerebrolysin as an add-on treatment resulted in a significant benefit for AIS patients following MT, characterized by an improvement in mRS and NIHSS scores, along with a reduced rate of hemorrhagic transformation. The administration of Cerebrolysin was safe and well tolerated. Further studies are required to confirm these results.

Early and Continuous Neurologic Improvements after Intravenous Thrombolysis Are Strong Predictors of Favorable Long-term Outcomes in Acute Ischemic Stroke