Key indicators for prioritizing swallowing assessment in acute ischemic stroke patients in the emergency room.

Vasculocentricity Versus Cerebrocentricity: What Stroke-Related Baroreceptor Reflex Sensitivity Changes Might Be Telling Us

[Figure: see text].

BACKGROUND:Specific clinical and demographic risk factors may be associated with improving or worsening neurologic outcomes within a population of acute ischemic stroke (AIS) patients with a history of obstructive sleep apnea (OSA). The objective of this study was to determine the changes in neurologic outcome during a 14-day recovery as it relates to initial stroke severity in AIS patients with OSA.METHODS:This retrospective study analyzed baseline clinical risk factors and demographic data collected in a regional stroke center from January 2010 to June 2016. Our primary endpoint measure was the National Institutes of Health Stroke Scale (NIHSS) score and our secondary endpoint measures included the clinical factors associated with improving (NIHSS score ≤7) or worsening (NIHSS score >7) neurological outcome. The relative contribution of each variable to stroke severity and related outcome was determined using a logistic regression. The regression models were checked for the overall correct classification percentage using a Hosmer–Lemeshow test, and the sensitivity of our models was determined by the area under the receiver operating characteristic curve.RESULTS:A total of 5469 AIS patients were identified. Of this, 96.89% did not present with OSA while 3.11% of AIS patients presented with OSA. Adjusted multivariate analysis demonstrated that in the AIS population with OSA, atrial fibrillation (AF) (odds ratio [OR] = 3.36, 95% confidence interval [CI], 1.289–8.762, P = 0.013) and changes in ambulatory status (OR = 2.813, 95% CI, 1.123–7.041, P = 0.027) showed an association with NIHSS score >7 while being Caucasian (OR = 0.214, 95% CI, 0.06–0.767, P = 0.018) was associated with NIHSS score ≤7.CONCLUSION:In AIS patients with OSA, AF and changes in ambulatory status were associated with worsening neurological outcome while Caucasian patients were associated with improving neurological outcome. Our findings may have significant implications for patient stratification when determining treatment protocols with respect to neurologic outcomes in AIS patients with OSA.

Relative Effect of Stroke Severity and Age on Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke.

Objective To study the effectiveness and safety of intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis therapy for acute ischemic stroke in patients with atrial fibrillation (AF).Methods A total of 94 patients treated with intravenous rt-PA thrombolysis within 4.5 hours after cerebral stroke onset were analyzed and divided into two groups:a non-AF group (n =64) and an AF group (n =30).Another 30 acute ischemic stroke patients with AF without thrombolytic therapy were selected as a control group.The prognosis of the three groups was compared.The National Institute of Health Stroke Scale (NIHSS) was used for comparison among the three groups before therapy and 7 days after therapy.The incidences of intracerebral hemorrhage (ICH) and symptomatic ICH (SICH) were recorded.The patients were followed up for 90 days and their clinical outcomes were assessed by using the modified Rankin scale (mRS).Results There were no significant differences in the NIHSS scores among three groups before treatment (P ＞ 0.05).The NIHSS scores were significantly lower in the AF and non-AF groups 7 days after thrombolysis therapy than those before thrombolysis therapy (P ＜0.05 and P ＜0.01),and no significant difference in the NIHSS scores was found in the control group before and after therapy (P ＞ 0.05).The incidence of ICH was significantly higher in the AF group than in the non-AF group (26.7％ vs.9.4％,P ＜ 0.05).No significant difference in the incidence of SICH was found between the AF and non-AF groups (13.3％ vs.6.3％,P ＞ 0.05).The favorable prognosis rate was higher in the AF and nonAFgroups than in control group (40.0％ vs.16.7％,P＜0.05; 45.3％ vs.16.7％,P＜0.01).No significant difference in very unfavorable prognosis rate was found between the AF and non-AF groups (20.0％ vs.18.8％,P ＞0.05).Conclusions It is effective and safe of rt-PA thrombolysis therapy for acute ischemic stroke patients with AF. Key words: Acute ischemic stroke; Recombinant tissue plasminogen activator; Atrial fibrillation; Injections ; intravenous ; Thrombolytic therapy ; Cerebral hemorrhage; Neurological function; Prognosis

Objective To explore the associations between type 2 diabetes mellitus (DM) and stroke by evaluating the clinical risk factors, characteristics, and outcomes of acute ischemic stroke (AIS) patients with and without type 2 DM. Methods A total of 1,156 AIS patients (including 410 with type 2 DM (AIS-DM group)) and 746 without type 2 DM (AIS-NDM group)) were included. Patients' demographics, auxiliary examinations, clinical manifestations, and treatment outcomes were recorded and analyzed. Results Among the included AIS patients, 35.46% had type 2 DM. The AIS-DM group had less males (59.76% versus 70.64%), less smokers (33.90% versus 41.96%), more patients with hypertension (72.93% versus 63.94%; p=0.002), higher triglyceride levels (42.93% versus 25.08%; p ≤ 0.01), and lower total cholesterol (147.06 mg/dl versus 175.31 mg/dl) than the AIS-NDM group. The proportion of patients with large artery atherosclerosis (LAA) in the AIS-DM group was lower (77.56% versus 85.92%; p < 0.05) than that in the AIS-NDM group, and the proportion of patients with small arterial occlusions (SAO) in the AIS-DM group was higher (27.07% versus 13.67%; p < 0.05) than that in the AIS-NDM group. The mean National Institutes of Health Stroke Scale (NIHSS) score at admission in the AIS-DM group was lower than that in the AIS-NDM group (4.39 versus 5.00; p=0.008), but there was no significant difference in the NIHSS score or the modified Rankin Scale score between the two groups at discharge. A total of 85 AIS patients underwent intravenous thrombolysis treatment with recombinant tissue plasminogen activator (rtPA). The door-to-needle time (DNT) did not differ significantly between the groups (49.39 ± 30.40 min versus 44.25 ± 15.24 min; p=0.433). In addition, there were no significant differences in the baseline NIHSS score, 7-day NIHSS score, and mRS score at discharge between the groups. After intravenous thrombolysis with rtPA, the AIS-NDM group had better recovery (44.30% versus 29.20%; p=0.017) and a higher ratio of good treatment outcome at discharge (65.60% versus 54.20%; p=0.762). Conclusions Type 2 DM is associated with AIS and its risk factors, such as dyslipidemia and hypertension. Patients in the AIS-DM group had less LAA and smaller arterial occlusions, and DM could exacerbate the short-term clinical outcomes in AIS patients.

Objective To investigate the relationship of National Institute of Health Stroke Scale(NIHSS)with heart rate variability(HRV)and cardiac complication in elderly patients with acute cerebral infarction, and to clarify the effect of early drug intervention on the regulation of autonomic nerve function in patients with high NIHSS score. Methods One hundred twenty-six inpatients with first-onset acute cerebral infarction(ACI)(the cerebral infarction group)and 40 healthy subjects with no history of stroke(the control group)were retrospectively enrolled.All subjects underwent examinations of NIHSS and 24 h dynamic electrocardiogram.According to NIHSS score, patients in the cerebral infarction group were divided into 3 subgroups: NIHSS score 0-4 group(n=32), NIHSS score 5-15 group(n=66)and NIHSS score ≥ 15 group(n=28). The difference in HRV parameters were compared between ACI patients and the controls.Ninety-four ACI patients with NIHSS score ≥5 were randomly divided into 2 groups: (1)the traditional treatment group(n=44), taking routine drugs for cerebral infarction; (2)the special treatment group(n=42), taking metoprolol sustained release tablet and Shensonyangxin capsule as add-on to the routine drugs for cerebral infarction.The 24 h dynamic electrocardiogram examination were conducted 30 days after treatment.The differences in HRV parameters and cardiac complications were compared between the two treatment groups. Results In patients with acute cerebral infarction, the time-domain parameters of normal-to-normal intervals(NNI), standard deviation of normal-to-normal intervals(SDNN), square root of the mean squared successive differences between normal-to-normaI RR intervals(RMSSD), percentage of adjacent normal-to-normal intervals that differed more than 50 ms(PNN50), frequency domain parameters low-frequency(LF)power and high-frequency(HF)power were significantly reduced as compared with those in the control group(P<0.05). While, pulse rate and frequency domain parameters of sympathetic vagus balance index(LF/HF)were significantly increased(P<0.05). The time-domain parameters(NNI, SDNN, RMSSD and PNN50)and frequency domain parameters(LF, HF)were significantly reduced in the NIHSS score 5-15 group and NIHSS score ≥15 group as compared with the control group and the NIHSS score 0-4 group(P<0.05). The time-domain parameters(RMSSD and PNN50)and frequency domain parameters(LF and HF)were reduced(P<0.05), and the frequency domain parameters(LF/HF)were increased(P<0.05)in NIHSS score ≥15 group compared with in NIHSS score 5-15 group(P<0.05). Compared with pre-treatment, the special treatment group after treatment showed that the time domain parameters(NNI, SDNN, RMSSD and PNN50)and frequency domain parameters(LF and HF)were significantly increased(P<0.05), the frequency domain parameters(LF/HF)were significantly reduced(P<0.05)and the incidence of cardiac complication(total incidence of atrial arrhythmias and ventricular arrhythmias and cardiac complication)were significantly reduced(P<0.05). As compared with the traditional treatment group after treatment, the special treatment group after treatment showed that the time domain parameters(NNI, SDNN, RMSSD and PNN50)and frequency domain parameters(LF and HF)were significantly increased(P<0.05), frequency domain parameters(LF/HF)were significantly reduced(P<0.05)and the total incidence of cardiac complication were significantly reduced(18.4% or 7 cases vs.40.0% or 16 cases, P<0.05). Conclusions The HRV is decreased in patients with acute cerebral infarction.The reduction degree of HRV is more significant along with the higher NIHSS scores, which suggests that patients with high NIHSS scores are prone to an impairment of autonomic nerve function.For patients with high NIHSS scores after stroke, early drug intervention for regulating autonomic nerve function can effectively prevent the occurrence of cardiac emergencies and improve the prognosis of stroke. Key words: Cerebral infarction; Heart rate; Autonomic agents

Normalized wall index, intraplaque hemorrhage and ulceration of carotid plaques correlate with the severity of ischemic stroke

Background and PurposeWhite blood cell count to mean platelet volume ratio (WMR) is increasingly recognized as a promising biomarker. However, its predictive capability for acute ischemic stroke (AIS) patients is relatively less researched. The primary aim of this study is to explore its prognostic value in AIS patients after reperfusion regarding 3-month poor functional outcome.MethodsA total of 549 AIS patients who had undergone vascular reperfusion procedure with complete 3-month follow-up were retrospectively recruited in this study. White blood cell count, mean platelet volume at 24 h of admission were recorded. Stroke severity had been estimated using the National Institutes of Health Stroke Scale (NIHSS) and poor outcome was defined as modified Rankin Scale (mRS) 3–6 at 3 months.ResultsAIS patients with poor functional outcome at 3 months displayed higher WMR. A positive correlation between WMR and NIHSS score was found (r = 0.334, p < 0.001). After adjusting potential confounders, WMR was still an independent risk factor for poor prognosis at 3 months (OR = 2.257, 95% CI [1.117-4.564], p = 0.023) in multivariate logistic regression model. Subgroup analyses further suggested a significant association between WMR and poor outcome in high baseline NIHSS (per 0.1-point increase: OR = 1.153, 95% CI [1.014-1.312], p = 0.030) group. Receiver operating characteristic (ROC) curves analysis was utilized to assess the predictive ability of WMR, indicating a cut-off value of 0.86. A nomogram that includes age, sex, NIHSS on admission, high WMR for predicting 1-year all-cause survival was also developed (C-index = 0.628).ConclusionsWMR is significantly correlated with stroke severity on admission and is proved to be an important prognostic indicator for AIS outcomes, especially in high NIHSS on admission group. Additionally, the developed nomogram that includes high WMR for predicting 1-year survival provides us with an effective visualization tool.

ObjectivesThe mechanisms of ischemic stroke severity and early neurologic deterioration (END) are not fully understood. The aim of the present study was to investigate the association of six variants in MMP‐9 gene with ischemic stroke severity and the risk for END in ischemic stroke (IS) patients with atrial fibrillation (AF).MethodsThis was a multi‐center, prospective, observational study of 615 acute IS patients with AF admitted to six participating hospitals between June 2016 and October 2017. Ischemic stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score on admission. END was defined as an increase of four or more points in NIHSS within 10 days of admission. Six variants of MMP‐9 gene were examined using mass spectrometry.ResultsAmong the 615 enrolled patients, 112 (18.2%) patients presented with moderate or severe stroke (NIHSS score ≥16), and 108 (17.6%) patients suffered from END within 10 days of admission. Multiple logistic analysis showed that prestroke antiplatelet therapy, prestroke anticoagulant therapy, rs3918242 CT/TT, and rs3787268 AG/GG were independent predictors for stroke severity. Cox proportional hazard regression revealed that diabetes mellitus, prestroke antiplatelet therapy, prestroke anticoagulant therapy, rs1056628 AC/CC, and rs3918242 CT/TT were independently associated with the risk of END.ConclusionsThe incidence of moderate or severe stroke and END was very common in acute IS patients with AF. MMP‐9 polymorphisms were independently associated with severe stroke and higher risk of END, and prestroke antithrombotic treatment was associated with less severe stroke and lower risk of END in patients with AF.

Objective To analyze the correlation of vitamin D with risk factors and severity of ischemic stroke. Methods Between July 2018 and September 2018, 200 patients who were admitted to our hospital due to the acute ischemic stroke were included as subjects.The medical history and examination results of the patients were collected.Triglycerides(TG), total cholesterol(TC), high density lipoprotein(HDL)、low density lipoprotein(LDL) and other biochemical indicators were detected by Roche automatic biochemical analyzer.25 (OH) D levels were detected by Sorin automatic chemiluminescence analyzer.The severity of ischemic stroke was scored according to the National Institutes of Health Stroke Scale (NIHSS). Results The levels of TG, TC, LDL, and apoB were significantly higher in patients with 25 (OH) D deficiency than that of undeficient patients(P<0.05).25 (OH) D was negatively correlated with age, TG, TC, LDL, apoB, and NIHSS score (P<0.05). Acute ischemic stroke patients were divided into mild, moderate, and severe groups according to the NIHSS score. 25 (OH) D level was significantly different between patient groups with different disease severity(P<0.05). The risk of acute stroke increased gradually with the decrease of 25 (OH) D level.Low level of serum 25 (OH) D (<14.5ng/mL) increased the risk of acute stroke by more than 5 times (OR 5.57, 95%CI: 1.77-17.49, P<0.05) compared to that when serum 25(OH)D was higher than 23.65ng/mL. There results were obtained by taking into account of age, sex, other vascular risk factors. Conclusion Patients with acute ischemic stroke show significantly low levels of 25 (OH) D. Low level of 25 (OH) D can increase the risk and severity of ischemic stroke. Key words: Acute ischemic stroke; 25- hydroxyvitamin D; Risk; Severity

Introduction: The National Institutes of Health Stroke Scale (NIHSS) provides a clinical measure of stroke severity. Molecular biomarkers that reflect severity of neurological injury may enhance the objectivity and accuracy of stroke severity assessment. Objectives: This study aimed to discover plasma proteins indicative of stroke severity in patients with acute ischemic stroke (AIS) using aptamer-based proteomics and supervised machine learning algorithms. Methods: We used clinical and proteomics data of AIS patients aged ≥18 years lodged within a prospective plasma repository from 2010 to 2014. We collected blood from each patient at hospital admission before administering any therapeutic intervention. Our outcome was differentially expressed levels of proteins in AIS patients classified by NIHSS scores. We classified AIS patients into mild NIHSS (0-7), moderate NIHSS (8-10), severe NIHSS (11-20), and critical NIHSS (21-42) subgroups. We performed aptamer-based proteomics using the plasma 7K SomaScan assay. For comparisons between the four NIHSS subgroups, we performed feature selection by sparse partial least squares discriminant analysis (sPLS-DA) using the MixOmics R package. We determined the area under the receiver operating characteristic curves (AUC-ROC) to classify the AIS-severity subgroups. Results: We included 40 AIS patients (mean age 63.3 years, 45% males) classified into four subgroups: 10 mild NIHSS, 9 moderate NIHSS, 11 severe NIHSS, and 10 critical NIHSS (Figure 1). SomaScan quantified 7307 protein targets, including 6373 unique proteins. Using the sPLS-DA approach, we identified two components classifying critical NIHSS (component 1, 10 proteins) and mild and severe NIHSS (component 2, 35 proteins) from moderate NIHSS. The panel of 45 proteins from the two components had an AUC of 0.96 to classify mild NIHSS, 0.66 to classify moderate NIHSS, 0.96 to classify severe NIHSS, and AUC of 0.97 to classify critical NIHSS from other subgroups. The top 5 proteins for AIS risk stratification were SELENOW, ANGPTL4, FABP3, CFL2, and KDM8 (Figure 2). Conclusions: Our study revealed distinct panels of protein biomarkers capable of classifying AIS patients into NIHSS-defined severity subgroups with high accuracy, particularly for mild, severe, and critical categories. These proteins may improve stroke severity assessment, especially in conditions where a clinical exam is limited, though further validation with larger cohorts is critically needed.

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

Background: Stroke is the third leading cause of death in developed countries and the leading cause of long term disability. Up to 10% of patients with acute stroke need mechanical ventilation (MV) due to different reasons. Identification of early markers associated with poor outcome appears to be of major importance in helping to provide the most appropriate management in stroke patients. The present study has the objective of determining the predictor accuracy of the National Institutes of Health Stroke Scale (NIHSS) score for the requirement of support of MV in patients with acute stroke and evaluating the outcome of patients who require ventilator support. Methods: The aim of the study was to determine the predictor accuracy of NIHSS score in determining the requirement for MV and outcome of patients of acute ischemic stroke. This prospective cohort study was carried out in Max Superspeciality Hospital Saket in New Delhi over a period of one and half years. Patients with acute stroke, defined as the presence of sudden onset of focal neurological deficit and admitted within 24 h of onset of symptoms, with age ≥18 years were included in the study. The patients who were already on ventilator support at the time of admission were excluded from the study. Results: Out of 139 patients of acute ischemic stroke and venous stroke, 32 patients were put on the mechanical ventilator. In case of ischemic stroke patients who required MV 21 (65.6%) were having NIHSS score between 6 and 13, 10 (31.3%) patients were having NIHSS score of ≥14 and only one (3.1%) was having NIHSS score of ≤5. We found the predictor accuracy of NIHSS score of about 82.7% in determining the need for ventilation support. Conclusions: NIHSS score was found to have predictor accuracy of 82.7% in determining the need for MV. Mortality rate was shown to be increased with increase in the NIHSS score. Keywords: The National Institutes of Health Stroke Scale (NIHSS) score; mechanical ventilation (MV); predictor accuracy; favorable; Modified Rankin Scale (MRS); mortality

Objective To investigate the value of HAT and SEDAN score scales in predicting hemorrhagic transformation (HT) following the recombinant tissue-type plasminogen activator (rt-PA) intravenous thrombolysis in acute ischemic stroke patients and risk factors affecting HT. Methods A total of 143 patients with acute ischemic stroke underwent rt-PA intravenous thrombolysis within 4.50 h of onset and their clinical data were collected. According to head CT after thrombolysis, patients were divided into HT group (18 cases) and non-HT group (125 cases). Single factor analysis was used to assess differences in HAT and SEDAN score scales and related risk factors of ischemic stroke in 2 groups, and further Logistic regression analysis was used to investigate independent predictors of HT. Receiver operating characteristic (ROC) curve was used to evaluate the sensitivity and specificity of HAT and SEDAN score scales in predicting HT. Results Univariate Logistic regression analysis showed that history of atrial fibrillation (AF), admission systolic blood pressure (SBP), admission blood glucose level, early low density of head CT, thrombolytic time window, National Institute of Health Stroke Scale (NIHSS), HAT and SEDAN scores were all risk factors for HT after thrombolysis ( P < 0.05, for all). Multivariate Logistic regression analysis showed that history of AF ( OR = 1.677, 95% CI: 1.332-2.111; P = 0.000), admission SBP ( OR = 1.102, 95% CI: 1.009-1.204; P = 0.031), admission blood glucose level ( OR = 1.870, 95% CI: 1.119-3.125; P = 0.017), thrombolysis time window ( OR = 1.030, 95%CI: 1.009-1.052; P = 0.005), NIHSS score ( OR = 1.574, 95%CI: 1.186-2.090; P = 0.002), HAT score ( OR = 2.515, 95%CI: 1.273-4.970; P = 0.008) and SEDAN score ( OR = 2.413, 95%CI: 1.123-5.185; P = 0.024) were risk factors for HT after thrombolysis. ROC curve analysis showed that HAT score could predict HT with 94.40% sensitivity and 41.60% specificity, and area under curve (AUC) was 0.70. SEDAN score could predict HT with 94.40% sensitivity and 65.62% specificity, and AUC was 0.77. Conclusions History of AF, admission SBP, admission blood glucose level, thrombolysis time window, NIHSS, HAT and SEDAN score scales were independent risk factors for hemorrhagic transformation after intravenous thrombolysis for treating ischemic stroke, while SEDAN score had high predictive value. DOI: 10.3969/j.issn.1672-6731.2015.02.008